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.
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.
*May not be* is the key, here. The OP also states that he doesn't know much about the patient or situation. I'm not against refusing treatment, but I would have to explore this patient's issues a bit more to sleep well at night. I can't trust that all is well with the information that's been given.
Finally Asians also hold the belief in reincarnation, especially if they are Buddhist, so they don't tend to worry so much about dying.
Just to clarify, Korea's predominant "religion" is none. Nearly 30% of Korea is Christian -- between Catholic and Protestant. (At least in the South...in the North, they tend to disappear.) Buddhism which I want to say is between 20-25% doesn't teach reincarnation either, to my knowledge. It's possible that some East/Southeast Asian tribal religions teach it, but by and large it's not a widely held teaching.
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.
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.)
I am hoping that you did 2 things. That you had a hospital translator (and not a member of the family paraphrasing) and that you did discuss potential follow ups. (even VNA)
If this was a head lac, then falling is a risk that home health could go into the house and perhaps make the patient safer.
In any event, you can't force someone to do a thing. What you can be sure of is that you have a translator who has no skin in the game who will translate word for word what you are saying. As opposed to the daughter/son whomever who is putting their own emotional spin on whatever you are talking about.
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.
who the heck, and you know that is not the four letter word i wanted to put there, accepted the daughter's signature????? if had been a sib, i might have attempted to sue the little... hm whatever.
I'm sorry for leaving out information. It was not my patient. It's just what I was able to catch on while it was happening.
I don't have his vitals, so I can't comment on that. He was fully awake and alert oriented. He had a fall and laceration in back of his head, I can verify this because I walked past his bed and there was blood on his pillow. I did not see the CT, but I know he had a brain bleed with midline shift, I think subdural, but I'm not sure. We did get a hospital translator, a Korean speaking nurse from ICU. Pt had no immediate family, just his girlfriend. I think some part of the pt refusing treatment had to do with his culture, as some of you have pointed out. He was full code and he lives at home.
It was just tough and slightly shocking to see, the pt had absolutely refused treatment.
Somewhat ironic, I had a pt my past shift (graveyard) who also refused transfer to contracted facility.
This time, he's a 92 year old hispanic male, spanish speaking only, with a right hip fracture. He seems to be fully alert oriented, knows his name, date and place he's at. He even refused morphine, so all he got was just a 1L of NS.
When it came time to transfer him to the facility, he refused, telling us that he's going to wait for his wife and son to meet him at the current hospital at 0800 (Time now is 0030). We had a translator tell him that he's hip is broken and he needs care at another facility because our hospital is not equipped to hand hip fx. He says "ok, I'll go but later on because I have a lot of things to do..Can My son get a job here?" We're going back and forth trying to explain to this "competent" man that he can't stay at this hospital and needs to be transferred.
So I finally give up talking to him and just call his son. His son speaks limited English, but enough to communicate. We speak on the phone and I instruct him to tell his father he needs to be transferred. Give phone to pt, son speaks to pt, pt says ok, I speak to son on phone, son says ok I told him. I say Ok, lets go transfer, pt refuse because he has to wait till the morning to go because he has a lot of things to do.
I'm about to LOOOSE IT. I finally tell them where it hurts...$$$.
"Hey [pt son], your father needs to be transferred, if he doesn't, then you guys have to put down $5000.00 deposit for him to stay here. You need to come here right now and tell him this because he doesn't understand. Either he is transferred to another facility and insurance takes care of the bill, or you're paying a $5000.00 deposit, I don't know how much more you have to pay after that."
Pt son says, ok, i'm on my way, give me 15 minutes.
Pt son comes, explains to father (probably about that $5000.00 deposit), they all agree within 1 minute, and pt agrees to finally 100% agrees to transfer and ambulance picks transfers him out. I kid you not.
I'm sorry for leaving out information. It was not my patient. It's just what I was able to catch on while it was happening.
