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.
If, at the age of 87, I get diagnosed with any kind of brain bleed, I'll be going home and calling it quits too. I already had brain surgery at 19. No way am I having it at 87. Why are people so opposed to the elderly accepting the inevitable? We are all going to die. 87 is old.
Competent adults of any age (and minor teenagers, in certain situations) have the right to refuse treatment. You CANNOT force a patient onto a transport gurney and transport him without his consent. That is 100% illegal.
Specializes in Psych, Corrections, Med-Surg, Ambulatory.
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.)
87? Maybe this had nothing to do with being Korean and everything to do with being 87. A lot of people past a certain age decide to forego the heroics and let nature take its course. Maybe all he wanted was a few stitches so his head lac wouldn't make a mess. Did he have a POLST or Advance Directive on file?
True ...there is plenty of information missing. OP stated that patient and "girlfriend" left in a taxi. I'm wondering who the "girlfriend" is and where they were headed. Board and care? Home? Why don't either of them drive? It could be for a simple reason or a more complicated one.
I also wonder what the patient was attempting to do when he fell and hit his head ...and why was a taxi called instead off 911 for a head injury?
There's just too much that suggests the patient may not be competent, to me. I could be wrong, but I would want to explore the issue before letting him taxi off into the night.
What is the "too much that suggests the patient may not be competent"? The OP states the patient was completely oriented, his situation was explained to him by a translator, yet he refused care. The fact that he has a girlfriend and left by taxi is pretty irrelevant. Lots of people have girlfriends, and lots of people don't drive. Lots of people have head injuries which don't render them incompetent. Desiring a course of action which may result in death doesn't indicate incompetence either.
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.
Thank you for saying this. We do this all the time at my facility - not ER, but ICU. We get a lot of chronic non-compliant COPDers and things of that nature. Most of them are end-stage. We have a couple that get admitted twice a month or so because the family calls 911 when they get obtunded, they get on the vent for a few days, get off, go home, get obtunded because they won't wear their CPAPs, get on the vent for a few days...
Most of them say DO NOT PUT THAT MASK ON ME! while they're awake. And most of them make themselves DNIs when they wake up from being on the vent. But - nobody cares. The families still call 911 and get them intubated every time, even though the patients don't want to go through that whole rigamarole any more. I'm sure most of them just want to die at home, but nobody wants to let them go. We want to stick ten million tubes in them instead and tie their arms down so they can't pull the tubes out that they didn't want in the first place. It makes me sick.
We had one who was so weak and debilitated we were shocked when she managed to self-extubate. We hadn't even been bothering to restrain her because she was alert and oriented, but too weak to even pick up the call bell. She immediately made herself DNI, family was called... and we got to hear the husband coming in and screaming at this frail, malnourished, 90 pounds soaking wet with massive, painful decubitus ulcers, 60-something years old female about how "selfish" and what a "horrible person" she was for wanting to be at peace. She ended up rescinding her DNI and got reintubated. I have never wanted to hit someone so badly in my life. It's awful what we do to patients against their will the second they fall unconscious.
Specializes in Adult and Pediatric Vascular Access, Paramedic.
I think I read on here that this particular patient is 87 years old, GOOD FOR HIM FOR REFUSING! He probably realizes his age is working against him and probably does not mind dying. He isn't a 20 year old with a lot of life ahead of him. If he needed surgery, do you really think someone of this age is going to get through that without a single hiccup?
You have to remember asian cultures, especially immigrants are very untrusting of American Healthcare for this reason, that they fear we will not honor their wishes and will do things to them without them knowing. Often times in this culture the family will obtain information in english and not translate everything to the patient because they want to hide how serious the illness is, which is why it is very important to get an interpreter that works for your hospital and is not related. Finally Asians also hold the belief in reincarnation, especially if they are Buddhist, so they don't tend to worry so much about dying.
As I said in a previous post american culture has a fear of letting what is natural happen, death. It's the inevitable that we want to stop it and in doing so we increase suffering. Do your patients a favor and start accepting that death happens and that preventing it isn't always the right thing to do for the patient.
Thank you for saying this. We do this all the time at my facility - not ER, but ICU. We get a lot of chronic non-compliant COPDers and things of that nature. Most of them are end-stage. We have a couple that get admitted twice a month or so because the family calls 911 when they get obtunded, they get on the vent for a few days, get off, go home, get obtunded because they won't wear their CPAPs, get on the vent for a few days...
Most of them say DO NOT PUT THAT MASK ON ME! while they're awake. And most of them make themselves DNIs when they wake up from being on the vent. But - nobody cares. The families still call 911 and get them intubated every time, even though the patients don't want to go through that whole rigamarole any more. I'm sure most of them just want to die at home, but nobody wants to let them go. We want to stick ten million tubes in them instead and tie their arms down so they can't pull the tubes out that they didn't want in the first place. It makes me sick.
