I have seen it all, or maybe not....

[Liebchen]

My goodness, I don't know what to make of this situation. I think the nurses are handling it very wrong, but since I am only 1st quarter, I will not judge, just ask questions.

I am shadowing in a local hospital. Here is the scenerio.

46 year old female enters the hospital for a two day stay after a complete abdominal hysterectomy. It is my understanding that she is self pay and has paid all bills upfront, this was the gossip at the front desk.

She has one child who is 18 years old. She wakes up, and tells the nurse that she wants the iv as well as the catheter removed. According to her chart, she has issues with being touched, she does not like to be touched due to previous abuse by her spouse.

Anyway, this patient wakes up, request to the nurse that she wants both iv and catheter removed. The nurses response was she could not do that because it was doctors orders. The patient tells the nurse she does not care about doctors orders and again request that these be removed, in addition she told the nurse that she would be going home at 8:00 PM that evening. The nurse told her she was going nowhere, and that she should go to sleep, she was just experiencing "side effects" from the drugs. The woman then told the nurse that she had 30 minutes to remove both, or she would remove them herself and that she was leaving the hospital that evening.

Soon, another nurse came in and asked the woman why she wanted to leave. The woman told her that she was self pay, and that she was unable to pay a large hospital bill and felt that she could take care of herself at home with the help of her family. This nurse explained that complications could happen, bleeding etc.

The woman said she was willing to take her chances. She again told the nurse to remove the iv and catheter. The nurse refused and said she would have to call the doctor. The woman told her she had half an hour to do so, as she wanted to start preparing to leave. The nurse then without asking this woman started to check her pad for bleeding. This woman pushed her away and told her not to touch her, that she would check and give her the results. The nurse then left. In the hallway, they discussed how insane this woman was and what a ***** and if she could not handle the care she should not have had the surgery. I might add that in her chart, she did have two large tumors as well as a 7cm ovarian cyst.

Soon, a social worker came in and started to tell this woman that the hospital was obligated to keep her for 48 hours after a surgery of this nature. The woman told her she wanted no more conversation, to please get whatever needed to be signed and take the iv and catheter out. They left to "speak with the doctor" after she told her that if she left the hospital she would be given no pain meds or prescriptions.

When they came back, this woman had removed (cut the port) the catheter as well as the iv. Her son was there, and they were walking out the door.

The hospital called security, who told her if she left she could be arrested. At that point, I do not know what happened, as the woman was escorted into an office and it was time for me to leave.

Will I encounter this often as a nurse? I sure hope not. This woman seemed, other than extreme pain to be of sound mind to me, but then again, I am a student. I thought, in my own opinion the hospital staff was rude, and I thought that the patient had the right to dictate their own care. Was I wrong?

[RNDreamer]

wow, I always thought that I patient had a right to sign out against the doctor's orders...threatening arrest does sound extreme...But I just barely started school, so what do I know...Too bad you didn't post this in the General Nurses forum so that we (future nurses) will know whether or not this situation was handled properly..

[Liebchen]

I, as well am a new student, and very naive myself. I will most definetly use this as a learning experience. I don't go back in until Friday, so I will not know the outcome until then.

I'm sorry, I was not certain where to post it.

[Daytonite, BSN, RN]

having been a staff nurse, supervisor and manager over the years, i have seen similar situations to this a couple of times. it does not happen very often.

first, you need to recognize that the patient had some mental and/or behavioral issues. these may or may not have been known about by the doctor before the surgery. you also must understand that the drugs of anesthesia can exert some powerful effects on people after their surgery as well. before a surgery is performed, especially something like a complete abdominal hysterectomy which is going to make the patient unable to ever have children again, the doctor would have, and should have, carefully gone over what the surgery was, what was going to happen during the surgery, what was going to be required as far as being hospitalized, and what was going to go on in the healing period. the doctor's office nurse who arranged the hospitalization would have also discussed the specifics of time required to be in the hospital with the patient as well as the method of payment. so, the patient would have know all this ahead of time. ask yourself why she has forgotten it now or chosen to ignore it.

