Ethics: Brain bleed sign out AMA

[Kbig2]

Hey guys,

I have an ethical delimna I just witnessed my colleague went through. We work in the ER. Unofficial motto of "stabilize and move".

His patient had a brain bleed with midline shift. He was awake and alert oriented to name place and time. No obvious deficiencies in mentation. Our facility is not stroke certified. He is suppose to be transferred to a stroke certified facility.

The ambulance is on our unit with a rn transport.

The pt at this time refuses to be transferred to the contracted facility. A member of the transport team, not the rn, refuses to take the pt because the pt refuses to be transferred. What we would have done was to just force the pt onto the transport gurney and have him taken to the facility let them deal with it over there. But the one team member refused, so we can't. We called family members, notified house supervisor, all the higher ups, tried to persuade pt but still refused.

Eventually we had the pt sign out ama as there was nothing we could do for him. He refused treatment. His girlfriend called a taxi and they went home. He's gonna go to sleep and not wake up.

He was not a psych pt. Should a 5150 be placed on him due to danger to self? (I remind you that he's alert oriented x3, no history or psych behavior.)

What do you guys think? Was it right? Was there something else that could have been done.? Should be have been forcibly transferred? What should have been done?

I'm interested to know how you would handle this ethical issue.

[rehric00]

If the pt was alert and oriented, they have every right to refuse treatment. As long as your staff did everything possible to educate the pt on the severity and ensure he knew the risks, I don't think you should let it weigh on you. It's no different than someone refusing chemo for a highly treatable cancer...

[Rose_Queen, BSN, MSN, RN]

What we would have done was to just force the pt onto the transport gurney and have him taken to the facility let them deal with it over there.

This is the ethical violation in this situation. Not a patient deciding he doesn't want treatment; that is perfectly within his rights.

Of course, since OP hasn't visited since January 5th, I doubt that they'll learn from the discussion that has occurred here.

[Jory, MSN, APRN, CNM]

There is no law or regulation in any state that allows us to ignore the patient's established wishes just because they are asleep or unconscious, where are you getting that from?

And being competent to make medical decisions is not defined by whether or not they are oriented. Someone can be oriented but not competent to make medical decisions and someone can think it's 1952 and still meet the required criteria to make their own medical decisions.

Regulations in my state.

Let's say you had a chest pain patient with elevated troponins that said he didn't want anything done (said) and started out the door.

Then that patient collapses on the floor. In the absence of a written directive, you can't stand over his body and say, "Well, we can't touch him because he said he didn't want anything done." And watch him die.

His condition has now changed and consent is implied. They will start treatment here.

If it's in writing, that's your choice.

[MunoRN, RN]

Regulations in my state.

Let's say you had a chest pain patient with elevated troponins that said he didn't want anything done (said) and started out the door.

Then that patient collapses on the floor. In the absence of a written directive, you can't stand over his body and say, "Well, we can't touch him because he said he didn't want anything done." And watch him die.

His condition has now changed and consent is implied. They will start treatment here.

If it's in writing, that's your choice.

There is no regulation in any state that says a patients appropriately established consent or refusal to a treatment is void once their condition changes. When a doctor says to a patient with elevated troponins that this is suggestive of a heart attack, and untreated could lead to cardiac arrest and death, and the patient refuses treatment, you can't then initiate treatment when the patient goes into cardiac arrest because "his condition has now changed", that's actually a potentially criminal act.