Obtaining Consent and Confrontation With Physician

[rn21191]

I've been a nurse in the same specialty for almost 4 years and have worked at a few different hospitals in a large city. I like to think I have learned to communicate effectively and respectfully with my coworkers and our doctors. Super long story short, my patient had been refusing surgery since admission. She was on the fence about pursuing treatment as her symptoms weren't too bad. It actually came to the point where they had decided to transfer her to a medicine service and transfer her out of the ICU because she was so adamantly refusing everything they were recommending. Psych was consulted and deemed her capable to make decisions for herself. The attending surgeon came and spoke with the patient, explained the importance of treatment and got her to agree to the pre op MRI. They scheduled her surgery for the first case of the next day. When I took over, she hadn't yet signed the consent form. At the beginning of my shift the resident came by and said he'd go in and consent her before she went to sleep. The unit went crazy and he wasn't able to come back until late at night. He went in to talk to her and immediately came back out of her room. He told me she was seeing things and not very awake and that he didn't feel comfortable getting her to sign then. He thought it would be best to let the attending come in the morning and do the consent form. I agreed with this and really respected him for knowing when to take a step back. I had kept her NPO just in case and she was ready to go as soon as that form was signed. Anesthesia came to get her at 645 and I told him I didn't think she had signed yet. He grabbed the chart and said that she had indeed signed the form. I was confused but figured I just missed the doctors rounding and the attending's conversation with her. Something didn't feel right but she wasn't refusing at the moment so I packed her up and brought the day shift nurse in to do report at the bedside before she went down for surgery. I briefly explained the situation and the day shift nurse asked the patient right away if she wanted to do this surgery. The patient said no she did not want to go so the day shift RN called the team and the day resident came in and immediately started pressuring the patient to go right then. He told her she would die without the surgery and that everyone was waiting for her so they had to go downstairs NOW. I politely asked the resident to call the attending as this is what the night resident said would happen. He called the chief resident instead and asked me why this was a problem as the consent for was signed the day before. I explained it had not and that the night resident felt more comfortably deferring to the attending. He got the chart and said that there was a signed consent form so he was still confused as to why I was being difficult. I told him his own resident didn't feel comfortable consenting her when she was half asleep and delirious. He went to call the resident and asked him what happened, and came back and started asking her orientation questions which she answered correctly. He asked if she knew the severity of her situation and she said yes but that she still didn't want the surgery. The chief came out into the hall and started yelling at me about how this was ridiculous and that it was inappropriate for me to let her say no. I believe he said "do you want her to die? That's what you're saying if you keep pushing this". I calmly stated that I was in no way telling her not to do it, but I was just reporting to them that she did not want to go. I said I was advocating for my patient and he got so angry at that phrasing. He said "Oh so you're the only one in this whole place who is advocating for her? I'm trying to save her life. I'm personally offended that you think I'm not advocating for her as well. I didn't really know what to say so I just let him walk away and call the attending. I went straight to my managers office and told her what was going on. She's great, and she called the chief to her office to talk. She actually said "why are you being mean to my nurses" and I loved her so much for that. He started to talk and then they saw the attending so the three of them talked in the hallway. My manager came back in and said the attending was telling the chief to be nice and listen to us, and that he wants us to know we can always come to him directly. The chief came into the office and apologized for the way he handled our interaction. He said he was frustrated because the attending was waiting on him and he felt like I was insinuating we weren't all on the same team. He said he hoped we could go forward working together in a positive way and I agreed. He left and I did feel better that we handled it right then and there. However, I have several concerns with the overall situation. First and foremost I was disappointed that the team felt they had the right to pressure her so much to have a truly risky surgery. Patient's can always revoke consent and they were acting like she could not do so. I was also worried that there was a chance she didn't even remember signing the consent and that it was obtained inappropriately. Lastly, I felt frustrated that the chief was trying to manipulate my feelings to get me to do what he wanted. I obviously want the best for my patients but I also have to look out for their best interests and listen when they're saying no. Lastly, I don't think any of the residents understood that I was trying to protect the patient's wishes, my own license, as well as the whole team. If something went wrong in surgery and there was any question of consent, we would all be dealing with a difficult situation. Any comments, similar experiences, or advice on how to handle this team going forward? After this situation and a few others with the same team I truly feel like I need to escalate this to someone above myself. I know I can't change a whole lot, but I feel like this is as good a time as any to express concerns.

[LovingLife123]

Why did they keep the signed consent if nighttime doc did not feel it was obtained properly? Why did he put it in the chart?

You did the right thing, but I totally understand the confusion on dayshifts part as there was a signed consent in the chart. It should have been destroyed.

[rn21191]

HAHA yes you're correct I sure did not keep it short

[txmurse69]

You did exactly what your supposed to do! Good job advocating for your patient and hopefully educating a resident.

[FolksBtrippin, BSN, RN]

You did the right thing.

I don't fault the doc for getting upset if he believes that she will die without the surgery. But you still did the right thing. She has the right to say no. Also, consent is not a piece of paper. Consent is agreement to the procedure. It doesn't matter at all if she signed or didn't sign. If she doesn't agree to the procedure, there is no consent.

