Beating my head against the wall

[Nurse Ratched]

Ughh.

Today MD writes an order ok'ing for a pt to smoke (we have facilities available.) Pt is on respiratory isolation. Infx control people say it's ok as long as we take appropriate precautions and keep other pt's out while she is there and clean the area afterward. Because of patient's physical condition (long story) it will take several staff members to ready her to smoke plus having to have one sit with her (in full isolation garb) plus cleaning out designated area afterward. I figured it would be a good 45 minutes invested in helping a patient smoke who is already extremely time consuming with her other medical needs.

I refused to assist pt in this. MD left for day. Passed it on to next shift who can do on their shift as they see fit.

Any thoughts?

[KlareRN]

Aot of mixed feelings here...so I have to give mine:

(I will take alot of flack for this)- It IS this womans right to smoke it she chooses. I have been involved in cases with ombudsmen and the state board of health over pt. rights. I had a 39 y.o. quad that hung posters on his door that the facility was mentally and physically abusive and violated his rights because he was a quad. (The situation was that we would offer his shower- he would refuse-but then want it in the middle of supper service. It took 2 people to do him. He would also insist that while up in his wc; he would have a 1 inch pleat on the outside of his pantleg all the way down to his feet (had to measure it the length of his leg). It took over an hour to get him up for the day because of all his quirks. We gave notice of discharge and went to a hearing to evict him due to his unreasonable requests. Know what we were told from 4 different area ombudmen and the state?

He has the "right" to have his shower whenever he wants just like you and I do. If we want to get up in the middle of our meal and shower- we do it. Just because he is unable to do it alone does not mean he loses that right. Also- we can dress how we want. So- he has the same rights. The posters on his door was his freedom of speech and even though all visitors could read them and think they are valid- we could not remove them because it was his "freedom of speech".

Our argument was that we did not have staff to provide that much time to just him and others were suffering from his unrealistic demands. Their question: "So are you saying you are neglecting some of your pts?" What a LOADED question. They told us we could not discharge him unless he had somewhere to go and we had to provide enough staff to ensure his "needs" were met. (I disagree that a 1" creased seam is a "need"). This all took place in a long term care facility but the hospital setting has the same pt rights.

So- it boils down to this woman has a "right" to harm herself just as you and I do. If she wants to smoke-unfortunately we are obligated to provide her with the tools and supervision/assistance she requires to do so. I have had Docs write orders for alcohol too.

Even though we do not agree with it- as nurses we are obligated to provide care for all pts. regardless of individual circumstances. We cannot judge what is right or wrong just as we must provide the same level of care for the child molesters, thieves, and whatever other low life comes thru the door.

Good luck with this woman. Hopefully she will return home soon and you can spend your time caring for someone that is more reasonable.

KlareRN

[hapeewendy]

unfortunately when you are in a hospital you do not get all the comforts of home

like your own bed, your favourite food, your own shower and yes sometimes you lose the ability to do the things you want like smoking or drinking

or watching Media or whatever it is you do on your own time.......

you are in the hospital for a reason, to get better, to get to the point where you can go back home or wherever it is you came from to resume your normal activities.

I dont think that this is the same as cutting someones calories or food intake at all, dieticians in hospitals play with food intake all the time to try to get the person in better condition and promote healing etc, doesnt mean that when the person goes home they dont burger and fry it back up again..... its just that when you are in the hospital they have many people who are trying to improve their health status

they have the right to refuse of course but we still have to try?

or should we just give up and let everyone smoke, drink, eat whatever they want and stay in the hospital forever cuz they will never get "better"

?

food, medical care, water ,shelter and the likes are all NEEDS , smoking isnt , if you want to break it down to something that simple , which I dont even feel we have to there you have it.......

I'm not mean little nasty nurse here or anything, I've had many patients who smoke, eat junk food etc, I have a huge problem with someone who is so sick and on isolation no less getting to go somewhere to smoke, outbreak of some kind happens because lets face it, people still dont know everything about infectious disease and routes of transmission, then most likely it was nursings fault because they didnt take proper precaution

damned if you dont damned if you do...

