Ethics: Brain bleed sign out AMA

ED Nurse, RN · Jan 2, 2016

Good question. I was wondering how he even showed up to get diagnosed if he felt fine and acted fine ...then like magic, the OP added some more information.

Yes, thank you, I knew I wasn't crazy! That info was not there originally.

RN_2012, BSN, RN · Jan 2, 2016

He didn't want to be treated further because he is 87 years old most likely. Quality of life and all that.

allnurses Guide · Jan 2, 2016

Well, we eventually let the patient go. As everyone pointed out, they have the right to do so.
I just felt like this pt really didn't understand what exactly is going on.
My force comment was a related to a psych patient who was on a hold and transferred out to another facility.
I say didn't quite understand because this pt (87 years of age) was of Korean ethnicity. Especially the older generation, They have a tendency to believe they are fine if they "feel" fine, such as not showing any s/s of sickness. I know this because I had a similarly aged patient few months back who came in with severe sepsis. Rectal temp of 104.7. Korean speaking only. Refused treatment because he said "I'm fine, I feel good, I go home." BP started at 150s/80s, and after couple hours he suddenly started dropping to 100s/60s, then minutes into 80s/40s. We got a translator to explain to him and still refused treatment. After few more times of getting to convince him, he eventually agreed when he stated "feel weak, tired". We threw a central line in him, and upon closer inspection, he's actually had multiple central lines inserted, started pressors.
We did not force him, he just didn't understand or was in denial until he actually started seeing/ feeling s/s of it himself.
Back to brain bleed pt,
I guess I just felt like he didn't really understand the full extent of what was really happening.
Or maybe I just don't understand why he refused...
Maybe another question is what you would have done in this situation? Would you have liked for this pt to stay in the ER even though can't treat? Any other possibilities?
I'm just trying to have a discussion.
(I don't know much about the pt, all I know was he was Korean speaking only, 87 years old, came to er for fall and laceration to back of head.)

So here's a scenario that might shed light on this - Some years ago I met a delightful 87 Y/O female who was having focal seizures in her right upper extremities. She was alert and oriented, very socially involved in her community and Senior center. She eventually had a Tonic Clonic seizure and went to the Ed. There on CT they found a large tumor in her brain. She refused brain surgery over and over. Her son (a do everything type) said we had to convince her. I sat down and talked at length to her and she told me about her life and her greatest fear of being a "Vegetable" I spoke to the son and relayed his mothers wishes. He refused to accept this. Brought in an expert to show she was not capable of making her own decisions. She had the surgery and suffered a bleed that left her alive but without speech, paralyzed on one side of her body, incontinent etc.... Still the son had her sent to Chemo and radiation........and she lingered....... When hospice was finally called in it took less than two days for her to pass.......I was with her when she did (She was my mother in law) her son could not be in the room to watch her pass so I stayed with her and held her hand.......... I do not fault my husband in this but it demonstrates how a person's wishes can be ignored and denied in the name of medical science. There are worse things than dying. especially when you are an octogenarian.

Hppy

sailornurse · Jan 2, 2016

I remember a 92 y.o man who refused cabg surgery but the daughter with poa signed for the surgery. He had a stroke during surgery and lingered. It was sad to watch plus the 2 brothers were very angry with the sister.

BuckyBadgerRN, ASN, RN · Jan 2, 2016

I hope you realize that YOU would be behaving unethically if you actually did this.

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.

BuckyBadgerRN, ASN, RN · Jan 2, 2016

I hope your DH isn't YOUR POA!

So here's a scenario that might shed light on this - Some years ago I met a delightful 87 Y/O female who was having focal seizures in her right upper extremities. She was alert and oriented, very socially involved in her community and Senior center. She eventually had a Tonic Clonic seizure and went to the Ed. There on CT they found a large tumor in her brain. She refused brain surgery over and over. Her son (a do everything type) said we had to convince her. I sat down and talked at length to her and she told me about her life and her greatest fear of being a "Vegetable" I spoke to the son and relayed his mothers wishes. He refused to accept this. Brought in an expert to show she was not capable of making her own decisions. She had the surgery and suffered a bleed that left her alive but without speech, paralyzed on one side of her body, incontinent etc.... Still the son had her sent to Chemo and radiation........and she lingered....... When hospice was finally called in it took less than two days for her to pass.......I was with her when she did (She was my mother in law) her son could not be in the room to watch her pass so I stayed with her and held her hand.......... I do not fault my husband in this but it demonstrates how a person's wishes can be ignored and denied in the name of medical science. There are worse things than dying. especially when you are an octogenarian.
Hppy

Graduatenurse14 · Jan 2, 2016

I didn't read the comments yet but my first thought was thank God we live in a country where we can't force [competent] people to do anything they don't want to do- no matter how badly they need the treatment. I agree with the person who refused to transfer a person against their will. I am not sure how the forcing him to be transported would work anyway- do you strap them down?

