Hard Time Dealing With Patient Rights

[ThatNursingDude]

Hello all,

So I'm still a rather new RN student, almost finished with my 2nd semester, and I have a huge problem: Patient Rights. Specifically their autonomy. In my classes we talk about advocating for the patient, for their rights, for their autonomy. But in clinical I've already been told to violate my patients twice! The first time I did violate my patient and I felt disgusted with myself. The second time I refused to violate the patient and made others angry at me. So I need your help! Please help me sort this out so I can have my morals in-tact and also stay on everyone else's good side! If someone could please take this really serious that would be so great as I'm stressing out big because of this. Also, please know this is barely my second clinical I've been to, and we were only taught how to do a head-to-toe assessment thus far, and that's all we're allowed to do. NOTHING else!

So here's the first scenario:

I walk into a female patients room. She was in a car wreck and cannot move much or talk, but can still make conscious decisions by shaking her head yes/no. My teacher tells me that she doesn't want any male nurses helping with changing/bathrooming before approaching her. The first thing my teacher wants me to do is auscultate posterior lung sounds so I walk up to her, introduce myself, and tell her what I'm going to do. As I move my stethoscope to her back she shakes her head no. Presumably, I think she doesn't want me to touch her as she feels uncomfortable with a male nurse. So I ask her if she doesn't want me to listen to her lungs and she shakes no. She shakes her head and her shoulder, "no". So I tell my teacher, "she doesn't want me to touch her." My teacher tells me, "It's okay, just do it." My teacher brings me to her and tells me to auscultate the posterior lung sounds as the patient remains tense as I'm listening. I myself feel awkward and disgusted with myself. Did I do the wrong thing? Cause I'm sure I did. I literally think I wont forget the way this female looked like and what I did to her... I have a huge problem with violating peoples' rights/autonomy.

The next scenario is a little different. This is the one I want the focus to be on. It's a little long as I want to give you the nuanced details.

A male patient about 9 days after having a right sided CVA is paralyzed on his left side of his body. At this point in time he has no decreased LOC. A nurse tech is with me in the room as the patient states he needs to urinate. As the patient says this, the tech states he needs to go and asks if I can help the patient. I naturally tell him yes.

So I'm in the room alone with the patient and the patient tells me they have him urinate into these containers with measurements on them that are sitting on the table by his bed. I pick it up, walk over to the patient's bed and ask him if he's ready to urinate. In my mind (as I was never taught this) I'm assuming I need to grab his member for him and place it into the container so he can urinate into it or at the least hold the container for him while he holds his member with his functional right hand (this is what I thought "help the patient" meant when the tech told me to help him). Anyway, the response he gives me after asking him if he's ready to urinate is, "Yeah, but I can do it by myself." I say, "Okay, would you like me to step out as well for your privacy?" He says, "Yes." So I step outside of his room for awhile. As I'm outside his room the tech comes back and says, "Did you help him?" I tell him, "Yes, let me see if he's done." I ask the patient if he's done and he tells me, "I don't know who designed these thing but when I ****** into it, it just came back out." I say, "Okay, so your bed is wet now?" He says, "Yes."

So, I tell the tech who is right outside the door, and he looks angrily at me and says, "Didn't you help him?" I said, "Yes. He told me he wanted to do it himself and he wanted his privacy." The tech then angrily tells me (which is what I'm shocked about): "Of course they're going to tell you that. You just do it anyway!!!" Immediately my brain breaks. Is this right? Am I supposed to disregard what my patient tells me? "Just do it anyway"!!!???

I feel bad for "causing" the mess so I offer to help the tech clean it/change the bed linens. He tells me, "No, just go away. I got it." And I once again feel like crap for this time doing what I feel was the right thing. Could someone please tell me if I did the right thing and also tell me how I can deal with this problem of wanting to stick of for the patients rights/autonomy without having others hate me for it? I feel like I'm less valuable to a employer for not possessing this trait.

Please, I'm so stressed. I'd gladly disregard a patients autonomy if their LOC was diminished in certain situations, but if they are alert and have complete LOC, I have no idea how I could ever violate their requests.

Thank you soooooo much.

[Anna Flaxis, BSN, RN]

Not saying it's ok or not, actually.

Okay.

Well, it is a fact that a competent patient has a right to refuse nursing care, and that if you proceed against the patient's wishes, it is unlawful.

[LadyFree28, BSN, LPN, RN]

Okay.

Well, it is a fact that a competent patient has a right to refuse nursing care, and that if you proceed against the patient's wishes, it is unlawful.

And yet, I still have my license intact, and will continue to; because I don't deal with absolutes. :)

For instance, I had a pt shake their head when they actively apirating; I had to bag and suction that pt all night before the decision was to transfer the pt out; when the pt came back, they thanked me, and we developed a great rapport; they admitted the no was because they were scared, but because of how I handled myself, they were appreciated that I didn't back down.

