I have noticed that I don't share the same view on Physician ordered fluid restrictions as most of the nurses I work with. I agree with educating the patient about why they need to limit their fluid intake as well as addressing issues that might be causing a patient's desire for water such as a dry mouth or chronic cough. I also agree that we shouldn't offer water beyond the fluid restriction when a patient isn't asking for water. I disagree with the idea that a patient who is capable of making their own medical decisions can be denied water even if they have exceeded their fluid restriction when they ask for water.
Some nurses draw the line at getting water for patients, saying that if the patient wants to get their own water then that is out of their control, leaving only ambulatory patients with the ability to obtain water. Other nurses take it even further, putting bed alarms on patients so they can yell at them when they get up to get water.
I agree it is frustrating to be treating a patient for fluid overload when they drink more fluids than they should, and care contracts are often appropriate (if we admit you to the hospital then you have to abide by your fluid restriction or you'll be discharged) but even prisoners of war can't be denied water, this strikes me as potential abuse.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
From a legal standpoint, I think we may be a little off track. It has been asserted that the decision maker is the MD, although the law sees it differently (below is an excerpt from a legal summary)
"During the past three (3) decades there has been a one hundred eighty degree (180º)
shift in the concept of the patient's right to make his own medical treatment decisions.
The current state of the law governing health care providers is that the patient is to be the
primary decision maker in all health care decisions affecting the patient."
Where I work, we sign an agreement to abide by the ANA Code of Ethics. This includes a Patient's right to self determination. The whole code is pretty long so here are some highlights:
"Patients have the moral and legal right to determine what will be done with their own person; to be given accurate, complete, and understandable information in a manner that facilitates an informed judgment; to be assisted with weighing the benefits, burdens, and available options in their treatment,
including the choice of no treatment; to accept, refuse, or terminate treatment without deceit, undue influence, duress, coercion, or penalty
; and to be given necessary support throughout the decision-making and treatment process."
"The nurse strives to provide patients with opportunities to participate in planning care,
assures that patients find the plans acceptable
and supports the implementation of the plan."
Regardless of a patients involvement in developing the plan of care, the patient must still consent to the treatment in the plan prior to us providing it:
"Except for legally authorized involuntary treatment, patients who are legally competent to make medical decisions and who are judged by health care providers to have decision-making capacity have the legal and moral right to refuse any or all treatment.
This is true even if the patient chooses to make a "bad decision" that may result in serious disability or even death.
To document that you have been given the option of obtaining a recommended treatment or test and have chosen not to, you may be asked to sign an Against Medical Advice (AMA) form to protect the health care provider from legal liability for not providing the disputed treatment.
Refusing a test, treatment, or procedure does not necessarily mean that you are refusing all care. The next best treatment should always be offered to anyone who refuses the recommended care.
"
It may take a Physician's order to start a heparin drip, but it only requires a patient's order to D/C it. And as a nurse, it's our responsibility to stop the drip if that is the patient's wish. It's also our responsibility to notify the the MD of the patient's refusal, which the MD can discuss with the patient, but in the end if the patient still refuses, it stays off.
My state's practice act does include enacting a plan of care as something an RN does, but if a patient refuses it, then it is no longer part of the plan of care.
The question of our involvement, enabling, liability, etc is an interesting one. The issue of refusing to enable a smoker by not giving them cigarettes is more straightforward, but in my state, dependent adults must be provided with food and water. In terms of food, this is described as a sufficient amount to meet daily nutritional requirements. Water on the other hand must be made available upon request and in a patient unable to make a request, it must be sufficient to alleviate assumed thirst and prevent dehydration. Some legal interpretations in other states even suggest that bringing water on request is not enough, but that it must be always available and within reach of the patient. In other words, failing to get a dependent, competent, patient water upon request is considered neglect, which would seem to be the overriding legal concern here. An MD order for the purpose of treatment does not override this right because, just like a refused heparin drip, a fluid restriction that is ordered as a treatment is no longer an active part of the plan of care if the patient does not consent to it, which means we can't use it to defend what appears to be neglect.
You are very correct that the debate is interesting. While I understand the reasoning in the ANA code of ethics, unfortunately it's tort law that I worry about more. There may be legal precedent in allowing more patient decision-making, but it doesn't seem to have spilled over into the lawsuit arena.