[Kooky Korky, BSN, RN]

You did a wonderful job! I think you should feel really good about the fact that, although it didn't feel great in the moment, you kept your cool and followed through.

It sounds like the other involved parties have apologized and even the attending supported a reconciliation of this situation. I would look for opportunities to continue to facilitate a good relationship with this team. It's not uncommon that incidents like this, when handled well as this one ultimately was, tend to strengthen working relationships. Everyone has just a little bit better idea of where others are coming from and that tends to be a good thing. Sometimes we need to move on, trusting that others have learned what they needed to learn.

One particular point (in which I babble yet again about past experiences). Although the CR kind of came out of the corner swinging with his intial comments to you, you handled it very well. I too, have responded, "I'm just trying to advocate for my patient" - but after a couple of instances and some time to think it all through, I do believe that those are kind of notorious "fightin' words" when speaking with other members of the health care team who are also trying to help the patient. I haven't said that phrase for years just because, regardless of anything else, it is rarely productive; it contributes nothing to the actual position I am advocating. Calmly and neutrally continuing to hammer away with facts is usually more productive - if you can phrase it as being on the same "side"...even better. ("It's hard for us because we want her health to improve, but she has a right to make her decision whether you and I agree with her or not" and "there is a process we must follow if we don't believe she has the capacity to make this decision" and "...just the same, I know you know that legally she can revoke her consent", etc).

I personally don't think you should escalate this. We need to be careful with the idea that every difficult situation in life needs to be "escalated" because "it shouldn't have happened in the first place." All of us are learning every day, with every patient and co-worker interaction, how to be better at what we do. The residents are learning too - - they are right in the thick of their formal education. I have no doubt a lesson was learned here based on your tenacity and your advocacy! When a situation such as this occurs and then has a positive outcome, IMO the right thing is to move forward in a collegial manner, allowing this incident to ultimately build the working relationship. You can keep your eyes open for evidence of change, but for right now you should have faith in the learning process. Expect that interactions with this surgery service will be better next time around and seek to make it so.

Very, very good work on your part. That was solid nursing work you did. :)

Sometimes surgeons and surgeons in training want to operate for the experience, not just to help the patient. Hopefully, the two aren't mutually exclusive.

If the nurse is not the one obtaining the consent, is it her responsibility to make sure the patient truly consents, hasn't revoked consent? I think that's the job of the one witnessing the consent.

Also, if Psych cleared her, is it the nurse's job the determine her orientation, lack or presence of delusions/hallucinations? If there is a change in the pt's condition, physical or mental, from the time of the Psychiatrist's evaluation, yes, the nurse should make that known to the surgeon ASAP. for self-protection, nurse should also inform her boss, chart it, tell Anesthesia - so the surgeon can't say he or she was not informed.

[Kooky Korky, BSN, RN]

Why did they keep the signed consent if nighttime doc did not feel it was obtained properly? Why did he put it in the chart?

You did the right thing, but I totally understand the confusion on dayshifts part as there was a signed consent in the chart. It should have been destroyed.

Destroying a medical document is not allowed. One could cross over it, leaving it still totally legible, just write "pt revokes consent at this time" and two workers sign and date it, and put it back in the chart. If there are only EMR's, I don't know how one would do this, maybe just a note that pt has revoked consent because...whatever the reason(s).

[NuGuyNurse2b]

I find it a little hard to believe that the physicians behavior was tolerated as much as it was, if the patient was capable of making decisions, and at every opportunity had refused the surgery, then the physicians actions should be reported to the state.

Unfortunately that is tolerated at my place. If your manager is a corporate slave and only sides with the powers that be, you are out of luck.

[JKL33]

Sometimes surgeons and surgeons in training want to operate for the experience, not just to help the patient. Hopefully, the two aren't mutually exclusive.

If the nurse is not the one obtaining the consent, is it her responsibility to make sure the patient truly consents, hasn't revoked consent? I think that's the job of the one witnessing the consent.

Also, if Psych cleared her, is it the nurse's job the determine her orientation, lack or presence of delusions/hallucinations? If there is a change in the pt's condition, physical or mental, from the time of the Psychiatrist's evaluation, yes, the nurse should make that known to the surgeon ASAP. for self-protection, nurse should also inform her boss, chart it, tell Anesthesia - so the surgeon can't say he or she was not informed.

Very generally-speaking, with these matters I stick with the bottom line, especially if someone has a different understanding of the "facts" or the related policies than I do.

In this case the bottom line is that the patient presently does not consent to the procedure. Even if one doesn't know the ins-and-outs of what psych says vs. what sugeon says...etc., EVERYTHING must be on hold until either a legally-valid consent is presented (or verified as such), the patient consents, or the surgery team accepts the patient's present refusal and cancels the surgery.

[Apple-Core, ASN, BSN, RN]

I like this response from JKL33: "It's hard for us because we want her health to improve, but she has a right to make her decision whether you and I agree with her or not" and "there is a process we must follow if we don't believe she has the capacity to make this decision" and "...just the same, I know you know that legally she can revoke her consent"....

What other succinct responses would avoid (as far as is possible) friction between staff, but allow the nurse to stand her ground for the patient's right?

Thanks!