[donmurray]

Wendy, my point was the "health fascism" involved in the limiting of patient choices by imposing those limits, and not by negotiating them. It's probably a tired old cliche, but the first thing we do to a new patient is depersonalise them by making them change into nightwear, often bathing first, etc etc This is really about establishing our power and control over them. When they object, or demand their "rights", we label them "difficult"

[SKM-NURSIEPOOH, BSN, RN]

...but not at the expense of other human beings who do not want to be exposed to second hand smoke!!! wearing isolation masks don't cut it...no one has the right to force employees to unwillingly expose them to cigarette smoke...no one. now if the patient is able to be wheeled out side of the facility & the staff that has to supervise are themselves smokers & don't mind being around second hand smoke...then i say fine. but to subject staff to unnecessary harm is just tooo much to ask of them!!! if this becomes more of a norm than an exception....there will be even more nurses leaving the profession...you can count on that!!!

its one thing to know going into this field that you'd might injure your back in lifting or turning patients...it's totally different thing when staff is expected to take physical or mental harm for the sake of the patients' rights....well what of the employees' rights??? if the state, ombudsmen, or the president of the united states, for that matter, says that patients have the right to smoke because these facilities are their homes...well i say fine...let these brilliant decision making individuals come-in & light them-up & we'll see just how much these patients' rights would continue!!!

this is a hot issue for me because i'm asthmatic & feel that i, or no one else, shouldn't be subjected to hazardous working environment...especially if we're against it!!! if & when i want to work in such environments, i'll put-in for hazardous pay...until then...don't infringe upon my rights not to be exposed to extra curricular poisoning on my job not of my choosing!!! giving patients extra sodas or cookies doesn't directly affect my health (outside of maybe having to have to turn them) & most are good at holding onto the side rails when i do...so this isn't as much of a problem to me as the second hand smoke is.

as far as the quad-patient wanting a shower doing meal times...yes he does have the right...however...if the facility is only staff to have a certain number of staff in the dinning area giving

meals...legally...this would take precedence over the patient wanting a shower (the needs of the many out-weigh the needs of the few). in addition, if this patient wants extra care for himself...he could hire a private nursing staff at his own expense!!! i've not heard of anyone being catered to like this unless they're related to someone high-up in administration. if this patient doesn't have the necessary funding for private staffing...he doesn't get the extra care...period!!! it would be impossible to provide extra care to all patients who want it simply because it's their right...it's not right to give one patient extra care & not provide that same service to the rest that are either paying privately or with public assistance. the units wouldn't be able to function properly if some sort of protocol isn't followed!!! too many accidents & emergencies can & do occur that would interfere with providing special or extra services that aren't necessary (giving showers doing meal times & setting-up patient for smoking in the above case) especially during besy times i.e. meals, medication administration & treatment times. people complain enough as it is about working long hours & not getting their rightful breaks....now we want to add unnecessary tasks to what is already a full plate for the nursing staff. this is just poor time management, not to mention, stressful for the staff to do so, imo!!!

i think that james is correct in stating that this doc simply not aware of just how difficult this situation is for the staff & maybe he would change the order...especially if proper documentation would justify him changing it.

[kids]

Originally posted by KlareRN

(edited down by kids)

I have been involved in cases with ombudsmen and the state board of health over pt. rights.

Wow, I feel for you...I have had 'this guy' and a few more like him(wonder why they are always quads?)...many conferences with the Ombudsman(s)...and State Inspectors responding to the patients complaints...bottom line was, the facilities won because one patients rights can not infringe on the rights of another patient...also had the facilities be supported because the patients behaviors constituted a hostile work environment.

[Furball]

My Mom's best friend DIED of lung ca...never smoked in her life but worked in smoky offices for many years....apparantly her health took a second seat to the right to smoke...oh well...c'est la vie.... Smoking is different than other so called vices because you do affect people in your vicinity...etoh/coffee/chocolate just doesn't just waft over to you in the environment. I would definitely refuse to sit with this pt breathing in smoke. I am very suprised that folks just don't get it......and that's all I'm gonna say about that.

