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.
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.
Well that's hurtful.
No it's not a lie, $5000.00 is the deposit at our hospital for pt's paying out of pocket.
Knew a nurse who actually did that. Had "DNR" tattooed over his heart and had a personalized tag on his motorcycle that said "IM DNR".
I thought of doing that for years -- until it came up in conversation with a hospital attorney who told me that there is no way that would be taken seriously or keep me from getting coded.
First, you tell us that the patient has insurance:
Either he is transferred to another facility and insurance takes care of th paying a $5000.00 deposit, I don't know how much more you have to pay after that."
Then, he doesn't:
No it's not a lie, $5000.00 is the deposit at our hospital for pt's paying out of pocket.
Which is it? To me, this reads as if you coerced the patient into transferring.
To me, this story†is more concerning than your willingness to physically force a patient to transfer.
Everything that you've posted and justified makes your entire nursing practice sound like an ethical lapse. I'm really starting to hope you're making this all up.
But I'll respond in case it's true, and pray you actually listen. (You wanted to have a discussion, no?)
Since you've resorted to financially manipulating a family member into a decision, did you at least tell them the cost of an ambulance transfer??
And you are setting yourself up for some hot water by not using certified medical interpreters. This is considered an equal healthcare access issue! It's not enough that someone is conversationally fluent. The hospital policy everywhere I've worked says that for clinical staff to be used to interpret, they must pass the certification exam for interpretation of their language. If no interpeter is available in house, we must utilize the telephone or video conferencing system to access an appropriate translator.
Under no circumstances is it okay to ask a family member to translate.
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.
You can't lie to a patient to coerce him into being transferred to another facility. By your own story, the patient has insurance. He is not a self-pay patient. You seem to have serious ethical issues with your nursing practice. I hope the patient's son calls a supervisor at the hospital and mentions this conversation. Or, better yet, someone at the state DPH.
And I don't see anything worthy of "laughing out loud" in this post.
First, you tell us that the patient has insurance:
Then, he doesn't:
Which is it? To me, this reads as if you coerced the patient into transferring.
To me, this story†is more concerning than your willingness to physically force a patient to transfer.
I did case management for a while. Insurance doesn't mean any hospital is included, for emrgency care yes, but once you are an admit things change. And insurance doesn't always cover everything. This small hospital likely is only contacted with a few providers and everyone else need to be transferred for care as they probably provide very limited services. I've had patients I was trying to transfer to contract facilities who refused to go and I'd have to explain to them their refusal resulted in the insurance company not covering it because they were staying at facilities not in the contract. So this could be very accurate.
Ambulance transfers are covered by the insurance typically if it's an emergency resulting in a hospital stay as it's cheaper to get them to an in contract hospital, unless it's observation or a short visit or the rare occasion where all the contracted hospitals are full.
insurance is a hot mess. The OP is likely trying to get people to places where the services are provided. However, anyone can refuse regardless if they're competent.
Specializes in Complex pedi to LTC/SA & now a manager.
Quite honestly it appears the OP has had some significant ethical breeches and crossing professional barriers. If you think it's funny to financially coerce a patient into transfer when consent was otherwise not given? Do you also erroneously believe that insurance won't pay if a patient signs out AMA? An insured patient declining transfer to a contracted facility does not convert to self pay. You lied.
Quite honestly it appears the OP has had some significant ethical breeches and crossing professional barriers. If you think it's funny to financially coerce a patient into transfer when consent was otherwise not given? Do you also erroneously believe that insurance won't pay if a patient signs out AMA? An insured patient declining transfer to a contracted facility does not convert to self pay. You lied.
This can be true though, I worked for an insurance company and if we had a patient who refused to transfer to a contracted facility and wished to remain inpatient at a out of network hospital despite our providing transport and arranging the transfer hospital stay fell on them. It's one of the many reasons I quit.
It doesn't hold any legal weight (no legal signature ) but it might prompt EMS to ask a few more pointed questions. But without the paperwork they're a full code. And as someone else says that paperwork tends to be very elusive the minute mama gets short of breath.
I don't think people purposfully lie about the AMA insurance issue. 20 YRS ago insurance would refuse to pay if you went AMA. Many nurses, case mangers and doctors don't know things have changed. I just heard someone the other day start to tell a patient this & when I said that's not the case anymore the nurse was surprised.
I empathize with the position you feel you were placed in with this patient's refusal for treatment of a potentially life-threatening problem. The right to refuse treatment is however, the patient's right as part of INFORMED consent for treatment. However, one may look at it; they do have the right to even choose death. The American Medical Association informs, "Patients have a right to participate in decisions about their medical care. This fundamental principle of medical ethics holds true for all types of medical treatments. Patients can refuse treatments even when such refusal is likely to result in death" (AMA, n.d.)
This situation is very disturbing but there is nothing anyone could have done. Well, perhaps pray that all works out...
:banghead:
:facepalm:
Kbig2
6 Posts
Well that's hurtful.
No it's not a lie, $5000.00 is the deposit at our hospital for pt's paying out of pocket.
It's a small community hospital.