I don't have his vitals, so I can't comment on that. He was fully awake and alert oriented. He had a fall and laceration in back of his head, I can verify this because I walked past his bed and there was blood on his pillow. I did not see the CT, but I know he had a brain bleed with midline shift, I think subdural, but I'm not sure. We did get a hospital translator, a Korean speaking nurse from ICU. Pt had no immediate family, just his girlfriend. I think some part of the pt refusing treatment had to do with his culture, as some of you have pointed out. He was full code and he lives at home.
It was just tough and slightly shocking to see, the pt had absolutely refused treatment.
Somewhat ironic, I had a pt my past shift (graveyard) who also refused transfer to contracted facility.
This time, he's a 92 year old hispanic male, spanish speaking only, with a right hip fracture. He seems to be fully alert oriented, knows his name, date and place he's at. He even refused morphine, so all he got was just a 1L of NS.
When it came time to transfer him to the facility, he refused, telling us that he's going to wait for his wife and son to meet him at the current hospital at 0800 (Time now is 0030). We had a translator tell him that he's hip is broken and he needs care at another facility because our hospital is not equipped to hand hip fx. He says "ok, I'll go but later on because I have a lot of things to do..Can My son get a job here?" We're going back and forth trying to explain to this "competent" man that he can't stay at this hospital and needs to be transferred.
So I finally give up talking to him and just call his son. His son speaks limited English, but enough to communicate. We speak on the phone and I instruct him to tell his father he needs to be transferred. Give phone to pt, son speaks to pt, pt says ok, I speak to son on phone, son says ok I told him. I say Ok, lets go transfer, pt refuse because he has to wait till the morning to go because he has a lot of things to do.
I'm about to LOOOSE IT. I finally tell them where it hurts...$$$.
"Hey [pt son], your father needs to be transferred, if he doesn't, then you guys have to put down $5000.00 deposit for him to stay here. You need to come here right now and tell him this because he doesn't understand. Either he is transferred to another facility and insurance takes care of the bill, or you're paying a $5000.00 deposit, I don't know how much more you have to pay after that."
Pt son says, ok, i'm on my way, give me 15 minutes.
Pt son comes, explains to father (probably about that $5000.00 deposit), they all agree within 1 minute, and pt agrees to finally 100% agrees to transfer and ambulance picks transfers him out. I kid you not.
They were out of there in a flash.
Money talks...lol
Sorry long post.
So morale of the story- you need to know the whole story before going in a room and trying to strong arm a pt into doing something.
As for your second story, again, so much wrong. I think you need to brush up on some ethics and your hospitals policies before you find yourself in hot water. I personally would not want to be a pt in your ED for fear of the treatment I would receive and the lies that seem to circulate, along with a serious lapse in judgement.
"Hey [pt son], your father needs to be transferred, if he doesn't, then you guys have to put down $5000.00 deposit for him to stay here. You need to come here right now and tell him this because he doesn't understand. Either he is transferred to another facility and insurance takes care of the bill, or you're paying a $5000.00 deposit, I don't know how much more you have to pay after that."
Pt son says, ok, i'm on my way, give me 15 minutes.
Pt son comes, explains to father (probably about that $5000.00 deposit), they all agree within 1 minute, and pt agrees to finally 100% agrees to transfer and ambulance picks transfers him out. I kid you not.
They were out of there in a flash.
Money talks...lol
Sorry long post.
You can't make up lies to convince people to do things. And I'm assuming it's a lie b/c I've never heard of such a deposit.
In your first scenario:
I hope the nurse was certified as a medical translator. Just b/c she speaks Korean, it doesn't mean she necessarily knows medical terms in Korean. We have many Spanish speaking nurses on our floor who's native language is English but they also speak fluent Spanish from living in a bilingual household. They struggle to translate medical terms b/c their nursing education was in English and they didn't learn medical terms in the Spanish they learned at home.
Pangea Reunited, ASN, RN
1,547 Posts
*May not be* is the key, here. The OP also states that he doesn't know much about the patient or situation. I'm not against refusing treatment, but I would have to explore this patient's issues a bit more to sleep well at night. I can't trust that all is well with the information that's been given.