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 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.
How were you going to "force" the transfer if he was fully oriented? Manhandle him so he can file an abuse charge on you later?
I think your unit needs an inservice on the patient's right to refuse. If he passes out, that's one thing. But we have patients that come into the ER all the time with chest pain, abnormal ECG's, and elevated troponins and refuse admission.
We have them sign an AMA form and let them go. No, we are not liable. That's why they sign the AMA. Some refuse to sign it and you have everyone who has seen the patient document their refusal to sign the AMA form.
You start trying to "force" a transfer on someone that doesn't want to go, you'll not only find yourself arrested, but out of a job and without a license. You have no legal right to do that to any consenting adult.
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.
If they are oriented they get the right to refuse ANY and all care that is suggested. You have no right to override that. Most states have regulations that if the patient passes out, that is "implied consent" even if they refused 2 seconds before going down.
No, if they are oriented we don't force them when they are awake. That is what you call assault and can get you in serious trouble on multiple levels.
Please do not try to say that raping a student who is too drunk to give consent is the same as an oriented adult that is not impaired under a substance
Specializes in Complex pedi to LTC/SA & now a manager.
If they are oriented they get the right to refuse ANY and all care that is suggested. You have no right to override that. Most states have regulations that if the patient passes out, that is "implied consent" even if they refused 2 seconds before going down.
No, if they are oriented we don't force them when they are awake. That is what you call assault and can get you in serious trouble on multiple levels.
Please do not try to say that raping a student who is too drunk to give consent is the same as an oriented adult that is not impaired under a substance
Actually it's battery. Assault is the threat. Battery is making contact.
If they are oriented they get the right to refuse ANY and all care that is suggested. You have no right to override that.
I'm not disagreeing with your larger point at all, but, whenever I see this kind of statement here, I always feel the need to point out that it's not quite that simple and straightforward; individuals' wishes can be overridden or disregarded by healthcare professionals if they lack the mental capacity to make informed decisions at the time, and there is more to capacity than simply being oriented.
I'm not disagreeing with your larger point at all, but, whenever I see this kind of statement here, I always feel the need to point out that it's not quite that simple and straightforward; individuals' wishes can be overridden or disregarded by healthcare professionals if they lack the mental capacity to make informed decisions at the time, and there is more to capacity than simply being oriented.
My response was to the OP's description of events and there was no mention of the patient's mental capacity being called into question.
I deal with many patients who are from facilities every day and a physician has to be very careful who they force treatment on. Just because someone has a mental or cognitive disability doesn't void their right to choices. It depends on how far advanced their state is and unless it's a life or death emergency, if you force treatment when that person has a POA and fail to run it by them first? You'll find yourself in a liability situation very quickly.
I deal with many patients who are from facilities every day and a physician has to be very careful who they force treatment on ...
And I work on the psychiatric consultation-liaison team for a major academic medical center, and I'm one of the people who gets called to do the evaluations to determine whether someone has capacity to make a medical decision when the physicians are questioning whether or not they can appropriately and ethically "force treatment" on someone.
It doesn't really matter whether the OP's scenario included any mention of the individual's capacity being called into question. You quoted another individual entirely and responded to that person by making a clear, unqualified statement that "If they are oriented they get the right to refuse ANY and all care that is suggested. You have no right to override that."
I'm not suggesting that the presence of a psychiatric or cognitive concern means that someone, by definition, lacks capacity. All I am saying is that there is more to whether or not someone has the capacity, and, therefore, right, to make decisions about her/his healthcare and have those decision respected than just being "oriented." Lots of people who lack the mental capacity to make informed decisions about their treatment are oriented to person, place, time, and situation. If it were just a matter of whether the person is oriented or not, there would never be any question or concern about whether or not someone lacked capacity -- it would be a simple, yes/no question (are they oriented or not?) Sometimes it's that simple, but often it is much more complicated than that.
I totally agree with you. Seems like all the staff need education on patient rights especially concerning this issue. Sad this is common practice & a surprise no one has sued yet for patient rights violations.
If they are oriented they get the right to refuse ANY and all care that is suggested. You have no right to override that. Most states have regulations that if the patient passes out, that is "implied consent" even if they refused 2 seconds before going down.