At my facility when a patient is placed on a fluid restriction, one half of the restriction is provided in their meals. The other half is able to be consumed freely. Typically I keep a running tally on the patient's whiteboard in their room so that they can participate and know where they are in their intake for the day.
I still believe that while the patient can participate in their care that the healthcare providers should direct the overall care. We all have seen patients that become confused or suffer from ICU psychosis or how many receive narcotics/benzos and other meds that affect their decision-making capacity. That is why to me decisions like refusal of some aspects of care should be managed in an outpatient capacity in a more well state. If a patient wants to refuse care it should not be done in a vaccume but should involve all pertient members of the healthcare team along with other members of the family, and if necessary a psych eval to ensure that the patient is competent to make that decision. If the patient still wants to refuse care then goals of treatment should be refocused to ensure that the wishes are respected.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
I agree there is a point at which patient's are no longer competent to make their care decisions, where that point is could be a thread all on it's own. In my experience, it has to be pretty severe for a Physician or LMHP to declare their care involuntary. I've seen a patients still coming off of fentanyl and versed who want to leave 20 minutes after a groin sheath was pulled and with questionable hemostasis at the site. Over and over again the Physicians say we have to let them go, even with the recent drugs they still are considered competent to make their own decisions. In an attempt to get the MD to hold a patient in the hospital, a nurse once asked if they were concerned that this patient might sue, the MD's response was that this was exactly why he couldn't hold them, it's denying a patient their right to autonomy that places him in the most legal jeopardy.
I don't know of any cases either way, but has there even been a case where a nurse has gone to court to defend an action that was based on preferences of a competent patient? I would think that, legally, going against the patient's wishes (if they are competent) would be far more risky. I'm a little skeptical that following the ANA code of ethics is path to jail.
You are very correct that the debate is interesting. While I understand the reasoning in the ANA code of ethics, unfortunately it's tort law that I worry about more. There may be legal precedent in allowing more patient decision-making, but it doesn't seem to have spilled over into the lawsuit arena.
At my facility when a patient is placed on a fluid restriction, one half of the restriction is provided in their meals. The other half is able to be consumed freely. Typically I keep a running tally on the patient's whiteboard in their room so that they can participate and know where they are in their intake for the day.
I still believe that while the patient can participate in their care that the healthcare providers should direct the overall care. We all have seen patients that become confused or suffer from ICU psychosis or how many receive narcotics/benzos and other meds that affect their decision-making capacity. That is why to me decisions like refusal of some aspects of care should be managed in an outpatient capacity in a more well state. If a patient wants to refuse care it should not be done in a vaccume but should involve all pertient members of the healthcare team along with other members of the family, and if necessary a psych eval to ensure that the patient is competent to make that decision. If the patient still wants to refuse care then goals of treatment should be refocused to ensure that the wishes are respected.
That is because, as I have said, when there is a poor outcome, they don't want us/doctors/anyone else using it as a defense. That, and the fact that ANA's policy is swiss cheese at best.
When there is a poor outcome: The responsibility to make the correct decision still lies on your shoulders. It will be deemed that "a reasonable nurse" would have done differently. The responsibility to not do harm to your pt. trumps anything ANA has to say.
Given ten pt's who refuse their fluid restriction and are given the water thus leading to a poor outcome...............I guarantee it that 9 of those cases will be judged to be the nurses fault for having given the water. They will state "This was an exception to the pt. autonomy standards and the nurse should have recognized that. It was not the nurses place to decide if the pt. was able to safely make the decision for themselves or not." Every single one of those cases will be seen as "an exception".
It's wonderful to be pt. focused and to go out of your way to protect their rights and all BUT................no one is going to back you up. You think anyone from ANA or anyone who wrote those standards are going to show up in court when you have a poor outcome?
Now you're grasping for straws. The issue at hand is a pt. not complying with fluid restrictins. Leave it at that. There are millions of unmentioned variables that can be brought into play to make on side right or wrong. But, in the end, the fact still remains.........if you knowingly give someone on fluid restrictions water and there is a poor outcome with said pt.................no one is going to back you up in court. Especially not the pt. rights activists and detached admin. who insisted you do.[/quotT
The fact REALLY is: after your pt. demands water, and you have notified the MD of this fact and the pt.s refusal to adhere to orders; AND you have documented ALL of the above; then the pt's water consumption and it's sequelae rest upon the pt., and NOT on you. Yes, even if you give the pt. 500cc's after he has demanded it, and it sends him into CHF.
