ethical question

pts trust their nurses.

this pt has put her trust in you.

it is inherently misleading and deceitful, what you are doing.

yep, it worked.

but what's going to happen if the other nurses don't support you:

and one of them tells the pt it was only ns?

how do you think the pt will feel?

some think placebos are ok.

overall, they have been outlawed r/t ethical considerations.

me, i've never done it and never will.

it's taking the easy way out, at a hefty price.

in the end, sooo not worth it.

leslie

I almost always told a patient that I was just flushing their IV with water. Some people never ask. She knew she needed an IV she pulled the other one out. How many times have I said (working nocs), that the Zofran/Tordol/Dilaudid/Compazine/Reglan may make you sleepy. Yes that is a side effect but a little extra emphasis on it could do wonders on an anxiety filled patient. Yes, these were all meds though. What it sounds like to me is what any nurse would have done anyway, basically, I am finished with you for the noc, close your eyes and get to sleep. Had she asked me directly in the am for more medication, I probably would have said that I didn't give her any other than an IV flush. That probably our talk had something to do with her being able to settle down. Kudos for taking a minute with her. Charting her nausea was good, factual. It got better on its own which meant that you did not neglect her health by not calling for a med. Her being sleepy and asking for more medication is just as it was charted an objective statement in your charting. How many psych pts have delusional thoughts and they are charted. "The pt states that the bugs are no longer on the wall now this RN has crushed them for him". Did the RN crush bugs, no. The RN denied that they were there.....get it. This scenario reminds me of peds psych. I don't think you did anything wrong. People tell nurses different things during their stays....this med did this, this RN did this, this helped this didn't, she let me do this, etc. Then we chuckle with each other afterwards. You didn't do anything wrong. Had you not adressed the nausea or anxiety and said the saline was a med because you were too lazy about calling an md for order than it would be totally different. Good for you to use your mental health skills instead of calling for psych meds. Sometimes a little kindness and positive thinking/reinforcment is all that was needed.

If you didn't lie M03BB then I don't think you did anything wrong. If your pt said "what are you giving me" and you either didn't answer or lied, then I think there is an issue.

First of all I'm a student, so I know alot of nurses on here is going to beat me over the head for even commenting but you asked for our input so here is mine:

Yes, you did something very wrong here. I'm not saying you are the worst nurse in the world, you are human and everyone makes mistakes. Number one you made the pt. think you were giving a med. That in its self is wrong. What if she had some kind of some insidous s/s she can blame that on the "medicine" you gave her even though you didn't give anything. Second, if she is requesting this medicine from the next nurse, and the nurse check the MAR and don't see your initials signed off, guess who's in trouble ??? The appropiate response would of been " No, this is just NS that I'm flushing your IV with, however since you really can't sleep maybe I can request a med for the doc to prescribe. " Now if five minutes you come back to check on her and she's asleep, obviously you aren't going to wake her up and give her a sleep aid. The fact that you neither confirmed or denied giving a med is also not appropiate. Thats the same as lying. I know I'm a only a student but right is right and wrong is wrong and I feel that ethically its wrong. Just my two cents, I pray that this whole thing will just be a learning experience and nothing more and nothing less.

I believe you did do wrong when you did not correct the patient and tell her that you only gave her a saline flush. I believe that is withholding information to a patient. I doubt anything will come of it since no harm was done, but only a physician can order a placebo to be used ,and withheld from a patient. Not being open and honest speaks to ethical concerns.

To prior post, she didn't say that she was giving NS. The patient didn't ask her if it was a med. Do you always talk your way through IV insertion? Yes, I do and probably most of us do, "this is normal saline, water, watever, it may burn. Or I just need to flush your IV so it doesn't get clotted (at scheduled times)" She didn't say she was giving her a med. Have I seen other nurses walk into a patients room and just talk and flush and walk out or flush with insertion and not saw what it was YES! When I worked nocs I would tell them that I had a 2 am antibiotic or an IV push tordol or reglan and if they were asleep did they want me to wake them up to tell them what I was doing or was it ok just to administer it and not wake them up for it. Now these were not pain meds!! Just scheduled abx, etc. I wanted my pts to know that hey, they may be half awake and someone in the dark is messign with their IV's. But if I could keep them asleep or groggy, they don't need to be awake for it. Information is the key. Do all the ER RN's talk pts through every step of the iv insertion when they are in a hurry - no. People believe that things work all on their own, without questioning. She did nothing wrong and didn't try to hide anything - hence her report and charting. Have you always told a pt how many mg of dilaudid they are getting? If it's 1-2mg and I don't think that they need 2, I don't give it. Do the other nurses sometimes. But usually we come to an agreement shift to shift of pain control responses from the meds. If they ask I tell them or say we have room to go up if we need to. She didn't play the NS as a placebo. She pacified the patient in a holistic way in my belief. Got the IV in again, now go to sleep, you must be exhausted, I will be back to check on you later sort of thing.

I speak to my patients and always tell them what I am doing. To just walk in and not ask a patient if I can see their iv, give saline or anything else is wrong!

