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.
You do realize that 87 is a perfectly acceptable age to die right?
People aren't supposed to live forever.
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.)
Gotta keep grandma alive so those social security checks don't stop. In my area we also get a lot of IHSS "caregivers" who have never worked a day in their lives, and get paid to mooch off grandma in addition to their own welfare cheques. They never, ever allow natural death, even when grandma (or worse-their own kids)is in a permanent vegetative state.
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.
The way I interpreted the OPs post was that the pt didn't want to leave/sign out AMA
He wanted to stay where he was for another 8 hours awaiting his family. He was happy to continue in the OPs ER taking up space and going nowhere.
There were two different stories. One patient with a brain bleed who wanted to go home/refused to be transferred and OP wanted to know if they could have forced him onto a stretcher and transferred him against his will.
The second was the patient with the fractured hip who didn't want to be transferred and she lied to his family to coerce them into agreeing to the transfer.
Gotta keep grandma alive so those social security checks don't stop. In my area we also get a lot of IHSS "caregivers" who have never worked a day in their lives, and get paid to mooch off grandma in addition to their own welfare cheques. They never, ever allow natural death, even when grandma (or worse-their own kids)is in a permanent vegetative state.
I like to tell myself there's a special place in hell.
Back in my CNA days, I had this LTC resident: blind, deaf, nonverbal, tubefed, contracted in every limb, and 75 lbs. Her nephew who was her POA insisted on full care. You know how many times he visited in the 3.5 years I worked there? Zero. He couldn't even be bothered to come and see this poor woman.
I'm wondering if the ED doc/radiologist etc decided this was a bleed that caused the fall, rather than a fall that caused a bleed. Either way, we can't hold people against their will, and to be honest I have learned that there are far worse things than death.
I like to tell myself there's a special place in hell.
Back in my CNA days, I had this LTC resident: blind, deaf, nonverbal, tubefed, contracted in every limb, and 75 lbs. Her nephew who was her POA insisted on full care. You know how many times he visited in the 3.5 years I worked there? Zero. He couldn't even be bothered to come and see this poor woman.
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
Were you able to convey MIL's wishes to her docs? I guess she didn't have a living well or health care proxy?L
ife must have been pretty rough in your household for a while with you in MIL's camp and knowing what all she'd have to, and did, endure and you husband wanting everything done, including surgery. I'm sorry you folks had to go through this. I pray for you all to be at peace now.
The only ethical dilemma here is you forcing a pt onto a litter for transfer- you do know that you laying hands on a pt forcing them to do something, while aaox4, is assault. ?
Actually, laying hands on an A&Ox4 pt against his/her will is battery. Simply making a threat to do so is assault.
I so agree with what you said and I'm the same way about my No: respect it. I also wondered about the "wait until they're unconscious" part...how is that even ok? How is that any different than forcing them when they're awake? How is it any different than, say, guy wants to have his way with girl, girl says no, guy gets girl drunk and passed out, guy has his way because girl is not coherent enough to say the no she's already said...No always means no.
I had a patient not long ago sign out AMA after he was diagnosed with a new esophageal mass causing tracheal deviation. You could see it protruding out of his neck and could hear the stridor. Pt refused to believe it was possibly cancer because he was only SOB and had throat pain for a few days. MD wanted to admit him for further evaluation and he refused. I still wonder about him...
Specializes in Psych, Addictions, SOL (Student of Life).
Were you able to convey MIL's wishes to her docs? I guess she didn't have a living well or health care proxy?L
ife must have been pretty rough in your household for a while with you in MIL's camp and knowing what all she'd have to, and did, endure and you husband wanting everything done, including surgery. I'm sorry you folks had to go through this. I pray for you all to be at peace now.
I was just a nursing student when this happened and I tried several times to get MIL to create an advance directive prior to her losing capacity. Not to go against DH but simply to honor her wishes.
As a family we recovered and all was eventually forgiven and we have moved on but you can bet I have a health care directive with a person I trust completely to honor my wishes when and if I become unable to make my own decisions.
MunoRN, RN
8,058 Posts
Are you talking about the hip or the brain bleed?