Patients are NOT obliged to follow our rules. They have the perfect right to behave like idiots. And yes, between the time that they say "no more" and they hit the exit door, you HAVE to treat them like the adults they are, if you don't, than THAT's when the lawsuits begin.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
Given ten pt's who refuse their fluid restriction and are given the water thus leading to a poor outcome...............I guarantee it that 9 of those cases will be judged to be the nurses fault for having given the water. They will state "This was an exception to the pt. autonomy standards and the nurse should have recognized that. It was not the nurses place to decide if the pt. was able to safely make the decision for themselves or not." Every single one of those cases will be seen as "an exception".
It's wonderful to be pt. focused and to go out of your way to protect their rights and all BUT................no one is going to back you up. You think anyone from ANA or anyone who wrote those standards are going to show up in court when you have a poor outcome?
Exactly, it's not the nurses place to decide that the patient is not competent although you seem to be arguing that we can deem the to be not competent. Unless there is an order otherwise, you have to assume that patients still retain their rights. It's denying a patient their rights that puts you in the most legal jeopardy, not abiding by their wishes, ask any Doctor. The fact that the docs I work with see less legal liability in letting a patient run out the front doors and into the parking lot still coming down off of versed while their femoral artery oozes than they do in declaring the patient incompetent is a good example.
In my state, the ANA code of standards is essentially law, since our Nurse Practice Act says that Nurses will "abide by prevailing ethical standards", it doesn't specifically refer to the ANA, although I can't think of a Nursing Code of Ethics that is more widely referred to than these.
Even if we ignore the ANA (an understandable reflex), established legal precedent is still pretty clear. I realize that it may have appeared that this section was part of the ANA code, but actually this is a summary of a patient's legal rights:
"Except for legally authorized involuntary treatment, patients who are legally competent to make medical decisions and who are judged by health care providers to have decision-making capacity have the
legal
and moral right to refuse any or all treatment. This is true even if the patient chooses to make a "bad decision" that may result in serious disability or even death.
To document that you have been given the option of obtaining a recommended treatment or test and have chosen not to, you may be asked to sign an Against Medical Advice (AMA) form to protect the health care provider from legal liability for not providing the disputed treatment. Refusing a test, treatment, or procedure does not necessarily mean that you are refusing all care. The next best treatment should always be offered to anyone who refuses the recommended care."
Now you're grasping for straws. The issue at hand is a pt. not complying with fluid restrictins. Leave it at that. There are millions of unmentioned variables that can be brought into play to make on side right or wrong. But, in the end, the fact still remains.........if you knowingly give someone on fluid restrictions water and there is a poor outcome with said pt.................no one is going to back you up in court. Especially not the pt. rights activists and detached admin. who insisted you do.[/quotT
The fact REALLY is: after your pt. demands water, and you have notified the MD of this fact and the pt.s refusal to adhere to orders; AND you have documented ALL of the above; then the pt's water consumption and it's sequelae rest upon the pt., and NOT on you. Yes, even if you give the pt. 500cc's after he has demanded it, and it sends him into CHF.
Patients are NOT obliged to follow our rules. They have the perfect right to behave like idiots. And yes, between the time that they say "no more" and they hit the exit door, you HAVE to treat them like the adults they are, if you don't, than THAT's when the lawsuits begin.
The next lawsuit I see for not talking to someone/treating someone like an adult.......will be the first. Now, lawsuits for harm being brought to a pt. via a nursing decision abound.
It's like they teach in school: Think things through to the end, whats the worst that can happen with a decision? Take every decision all the way through to worst case scenario.
1. Give water: Poor outcome possible, pt. dies from poor outcome not impossible. Lost license, fine, maybe jail time.
2. Don't give water: Pt. insists you "treat them like a child" and give a poor survey result. At worst, your manager gives you a scolding for not being "tactful" enough.
IDK. I wonder how many of the people who believe the ANA standards and "protecting pt. rights" will protect them from being thrown under the bus if there is a poor outcome are newer nurses who haven't experienced being thrown under the bus yet.