This is interesting. To see different takes on this situation. I talk and give. But, not sure what side of the fence I fall on with this... I can visualize OP and the situation just unfolding, and working out well... would you return with med and give it after finding pt asleep, wake them and give it? or- come back around and see if still asleep, if so hold? Why not?

I hope nothing detrimental comes from this ethical dilemma OP!

If I had been there and you'd asked me for my recommendation, I would have said to call the doc and plead for some Ativan, since you would have addressed two things: nausea and anxiety and not had to sweat ethical bullets.

PS. If there was some emisis with the nausea unabated, I would have told you to request an NG to LIS.

Your patient has the right to informed consent. Seems like you lied to the patient. She thought she was getting medicine but instead got a placebo. The fact that it worked doesn't justify it. The ends don't justify the means. The patient asked for medicine. If I thought I was getting medicine and it turned out to be saline, I'd tell the charge nurse to get me a new nurse.

I got her back in bed and told her it was time to relax and close her eyes, turn off her TV and attempt to sleep. I flushed her IV with saline (since it was a new IV). She thought I was giving her some sort of medicine. I did not confirm or deny it. I just said, "it's time to relax now". She ended up sleeping the rest of the night. At 0530 she woke up to void and asked if she could have "some of that same great medicine". Again, I didn't confirm or deny it and our saline flushes are due at 0600, 1400, and 2200. Since it was 0530, without a word, I flushed her IV again. She said thanks and went back to sleep. In my report to the oncoming shift I mentioned her thinking the saline was a med and said, "it seemed to work great". Well, the nurses (after I left of course because heaven forbid someone actually say something to your face) all gathered at the nurses' station and were talking about the legal ramifications of what I had done, giving a placebo without consent, etc. I heard about it from one of the night shift nurses who stayed late to chart. She said, "I hope you didn't chart it anywhere". I had charted that the patient had complained of nausea all night but stated it was gone after I flushed her IV with saline. I also charted that the patient asked for the "same great medicine" meaning the saline but didn't mention that when she asked for it like that I gave it to her. I charted it simply because i thought it spoke to her mental status. Personally if I were a doctor or NP I would want to know that the patient felt better even though she was given nothing. My concern is, did I truly do something wrong here?

I'm also concerned about her ambien being DC'd. Ambien is addictive. How long has she taken it and how long didn't she get it? Could her anxiety and difficulty sleeping (as well as the nausea) be related to withdrawal? It's possible!

I'm glad she did fall asleep.

I flushed her IV with saline (since it was a new IV). She thought I was giving her some sort of medicine. I did not confirm or deny it. I just said, "it's time to relax now".

How do you know she thought you were giving her a med? Did she ask you? How did you respond...or did you just say that it was time to relax?

At 0530 she woke up to void and asked if she could have "some of that same great medicine". Again, I didn't confirm or deny it and our saline flushes are due at 0600, 1400, and 2200. Since it was 0530, without a word, I flushed her IV again.

So, when she said this, you didn't say anything (related to her statement or otherwise) and then your next action was to flush her IV?

I have moments where I take opportunities to be "vague" because I personally feel that a patient will benefit with less information at that moment (ie, what it means that I'm drawing a B set of cardiac enzymes and the A set was slightly elevated. They don't need to know the details, I'm sure they will still know to tell me if they are having chest pain--but just in case I will always ask as part of each assessment :) ). Yes this is an example of paternalism. But it's a judgement call. If they ask a probing question ("Is this going to tell you whether or not I'm having a heart attack?") I will answer them as best as I can or get an MD to their bedside--but if they seem relatively unconcerned (because they are unaware) when I draw their labs, if they ask I'll say "just checking out some of your chemistries"--I'll say that even if they don't ask.

But if a patient asks a direct question, or implies a question, or states an assumption about any treatment (or medication!) you are giving them, really your only option is to disclose what you are doing or correct them if they are misinformed. You don't have to say "this is normal saline, and thus it definitely WON'T help you sleep"--you can laugh gently and say you are just flushing their IV, then change the subject and talk about relaxation techniques, put some lotion on her back, ask her if she needs more pillows, etc.

Besides the non-disclosure element of your story (tsk tsk), the one other question that comes to my mind is that maybe investigating her nausea and anxiety (and the fact that she says she usually takes ambien) is important. I would ask her about how she usually sleeps at night, what she thinks is making her nauseas, and if she takes benzos on a regular basis (maybe she takes ativan in addition to ambien) which was accidentally left off her med list. In my experience, this happens sort of a lot, and patient's tend to be unaware of symptoms of benzo withdrawal. Maybe they thought they wouldn't need them in the hospital, maybe they've been taking them regularly without a prescription. Whatever the reason, you want to know that something like this isn't what's going on.

I definitely don't think you're the worst nurse, or even a bad nurse. You sound like a good nurse, in fact :) And I admire that you are taking this situation to heart and asking for advice--it's hard to put yourself on the line like that. You ask us because you care about your patients.

-Kan