I work on a neurosurgical unit where we have had people with subdurals with midline shifts sign out AMA. It's hard to watch since you know that there could be deadly consequences but we can't force them to stay if they are legally competent. Yes, they have very poor judgement and insight, prideful and impatient but legally competent.

imintrouble, BSN, RN · Jan 2, 2016

Once I'm sure my patient understands the ramifications of whatever I'm telling them, I accept their decisions.

I don't care how old they are, only that they understand what I'm telling them.

One of the things I personally hate is when someone tries to wheedle me into saying yes, when I've been firm about no.

I consider it a sign of respect to not question my patient's decision about their healthcare.

Someone posted they'd just wait til the patient went unconscious, and impose their will on them once they could no longer say stop.

Just because a person can no longer speak, doesn't mean we get to forget what they said when they could.

Here.I.Stand, BSN, RN · Jan 3, 2016

We got a translator to explain to him and still refused treatment.

Um...Korean people are quite capable of understanding explanations. You got a medical interpreter, so it's not like you failed to provide the information.

Maybe another question is what you would have done in this situation? Would you have liked for this pt to stay in the ER even though can't treat? Any other possibilities?

What I would have done is secured a certified medical interpreter to explain what was happening to him (with the MD, of course) and the risks of declining treatment. Would I have liked him to stay...that doesn't matter. It's his life, his decision. You called him a taxi, so he was not putting other drivers at risk, should he herniate on the highway.

No, if he refuses there are no other possibilities. That's what we were all saying.

Then I would bow respectfully and bid him "annyeonghi gaseyo." :yes:

vampiregirl, BSN, RN · Jan 3, 2016

Just a thought - the OP stated the patient refused transfer to the "contracted" facility. I'm hoping that someone verified that the patient wasn't refusing transfer to a particular facility.

I've encountered many patients who for whatever reason (a family member had a bad experience, the general reputation, etc) refused to be transferred to a specific facility. They were ok if offered the option to go somewhere else.

It's hard when a patient makes a choice that doesn't seem like the best choice. The thing is, it's not our choice to make. There are so many things at play that often we are not aware of. Our job is to ensure that the patient has capacity to decisions at that moment and provide the appropriate information to the patient so they can make an informed decision.

ambobam · Jan 3, 2016

The refusing member of the transport team was right.

You can't force a patient to do anything.

Karou · Jan 3, 2016

I say didn't quite understand because this pt (87 years of age) was of Korean ethnicity. Especially the older generation, They have a tendency to believe they are fine if they "feel" fine, such as not showing any s/s of sickness. I know this because I had a similarly aged patient few months back who came in with severe sepsis. Rectal temp of 104.7. Korean speaking only. Refused treatment because he said "I'm fine, I feel good, I go home." BP started at 150s/80s, and after couple hours he suddenly started dropping to 100s/60s, then minutes into 80s/40s. We got a translator to explain to him and still refused treatment. After few more times of getting to convince him, he eventually agreed when he stated "feel weak, tired". We threw a central line in him, and upon closer inspection, he's actually had multiple central lines inserted, started pressors.
We did not force him, he just didn't understand or was in denial until he actually started seeing/ feeling s/s of it himself.
Back to brain bleed pt,
I guess I just felt like he didn't really understand the full extent of what was really happening.
Or maybe I just don't understand why he refused...
Maybe another question is what you would have done in this situation? Would you have liked for this pt to stay in the ER even though can't treat? Any other possibilities?
(I don't know much about the pt, all I know was he was Korean speaking only, 87 years old, came to er for fall and laceration to back of head.)

So, did you or anyone ask him why he was refusing? That's missing from your post, and that's really vital information to ask.

He could have a perfectly rational reason for refusing treatment. He is 87. Perhaps he felt like death wasn't a terrible thing. Who knows? Hopefully you asked him why.

I also hope a qualified medical interpreter was used during the discussion.