secondly, the financing of an elective surgery is usually discussed before admission. most surgeons that i know of won't cut on any patient until they know how their fee is going to get paid. most hospitals won't admit any patient for an elective surgery without getting some kind of documentation in writing as to how the hospital bill is going to get paid. hospitals are, after all, in business to keep going, even if they are charitable institutions. if a patient doesn't have insurance, then the hospital wants some kind of assurance that payment is going to be made. this is all discussed and settled before the patient even gets their butt in a bed. again, ask yourself why she has forgotten it now or chosen to ignore it.

thirdly, it's none of the nursing staff's business how a patient's stay is being financed! so, anything and everything that was heard about the patient's bill at the nursing station was just gossip. you should let it go in one ear and out the other. some of the conversation you heard from the staff about the way the patient was behaving was also inappropriate and was just gossip and judgmental. you should also let that go in one ear and out the other as well. it only indicates the level of misunderstanding on the part of the staff.

fourth, once a patient is under the care of licensed staff, it is that staff's duty that, yes, they respect the patient's wishes. however, as licensed nurses, each state requires that they also have a duty to follow standards of care. now, a patient may refuse a standard of care, but it is up to the licensed nurses to explain to the patient why certain things are being done to them as kindly and tactfully as possible, what is likely to happen if they don't do what is being asked of them, and to notify the physician of what is going on immediately. still, some patients will insist on going against the standard of care. and, that is their right although it doesn't mean it's the right decision for them to make. each facility has policies in place for how the staff is to handle these kinds of situations and they need to be followed to the letter to preserve the facility's legal rights as well as the patient's legal rights in case a lawsuit ensues. we don't know if the facility was doing that. it sounds from some of the things you describe that they were in the process of doing just that. however, the patient was being impatient and not willing to listen. i've seen plenty of patient's remove their own ivs and catheters. most of them were confused when they did it. it isn't always a pretty site. i've never refused this of a patient, but i've tried my hardest to keep them in place as long as possible until it's a "for sure" that they are going home because they're traumatic enough to insert. i have to wonder what was so urgent that the patient had to have these things removed quickly and couldn't wait 10 more minutes or 2 hours while the doctor was contacted for discharge orders? now, i wouldn't have spoken this thought to the patient, but it would have been in the back of my mind. something wasn't right about this patient's behavior.

something else that strikes me as well is that people who are alcoholics and do not admit to their drinking often go into acute dts during their postop recovery. people in acute dts after surgery with some anesthetic or narcotic agents on board can get very psychotic and do some real hair-raising and manipulative things that are scary. you say she "cut" her port. did she use scissors? that's not normal in anybody's book. neither is acting out and insisting on having to leave right away. this patient's behavior sounds very suspiciously like someone who is either psychotic or starting to have dts. is it possible that might have been going on here? many times a drinking problem doesn't get discovered until this kind of situation rears it's ugly head. paranoia is a common manifestation in detoxing people and their first thoughts are to get out of their present situations against all normal reasoning. these situations require special handling and not discharge because these patients are a danger to themselves. treatment usually involves sedation and sometimes they have to be placed in restraints.

i'm not totally convinced we're getting the whole story. i would agree that there is no reason to treat any patient rudely. to hold a patient in the hospital against their will is false imprisonment. but is it also a sticky situation to allow a patient to leave after a very serious invasive procedure and in the middle of treatment that they originally agreed to accept. an important element that is missing here is what the patient's doctor had to say about all this and what was in the patient's prior mental history.

[Liebchen]

Ah, I see. I did not stay long enough to see what the outcome was, with the doctor or without. I do not know if she was a drinker or not. I don't remember reading anything pertaining to that.

I know that, to me, an inexperienced student, she seemed fine. She did not rant and rave in ways that I picture a psychotic person behaving, but I may have the wrong image of a person not in their right mind. I haven't gotten that far in school yet.

