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.
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.
OP, please do the following on your next shift at work:
Go to whatever educational/policy resources your department has. Online, in a binder ... whatever.
Read your policies and procedures re: transfer.
Go find your charge nurse and/or educator and tell him/her that you need to be educated re: EMTALA, because you have a significant knowledge deficit in that area and are a walking potential risk management nightmare.
An insured patient declining transfer to a contracted facility does not convert to self pay. You lied.
It's not that uncommon for my hospital to admit people from the ED and then have SW told the next day by the insurance company that our hospital is not covered by them, the individual needs to be transferred immediately to Hospital X, and the insurance co. is not going to pay for the person to be treated at our hospital. That does happen. (At my hospital, the individual is in an ambulance so fast, it makes your head spin.)
Specializes in Complex pedi to LTC/SA & now a manager.
It's not that uncommon for my hospital to admit people from the ED and then have SW told the next day by the insurance company that our hospital is not covered by them, the individual needs to be transferred immediately to Hospital X, and the insurance co. is not going to pay for the person to be treated at our hospital. That does happen. (At my hospital, the individual is in an ambulance so fast, it makes your head spin.)
Referring to if hospital is in network. If out of network and emergent insurance must pay per emtala.
It's not that uncommon for my hospital to admit people from the ED and then have SW told the next day by the insurance company that our hospital is not covered by them, the individual needs to be transferred immediately to Hospital X, and the insurance co. is not going to pay for the person to be treated at our hospital. That does happen. (At my hospital, the individual is in an ambulance so fast, it makes your head spin.)
In that case, the patient still wouldn't have to foot the bill though. And if there are out-of-network benefits to the plan, it may in fact pay. The OP has no way of knowing that the details of the patient's plan and has no business telling the family that they would need to front $5000 because the patient didn't want to be transferred.
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.[/quote
I'm not defending the above. But just for the record, what could be done with the above pt?
There are 8 hrs until this pt is willing to leave.
Your ER is busy, and he's taking up a bed for all that time.
Can you admit him to the floor for 8 hrs? Is it ethical to admit him to the floor just to wait for his wife and son?
What if all the ER patients said they wouldn't leave until .......?
She could try not manipulating or lying to the patient.
No argument about that from me. I'm not ER, and I'd really like to know what would be done with a patient who didn't want to follow the plan of care, but didn't want to leave either.
BuckyBadgerRN, ASN, RN
3,520 Posts
You scare me, OP. A lot. A lot a lot.