No, if they are oriented we don't force them when they are awake. That is what you call assault and can get you in serious trouble on multiple levels.
Please do not try to say that raping a student who is too drunk to give consent is the same as an oriented adult that is not impaired under a substance
There is no law or regulation in any state that allows us to ignore the patient's established wishes just because they are asleep or unconscious, where are you getting that from?
And being competent to make medical decisions is not defined by whether or not they are oriented. Someone can be oriented but not competent to make medical decisions and someone can think it's 1952 and still meet the required criteria to make their own medical decisions.
I think you are wise to be cautious. And honestly, reading some of the other posts I'm disappointed in the level of snarkiness being expressed.
You not only wanted to protect yourself but your license. People may appear to be A&O x 3 but may not have a true understanding of consequence. Having been in a couple of situations like that, the team asked for an emergent pscyh eval to complete an extremely thorough assessment. One case the pt was found to be truly competent to make such a decision and we documented the heck out of everything and called him a cab. In another situation the pt was not competent and was compelled to stay.
Bottom line, sounds like you did the best you could. I'd recommend speaking to your manager to review your policy for such situations
There is no law or regulation in any state that allows us to ignore the patient's established wishes just because they are asleep or unconscious, where are you getting that from?
And being competent to make medical decisions is not defined by whether or not they are oriented. Someone can be oriented but not competent to make medical decisions and someone can think it's 1952 and still meet the required criteria to make their own medical decisions.
There is generally, and specifically stated in the laws of a few states, the doctrine of "implied consent," which means, basically, that if someone presents unconscious or otherwise unable to give or withhold consent for treatment, providers may assume (until informed otherwise) that the individual would want necessary emergency treatment provided. That is the principle under which people found down and brought to an ED are treated, or children are treated in an emergency situation even if their parents/guardians can't be reached for consent. It happens every day (when unconscious trauma victims are brought into an ED, providers don't stand around and wait for them to come to in order to find out whether they want treatment or not), but I've never heard of that being interpreted to mean that, if someone has made her/his wishes previously known, healthcare providers can override those wishes as soon as they pass out (or fall asleep! ). Heavens, if that were the case, we could all creep around hospitals at night and do whatever we wanted to to people.
There is generally, and specifically stated in the laws of a few states, the doctrine of "implied consent," which means, basically, that if someone presents unconscious or otherwise unable to give or withhold consent for treatment, providers may assume (until informed otherwise) that the individual would want necessary emergency treatment provided. That is the principle under which people found down and brought to an ED are treated, or children are treated in an emergency situation even if their parents/guardians can't be reached for consent. It happens every day (when unconscious trauma victims are brought into an ED, providers don't stand around and wait for them to come to in order to find out whether they want treatment or not), but I've never heard of that being interpreted to mean that, if someone has made her/his wishes previously known, healthcare providers can override those wishes as soon as they pass out (or fall asleep! ). Heavens, if that were the case, we could all creep around hospitals at night and do whatever we wanted to to people.
At least where I've worked, "implied consent" is differentiated from "medical necessity", but yeah, either way you don't get to have your way with a patient just because they aren't able to physically or verbally defend themself. "Implied consent" refers to a patient that called 911 and then is found down by responders, or a patient who collapses in the ED doorway; there was at least a suggestion that they were seeking care. A patient found down at home who didn't call 911 or otherwise seek care is treated under medical necessity, which is where we assume they want full care until we have evidence otherwise even though they took no actions that implied consent.
). Heavens, if that were the case, we could all creep around hospitals at night and do whatever we wanted to to people.
Jory, MSN, APRN, CNM
1,486 Posts
How were you going to "force" the transfer if he was fully oriented? Manhandle him so he can file an abuse charge on you later?
I think your unit needs an inservice on the patient's right to refuse. If he passes out, that's one thing. But we have patients that come into the ER all the time with chest pain, abnormal ECG's, and elevated troponins and refuse admission.
We have them sign an AMA form and let them go. No, we are not liable. That's why they sign the AMA. Some refuse to sign it and you have everyone who has seen the patient document their refusal to sign the AMA form.
You start trying to "force" a transfer on someone that doesn't want to go, you'll not only find yourself arrested, but out of a job and without a license. You have no legal right to do that to any consenting adult.