I have more stories like this; I am very willing to share. :)

[Anna Flaxis, BSN, RN]

Apples and oranges.

In the OP's example, a competent adult patient refused to allow her lungs to be auscultated by a nursing student, and the nursing student proceeded anyway.

In your example, an emergent situation was present, and it is arguable that the person's judgment could have been altered at the time.

Those are two completely different scenarios.

I am interested here in addressing the OP's concerns. In neither example he gave was an emergent medical condition present, and so his patients' refusals of nursing care should have been honored.

What I find disturbing is that you seem to take pride in ignoring your patients' wishes.

[Susie2310]

And yet, I still have my license intact, and will continue to; because I don't deal with absolutes. :)

For instance, I had a pt shake their head when they actively apirating; I had to bag and suction that pt all night before the decision was to transfer the pt out; when the pt came back, they thanked me, and we developed a great rapport; they admitted the no was because they were scared, but because of how I handled myself, they were appreciated that I didn't back down.

I have more stories like this; I am very willing to share. :)

The example you have given is a quite different situation from the OP, where the patients were not, according to the information we were given, experiencing emergency situations. The OP's post did not detail a life or limb-threatening situation. We were discussing the original post on this thread, not discussing all the situations in which different types of consent may apply.

[Thessaliad]

Both you and your instructor are lucky that there were no witnesses to the first event; at my facility, both of you would have been investigated for patient abuse. If the instructor was an employee at my facility, she could have been fired, and reported to the Board of Nursing and possibly lost her license. Lack of mental capacity does not absolve the nurse from obtaining consent--if a patient declines the first time, you try to explain the purpose of the procedure. If the patient declines again, you get someone else and see if that person is able to perform the procedure. Placing hands on a patient FOR ANY REASON is battery and unless you have a doctor's order to place hands on a patient without their consent, the only mitigating circumstances are when the life of the patient is in danger, unless it goes against their wishes for emergency interventions, and that changes from state to state. This includes basic care such as toileting and bathing. If the patient continues to decline basic care, there needs to be a psych consult and a care conference. The treatment team needs to be aware of the situation, as this sort of situation is where people lose their jobs and careers are ruined.

tl;dr

Your instincts were correct. You should not have gone through with that procedure, but with the pressure to perform under the eyes of an instructor you did as you were told, which is understandable. At the very least, I would consider asking another instructor for guidance, and if no luck there, talking to the Dean of your program.

XXXXX

I had the same thing happen to me once, where my CNA instructor (who was a nurse working for a community college) told me to brush a patient's teeth, and the patient declined, and I told the instructor that. She told the patient, who had advanced MS but was mentally intact, that her teeth needed to be brushed. The patient said no, clearly, and shook her head. My instructor told me I had to, and I declined. She grabbed the toothbrush out of my hand, and proceeded to brush the patient's teeth. The patient was crying and calling for help, and I was so appalled I was frozen. To this day I regret not calling the school to complain about the incident, and the harm that was done to the patient.

The instructor failed me for not providing patient care.

Fifteen years later, I am now working as a psych RN with some of the most dangerous patients in my state. I deal with the issue of consent every day. If a patient declines care, I document meticulously. Documentation is your lifeline. If the patient continues to decline, measures must be taken and added to the patient's treatment plan. It may be that you need an order from the MD, "May place hands on to perform assessment," but I will almost guarantee you that the MD will not want to do it because they would perceive it as giving an order to assault a patient.

[LadyFree28, BSN, LPN, RN]

The example you have given is a quite different situation from the OP, where the patients were not, according to the information we were given, experiencing emergency situations. The OP's post did not detail a life or limb-threatening situation. We were discussing the original post on this thread, not discussing all the situations in which different types of consent may apply.

And MY response was SOLELY to inform the OP that there will be times as the one that I shared; I'm addressing a particular part of his OP:

Please help me sort this out so I can have my morals in-tact and also stay on everyone else's good side! If someone could please take this really serious that would be so great as I'm stressing out big because of this. Also, please know this is barely my second clinical I've been to, and we were only taught how to do a head-to-toe assessment thus far, and that's all we're allowed to do. NOTHING else!

I'm speaking about MOVING FORWARD; and to hone those skills when the next issues rise; I, personally would want the OP to go into The next scenario BETTER equipped in realizing that the next time someone says NO, you MAY have to intervene, it not "all hands off" when a pt days no, and the OP has to learn to discern between the two; it's never "always" in this business...

[caliotter3]

I can empathize with your feelings of misgiving in both situations. I suffered the same thing while in a testing situation with my instructor at bedside. The client clearly stated his desire for us to leave him alone and the instructor forced me to plow on through. When I protested to the next in line, I was rebuked, failed for the task at hand, and told no cogent reason why the instructor was "right". To this day, I maintain that what was done to this patient was in direct violation of his right to refuse. I consider myself lucky that he did not file a formal complaint against me. A fine line between self preservation and what is 'moral' or 'legal'. Sometimes we can not navigate this line without becoming a casualty. Kudos to you for even recognizing the situations for what they really were. Hope that you are able to safely, and successfully, get through the rest of your program.