We had one who was so weak and debilitated we were shocked when she managed to self-extubate. We hadn't even been bothering to restrain her because she was alert and oriented, but too weak to even pick up the call bell. She immediately made herself DNI, family was called... and we got to hear the husband coming in and screaming at this frail, malnourished, 90 pounds soaking wet with massive, painful decubitus ulcers, 60-something years old female about how "selfish" and what a "horrible person" she was for wanting to be at peace. She ended up rescinding her DNI and got reintubated. I have never wanted to hit someone so badly in my life. It's awful what we do to patients against their will the second they fall unconscious.
I hope security was called for a patient being verbally assaulted by a guest on the premises. I wonder if there's a minimum age for which mandated reporters can make VA reports? Or can it be anyone we deem vulnerable?
And why the hell are the paramedics/ED/units intubating people with documented DNI orders??
You have to remember asian cultures, especially immigrants are very untrusting of American Healthcare for this reason, that they fear we will not honor their wishes and will do things to them without them knowing.
I hope security was called for a patient being verbally assaulted by a guest on the premises. I wonder if there's a minimum age for which mandated reporters can make VA reports? Or can it be anyone we deem vulnerable?
And why the hell are the paramedics/ED/units intubating people with documented DNI orders??
I can see how that would make you sick.
I didn't call security on the husband that time - in hindsight, I wish I had. She had been my patient earlier in the week but wasn't my patient that night, but I should have stood up for her anyway.
I can tell you exactly how we're intubating people with DNI orders. Family calls EMS about unresponsive patient. EMS gets there, notes patient is obtunded and not protecting his/her airway. Family plays dumb about living wills/DNI/whatever, asks EMS to help the patient now because they want Daddy to live, and EMS intubates. Everyone gets to the hospital, RN is doing admission history and asks if patient has any sort of living will/portable DNR/HCPOA forms... and someone finally says "He has some sort of papers, we'll see if we can find them" as vaguely as is humanly possible. The papers finally get there, conveniently on the day we are planning to extubate Daddy anyway - and they are DNR/DNI papers, of course. If EMS can't ask the patient, we're relying on the families to be honest - and some of them just aren't.
Hugs. .hindsight is 20/20. Of course it's easy for me to play Monday morning quarterback too, not being IN that situation.
Gotcha about the family playing dumb about the DNIs. Makes me think medical alert tattoos to the chest are a good idea.
I didn't call security on the husband that time - in hindsight, I wish I had. She had been my patient earlier in the week but wasn't my patient that night, but I should have stood up for her anyway.
I can tell you exactly how we're intubating people with DNI orders. Family calls EMS about unresponsive patient. EMS gets there, notes patient is obtunded and not protecting his/her airway. Family plays dumb about living wills/DNI/whatever, asks EMS to help the patient now because they want Daddy to live, and EMS intubates. Everyone gets to the hospital, RN is doing admission history and asks if patient has any sort of living will/portable DNR/HCPOA forms... and someone finally says "He has some sort of papers, we'll see if we can find them" as vaguely as is humanly possible. The papers finally get there, conveniently on the day we are planning to extubate Daddy anyway - and they are DNR/DNI papers, of course. If EMS can't ask the patient, we're relying on the families to be honest - and some of them just aren't.
I didn't call security on the husband that time - in hindsight, I wish I had. She had been my patient earlier in the week but wasn't my patient that night, but I should have stood up for her anyway.
I can tell you exactly how we're intubating people with DNI orders. Family calls EMS about unresponsive patient. EMS gets there, notes patient is obtunded and not protecting his/her airway. Family plays dumb about living wills/DNI/whatever, asks EMS to help the patient now because they want Daddy to live, and EMS intubates. Everyone gets to the hospital, RN is doing admission history and asks if patient has any sort of living will/portable DNR/HCPOA forms... and someone finally says "He has some sort of papers, we'll see if we can find them" as vaguely as is humanly possible. The papers finally get there, conveniently on the day we are planning to extubate Daddy anyway - and they are DNR/DNI papers, of course. If EMS can't ask the patient, we're relying on the families to be honest - and some of them just aren't.
THIS is so true! So frustrating I want to scream! Im getting a copy of my DNR/DNI tattooed to my chest!
I wonder if there's a minimum age for which mandated reporters can make VA reports? Or can it be anyone we deem vulnerable?
KelRN215, BSN, RN
1 Article; 7,349 Posts
If, at the age of 87, I get diagnosed with any kind of brain bleed, I'll be going home and calling it quits too. I already had brain surgery at 19. No way am I having it at 87. Why are people so opposed to the elderly accepting the inevitable? We are all going to die. 87 is old.
Competent adults of any age (and minor teenagers, in certain situations) have the right to refuse treatment. You CANNOT force a patient onto a transport gurney and transport him without his consent. That is 100% illegal.