ethical problem

Jolie, BSN · Mar 3, 2007

I am unaware of any law that protects an RN who disagrees with the care of a terminally ill client. But in any circumstance, a client has the right to refuse care and treatment. If he states that he doesn't want to be turned, I believe it is your responsibility to explain the risks and benefits to the client, and then abide by his wishes. I would recommend thoroughly documenting the encounter with the client so that you are not accused of failing to provide care.

Pepper The Cat, BSN, RN · Mar 4, 2007

we are looking for the law that protects the RN from legal action if we disagree with the terminally ill client care?
Purely hypothetical
EX: client is terminally ill & one nurse wants to turn him b/c hospital policy but client refuses to be turned b/c of the intense pain it causes.

Pt has the right to refuse care. All the nurse has to do is document that pt refused to be turned due to pain. Also, MD should be notifed that pain meds need to re reassessed, but that is a whole other topic

Additionally the nurse should look at the pros and cons of turning the pt - what are the benefits of turning? Are pressure ulcers really a concern if the pt is terminal? (by terminal, I am assuming you mean death is going to occur very soon)

Myxel67 · Mar 4, 2007

I would call MD for increased pain meds, possibly morphine drip. Then turn pt after pain med kicked in. And maybe ask for a hospice consult.

caliotter3 · Mar 4, 2007

Offer to turn per protocol and each and every time the pt refuses, explain the rationale of turning and document his refusal. That way, no one can accuse you of not doing your job. If the pt is surviving long enough for time to be less of a factor, notify MD, address problem in appropriate pt care conferences. Also, look for alternative nrsg actions, such as pressure relieving measures, etc. But always document his refusal. I have had pts who play the game both ways (but they were not terminal).

meownsmile, BSN, RN · Mar 4, 2007

At the point the patient is terminal and you are providing comfort care it should be up to the patient if they want to change positions,, or the patients family if they want the patient to be turned. What does it matter if they arent? Let the family or patient dictate their own care,, just make sure you chart your actions fully.

MS._Jen_RN, ASN, RN · Mar 4, 2007

If you are talking about hospice or comfort care the institution should have policies/procedures/guidelines specifically for that patient population. If not some should be developed with the aid of a terminal care?hospice specialist.

~Jen

ohiococowgirl · Mar 4, 2007

thank you all for your response, this was a critical thinking exercise for roles/responsibility class & my answers coincided with yours which means the right track. Our teachers are always enforcing the importance of charting. With all of your responses charting is a high priority. Thank you again.

Agnus · Mar 4, 2007

we are looking for the law that protects the RN from legal action if we disagree with the terminally ill client care?
Purely hypothetical
EX: client is terminally ill & one nurse wants to turn him b/c hospital policy but client refuses to be turned b/c of the intense pain it causes.

The pt has a right to refuse anything.

This is where nursing judgement comes in. Nurses are professionals who are paid to and expected to use their professional judgement. We are not low paid "clerks" who follow mindlessly a script given to us.

If you fail to follow good nursing judgement you are more at risk for a law suite In my oponion than if you just blindly follow a policy.

Policies are NOT the end all be all of what we need to be legally doing in nursing. Many policies are not in line with the Standard of Care. The standard of care is NOT what the hospital policiy says it is but is what is practiced by the profession and hospitals in general AND is demonstrated to be Best Practice based on evidence based research as far as the research is available.

You can have policies that are very poor practice and as you well know policies are often out dated.

Remember that term "critical thinking" that you heard so much about in school? This is were it comes in.

You are obligated to do what is best for the patient reguardless of policy.

I am not saying to blatenly disreguard policies and procedures. A nurse or hospital that does not follow the institutions own policy will be easier to sue than one who does. I am saying that a nurse is obligated to use her professional judgement.

Here is what I would do. If the patient is in such terrible pain then I would see about getting relief for that pain. If this is a dying patient I would not overly concern myself with the possibility of pressure ulcers. His comfort is more at stake than a pressure ulcer which may or may not form. I frequently have ordered CNAs not to turn a dying patient because the distress and discomfort it would cause would not justify the benefit.

As far as being legally protected, I have yet to see anyone even speak of suing in such a case.

For such a suit to take place it would almost have to be a case where the ulcer caused the death (since we ARE talking about a dying pt.) Or incresed his suffering in some way.Ulcers do form on dying patients. Yet amazingly I can't recall the last time I had a dying pt whom we deliberately did not turn who formed an ulcer as a result. (though it no doubt has happened I just cant recall the last time it did)

Law suits MUST demonstrate that real harm was done. Yes an ulcer is harm in a viable patient. Harm is also unessairly inflicting pain such as inorder to comply with a policy. Even though that policy is not apropriate for all patients.

It is apropriate to turn patients to prevent ulcers. We also have special beds today that elimate the need to turn patients q2 when tuning is difficult (for pt or nurse) or even painful for the patient. When a pt is dying the prevention of ulcers is NOT a high priority.

If we simply are expected to follow policies we would not need our nursing education to do our job. All we would need is a set of written policies and proceedures written as a step by step guide and anyone could do our job.

You would legally be in greater danger by not following professional judgement than to blindly apply every policy to every patient without reguared to individual needs.

The pt's right to refuse always takes priority over any policy.

Document what you did and the reason.