[Nurse Ratched, RN]

I wish I could plead ignorance on the docs behalf, but the doc is aware that the pt is a total transfer and is unable to safely hold a lit cigarette and that she is in respiratory isolation. If he can't put two and two together that that makes it *extremely* difficult and time-consuming to carry out his order, not to mention unsafe, then he is an idiot. I know him not to be an idiot, but also to be a human with frailties like the rest of us who probably doesn't want to be the bad guy when a fairly pitiful patient is requesting this.

And if my refusing to do this is considered discrimination, then I figure there's no better time to take my Liability Insurance out for a spin and see what the courts say. If a patient suggested that refusal to do this was a violation of her rights, then I would have to respond that I have a right not to be exposed to smoke.

But again, this is all off-topic. I don't care if this person smokes. but if she can't accomplish that independently without putting others in harm's way, then I am not going to facilitate it. And in a group setting, one's rights do not exist in a vacuum. They must be weighed and measured against the rights and safety of the group as a whole. In the quad shower example, if another resident was starting to get up and ambulate and was at a fall risk, that other patient would just have to wait for his shower. I wouldn't leave the potential fall to tend to a lesser priority need.

And that's what this thread is really about. We have to prioritize as nurses. Safety of our patients first and foremost. Meeting their basic needs - food, hygeine, comfort - and their medical needs. Documenting all of the above. I don't know about the rest here, but I'm doing well to get that done in a shift without throwing in situations like this. This is not a nursing priority.

[ceecel.dee, MSN, RN]

I've gone out to smoke with only one patient......a woman who was BOMBED at 1030 in am and her boy"friend" (also drunk) comes into ER "to get her help". He cannot stand without swaying. It's 36 degrees out. She won't come in so I have to run out to the car in the clinic parking lot (clinic will not see her), where it takes me a full 8 minutes to talk her into coming in. The only way I could convince her to trust me was to let her smoke 2 WHOLE cigs in the car and finish her LITER OF VODCA without nagging her....we talked about her life, her kids, my kids...I was freezing (scrubs aren't warm...ever noticed this in a brisk Minnesota spring breeze?) Before entering ER, we made a deal that the only way she was coming in for the help she knew she needed, was if I let her smoke when she needed to. I was EXTREMELY good natured about this whole senario, including the near fist fight between the lovebirds.

Maybe I need to smoke.....

AND.......NEVER IN MY LIFE HAVE I BEEN ACUSED OF BEING LIBERAL!

[NurseDennie, BSN, RN]

Nurse Ratched - You are Gorgeous!!! Wow!!

Love

Dennie

[Nurse Ratched, RN]

NurseDennie - that is so sweet - I wish it was me!! :) My avatar is Lucy Lawless of Xena, Warrior Princess fame.

[NurseDennie, BSN, RN]

Ooops - sorry. I've never heard of her, but she's a very attractive person, isn't she? But she looks normal, as opposed to a model or somebody.

I just assumed that it was your picture - Not good to assume, I know.

Love

Dennie

[mother/babyRN, RN]

Any doc who knwingly puts a patient at risk or unreasonably taxes a unit because he or she doesn't want to hear it, is a buffoon. If the pt refused a nicotine patch, she should have been given the information that smoking, especially with her condition and the fact that she currently resided in a hospital environment, was not and would not be tolerated.

Just because a doctor writes an order doesn't mean its written in stone. Had I been a member of the oncoming shift, even given your thoughts on the matter, I would have considered a turf to me.

The pt most likely ( as most of them will) would somehow manage or coerce a family member or friend, to sneak one in the room.

Whether or not you smokers agree and non smokers disagree, staff should not be charged with having to carry out inappropriate orders due to the cowardice of the doctor.

And, if being busy was (and usually is) a factor, I would have called the supervisor and told him or her that he or she would be assisting. If there was a respiratory illness present in the patient, I would have no difficulty informing her I could not participate in bringing her out to smoke. In the old days physicians and nurses were allowed to set appropriate limits. Unfortunately, that is not always the case...

And, had the patient developed complications, or become sicker due to being brought out to smoke, she could and quite possible might bring a lawsuit against the doc, facility and you for practicing negligence of care with regard to her. Doesn't matter if you have an order. If the order, in a court of law, was deemed inappropriate and you knowingly carried it out, its your licence...