I know during my first year of nursing, I would have given the water and documented everything and waxed/wained about pt. rights. Fast forward through a little over four years of being on the job and my views are very different. I've had more than a few instances where managers/institutions have tried to throw me under the bus despite me following policy/procedure to the tooth.
No matter what the law/policy/procedure/standard is, it still comes down to you making the decision. If there is a poor outcome, you've done something wrong, period.
As I stated before too, yes, pt's are well within their right to do as they please............after going AMA. A pt. who is at risk for a poor outcome who wants to drink as they please, can do so at home where no one has to worry about being pinned as the bad guy for their decisions. AMA is the way to freedom if you are not interested in your health. Sitting in the hospital driving up costs are not. Ask any case manager about that one.
Exactly, it's not the nurses place to decide that the patient is not competent although you seem to be arguing that we can deem the to be not competent. Unless there is an order otherwise, you have to assume that patients still retain their rights. It's denying a patient their rights that puts you in the most legal jeopardy, not abiding by their wishes, ask any Doctor. The fact that the docs I work with see less legal liability in letting a patient run out into the parking lot still coming down off of versed while their femoral artery oozes than declaring the patient incompetent is a good example.
I wouldn't really need the ANA to back me up since the law does that pretty well. I realize that it may have appeared that this section was part of the ANA code, but actually this is a summary of a patient's legal rights:
"Except for legally authorized involuntary treatment, patients who are legally competent to make medical decisions and who are judged by health care providers to have decision-making capacity have the
legal
and moral right to refuse any or all treatment. This is true even if the patient chooses to make a "bad decision" that may result in serious disability or even death.
To document that you have been given the option of obtaining a recommended treatment or test and have chosen not to, you may be asked to sign an Against Medical Advice (AMA) form to protect the health care provider from legal liability for not providing the disputed treatment. Refusing a test, treatment, or procedure does not necessarily mean that you are refusing all care. The next best treatment should always be offered to anyone who refuses the recommended care."
So how would you handle the heparin drip scenario?
I've been in the heparing gtt. scenario. Both times this is exactly how it went:
1. FIRST document pt. refusing heparin, then turn it off. Mention alternatives that may be available to the pt. to get their reaction to it (might switch the pt. to lovenox etc.....).
2. Call physician AND page Case Management.
3. Talk to physician and Case Management, inform them of pt. refusing critical theraputic measures. If the pt. liked any alternative means of tx, tell them so. In both my cases, the pt. refused all other means of tx.
4. Both times.........the pt. was immediately D/C'd after a lengthy conversation with the doctor on the phone. IDK exactly what was said but from what I was told and what I picked up from the pt as I wrote their D/C paperwork...........it was simply "If you don't want treated by us, its best you not be here. We will be unable to justify your stay in the hospital to your insurances unless you agree to the tx." One, not both, were visited by the on call case manager before leaving.
Specializes in Psych/CD/Medical/Emp Hlth/Staff ED.
The next lawsuit I see for not talking to someone/treating someone like an adult.......will be the first. Now, lawsuits for harm being brought to a pt. via a nursing decision abound.
It's like they teach in school: Think things through to the end, whats the worst that can happen with a decision? Take every decision all the way through to worst case scenario.
1. Give water: Poor outcome possible, pt. dies from poor outcome not impossible. Lost license, fine, maybe jail time.
2. Don't give water: Pt. insists you "treat them like a child" and give a poor survey result. At worst, your manager gives you a scolding for not being "tactful" enough.
IDK. I wonder how many of the people who believe the ANA standards and "protecting pt. rights" will protect them from being thrown under the bus if there is a poor outcome are newer nurses who haven't experienced being thrown under the bus yet.
I know during my first year of nursing, I would have given the water and documented everything and waxed/wained about pt. rights. Fast forward through a little over four years of being on the job and my views are very different. I've had more than a few instances where managers/institutions have tried to throw me under the bus despite me following policy/procedure to the tooth.
No matter what the law/policy/procedure/standard is, it still comes down to you making the decision. If there is a poor outcome, you've done something wrong, period.
As I stated before too, yes, pt's are well within their right to do as they please............after going AMA. A pt. who is at risk for a poor outcome who wants to drink as they please, can do so at home where no one has to worry about being pinned as the bad guy for their decisions. AMA is the way to freedom if you are not interested in your health. Sitting in the hospital driving up costs are not. Ask any case manager about that one.