[RainMom]

I would also suggest that sometimes a "No" is really more like "Not right now". Confused pts often say no the first time, but are agreeable a little later (if it's a task that can be delayed a bit).

In the first scenario, perhaps the pt was having a rough morning, didn't sleep the night before, increased pain, emotional, etc. Maybe she was afraid of the increased pain that would be caused by moving her to listen to her back & would have been okay with limited auscultation of the anterior & lateral; save the posterior fields for when she gets up to a chair, BR, PT. I know communication was limited to yes/no; you have to learn to ask the right questions sometimes. Pts often say no when they are scared or don't understand what is expected of them. If the answer is still no, then chart refused.

With the second scenario, I would have done the same except possibly staying in the room due to the fall risk post-stroke. Goal is for the pt to return to their baseline of independence, as much normal activity as possible; sometimes too much help is detrimental.

[wheeliesurfer]

LadyFree28, I take GREAT exception to what you say, even in your example of the aspirating pt. If a pt. is A&O and denies/refuses care for ANY reason their wish should be respected and documented in the pts. chart notes VERBATIM! CYA, so to say. The fact that they "could" suffer more harm than good is NOT your concern anymore than deciding that they don't "really" want to be a DNR and that they "could" have a better/more favorable outcome if you just treated them instead.

This is what I was taught, NOT to be misconstrued as legal advice. If a pt. is NOT a DNR, you follow their wishes and WAIT for them to deteriorate (aka lose consciousness/pass out) and THEN act in accordance with what a reasonable and prudent person would want done in that situation (suction/bagging/CPR......). If you touch a pt. against their will it is considered battery and charges CAN be brought against you AND your license, even if it hasn't YET happened in all your years of experience. Once a person is no longer A&O you have implied (as opposed to informed) consent and battery isn't as much of an issue (DNR an exception). This should all go back to your CPR training and information learned about Good Samaritan Laws, implied consent, informed consent, neglect, abandonment, etc. laws.

[LadyFree28, BSN, LPN, RN]

Apples and oranges.

In the OP's example, a competent adult patient refused to allow her lungs to be auscultated by a nursing student, and the nursing student proceeded anyway.

In your example, an emergent situation was present, and it is arguable that the person's judgment could have been altered at the time.

Those are two completely different scenarios.

I am interested here in addressing the OP's concerns. In neither example he gave was an emergent medical condition present, and so his patients' refusals of nursing care should have been honored.

What I find disturbing is that you seem to take pride in ignoring your patients' wishes.

Who said I take pride in ignoring pt wishes?

I can easily say you take pride allowing your pts to be unsafe?

Let's not make ASSumptions, dear.

Here's the deal; the OP can not shy away from making this decision where it may warrant an escalation if care, that's my point; I'm interested in helping the OP hone skills from a shocking experience; I don't want the OP to shy away from situations where when someone says "no" and it needs to be addressed; then doesn't react, then will have to explain why he didn't intervene.

I am comfortable making astute decisions where there the need for intervention is GREATER than a "no" from a pt that may be lacking insight; let's not mistake a intact person that may be incoherent in the course of their care.

[LadyFree28, BSN, LPN, RN]

I would also suggest that sometimes a "No" is really more like "Not right now". Confused pts often say no the first time, but are agreeable a little later (if it's a task that can be delayed a bit).

In the first scenario, perhaps the pt was having a rough morning, didn't sleep the night before, increased pain, emotional, etc. Maybe she was afraid of the increased pain that would be caused by moving her to listen to her back & would have been okay with limited auscultation of the anterior & lateral; save the posterior fields for when she gets up to a chair, BR, PT. I know communication was limited to yes/no; you have to learn to ask the right questions sometimes. Pts often say no when they are scared or don't understand what is expected of them. If the answer is still no, then chart refused.

With the second scenario, I would have done the same except possibly staying in the room due to the fall risk post-stroke. Goal is for the pt to return to their baseline of independence, as much normal activity as possible; sometimes too much help is detrimental.

Thank YOU for posting a more concise perspective; my straightforwardness is being construed with pts rights violations where I'm trying to steer the OP to remain assertive in care at the right time, DESPITE an very unfortunate introduction in delivering care in that gray area.

Nothing worse than seeing someone decompensate and a person freeze up when a pt is "saying no"-I don't want the OP to be that person.

[wheeliesurfer]

If it may warrant an escalation of care, then you would be better served by taking a hands off approach (calling a RR or the MD) and having the pt. transferred to a higher level of care BEFORE they go too far downhill than after you have committed battery. If in the process of calling the MD/RR your pt. is no longer A&O then you have implied consent (if they are not DNR) and can treat/code then. Easy peasy!