According to the law in my state, not giving water to a competent patient who requests it is a crime, which is far worse than a bad survey result. Free access to water for a competent patient is the patient's right, no one will argue that the patient may not be making the best choice, but you can't be held responsible for the choices a patient makes of their own free will in any court of law, if there are any examples where this has happened I would be interested to see it. Otherwise I don't see how violating one set of laws that seem pretty clear to potentially avoid another law that doesn't even seem to exist is a smart legal decision. AMA forms are not just for discharges, you are free to have the patient sign them for any treatment they are refusing while still in the hospital, further protecting you from liability.
In my state the ANA code of ethics is essentially the law, our Nurse Practice Act states that we must "abide by prevailing ethical standards", of which the ANA code of ethics would seem to be a obvious source.
According to the law in my state, not giving water to a competent patient who requests it is a crime, which is far worse than a bad survey result. Free access to water for a competent patient is the patient's right, no one will argue that the patient may not be making the best choice, but you can't be held responsible for the choices a patient makes of their own free will in any court of law, if there are any examples where this has happened I would be interested to see it. Otherwise I don't see how violating one set of laws that seem pretty clear to potentially avoid another law that doesn't even seem to exist is a smart legal decision. AMA forms are not just for discharges, you are free to have the patient sign them for any treatment they are refusing while still in the hospital, further protecting you from liability.
In my state the ANA code of ethics is essentially the law, our Nurse Practice Act states that we must "abide by prevailing ethical standards", of which the ANA code of ethics would seem to be a obvious source.
Again, the first lawsuit I see pertaining to refusing to participate in poor health decisions will be the first. It can't be prosecuted. There are loop holes galore in which a nurse can claim that supplying the water presented a threat to safety. NO COURT is going to prosecute a nurse for refusing to participate in a "dangerous" decision. That'd open the flood gates to all sorts of things the court can't be bother with ruling on......................do we have to supply a smoke room then too, are we responsible to supply Pepsi for the diabetic already in the ICU for DKA.
The idea of a pt's rights being trampled on when no one will fetch water is "paper nursing". It sounds great in the classroom, but has no real practical application.
If the priority is purely what's best for the patient, then wouldn't we want to still maintain portion control and the ability to track accurate I&O's?
I think as a general rule, finding your patient drinking out of the toilet is a sign that you may need to re-evaluate your plan of care.
HamsterRN, ADN, RN
255 Posts
From a legal standpoint, I think we may be a little off track. It has been asserted that the decision maker is the MD, although the law sees it differently (below is an excerpt from a legal summary)
Where I work, we sign an agreement to abide by the ANA Code of Ethics. This includes a Patient's right to self determination. The whole code is pretty long so here are some highlights:
Regardless of a patients involvement in developing the plan of care, the patient must still consent to the treatment in the plan prior to us providing it:
It may take a Physician's order to start a heparin drip, but it only requires a patient's order to D/C it. And as a nurse, it's our responsibility to stop the drip if that is the patient's wish. It's also our responsibility to notify the the MD of the patient's refusal, which the MD can discuss with the patient, but in the end if the patient still refuses, it stays off.
My state's practice act does include enacting a plan of care as something an RN does, but if a patient refuses it, then it is no longer part of the plan of care.
The question of our involvement, enabling, liability, etc is an interesting one. The issue of refusing to enable a smoker by not giving them cigarettes is more straightforward, but in my state, dependent adults must be provided with food and water. In terms of food, this is described as a sufficient amount to meet daily nutritional requirements. Water on the other hand must be made available upon request and in a patient unable to make a request, it must be sufficient to alleviate assumed thirst and prevent dehydration. Some legal interpretations in other states even suggest that bringing water on request is not enough, but that it must be always available and within reach of the patient. In other words, failing to get a dependent, competent, patient water upon request is considered neglect, which would seem to be the overriding legal concern here. An MD order for the purpose of treatment does not override this right because, just like a refused heparin drip, a fluid restriction that is ordered as a treatment is no longer an active part of the plan of care if the patient does not consent to it, which means we can't use it to defend what appears to be neglect.
http://www.akerman.com/documents/Website%20-%20Larcombe%20Article3.pdf
http://nursingworld.org/ethics/code/protected_nwcoe629.htm
http://www.emedicinehealth.com/informed_consent/page7_em.htm