What I saw, was a very calm person, obviously in pain, concerned about the bills. I do not know her history. I did see her son explain, or try to explain that she was worried about the bills and felt that she could maintain her care on her own. He also explained that she did not feel safe there due to issues with her ex-husband of which there was an alert as well as a copy of a protection order in her file.) Basically he said the same things she said and then security stepped in. I realize that as nurses we will run into many situations, but this one really disturbed me. Not so much the patient, but the nurses behavior. It was almost like, they had something to prove.

I did not see her get upset until (I felt) she felt threatened by their actions. I strongly felt that if someone could have sat down with this woman and taken the time to explain in a more gentle tone, that perhaps she could have been at least convinced to stay "willingly" another night.

I don't know what she cut it with, I am assuming bandage scissors that are kept in the room. I agree that is not something that I would consider rational behavior. At the same time, I saw her ask reasonably to stop care and allow her to go home.

I guess that I do not know hospital policy. You can bet that I will never forget this and will always learn what the policy's are.

I am a strong advocate against gossip and hopefully I will always use good judgement when I become a nurse.

[caliotter3]

From your description it sounds as if the hospital personnel could have done a better job in following the p/p for leaving against medical advice. Threatening to have her arrested as she was walking out the door was inappropriate. But with all the banter around the nursing station concerning her financial affairs, I'm not surprised that they didn't display more professionalism. I found this thread quite interesting, since as a person without health insurance and needing the same care, I could very well have been this patient, sans a son to help me get out the door. It's interesting to hear that nurses had the time to discuss somebody's pay status. They should spend more time discussing nursing care. In all that time someone could have called her doctor to inform him/her about the situation. Not a good example for nursing students.

[Hydakins]

Threatening to arrest? Is that something that varies state to state? I have never heard of that in NY or NJ. The patient has the right to go agains doctors orders if they want to from what I've been told and in the experiences that I've had.

[heron, ASN, RN]

A legally competent adult who has been informed of the risks and possible consequences of her choice may refuse ANY medical intervention or treatment, including lifesaving tx. I read a medical journal article that recounted the story of an accident victim with a transected spinal cord who refused tx in the emergency room because he did not want to live as a quad. They had to let him sign out. If staff documents adequate information re risks and pt has NOT been proven legally incompetent, then the actions of the staff leave them open to criminal charges for assault, battery and kidnapping. Was the facility's risk management dept involved in this? How did the facility prove the pt's incompetence?

[canoehead, BSN, RN]

I don't think arresting her was an option- what did she do wrong? It was definitely an intimidation tactic, and inappropriate.

Given the way she was treated- checking her pad without warning her, and threatening her with arrest, it was a pretty unpleasant situation. I would have done the same (cut the catheter) if I didn't know how to deflate the Foley balloon. She came into the hospital with issues about control and abuse, so her reaction shouldn't have been unexpected.

[brissie]

I'm guessing that if they "threatened" arrest then there were, as Daytonite suggested, underlying psych issues previously disgnosed going on here, maybe the MD had ordered a psych hold....you knows...just a guess.

[Liebchen]

I have now returned to clinic and have found that this woman is getting on with her life and the hospital has made some sort of financial agreement with her.

Apparently it was handled incorrectly and there has been a changing of the guard, so to speak.

The change has been good, and there are many smiling faces. The atmosphere has changed and I am now having positive thoughts again about my future career.

I am not happy that she had a bad experience, but I am happy that she went the distance with her concerns and was willing to stand up to the challenge.

This should be a lesson for all, I know I learned from it. The patient does have rights and sometimes you will get that one who is not "compliant betty".

Everybody should be involved in their own health care decisions.

[DaFreak71]

I have not always had health insurance, but I am fortunate that I now do. Even though the health insurance that my husband and I had was substandard (even though he is a RN with the very hospital he was admitted to), we were aware of what the insurance would and would not pay. In our case, if he stayed beyond a certain time of day, he would be charged for another full day in the hospital. It is possible that because she paid in advance for the procedure, she was concerned about an "extended" stay and wanted to avoid the cost of additional days. Although she should have been (and probably was) informed ahead of time of how long she would be in the hospital. With that being said:

Her psychological issues should not be factored into this situation. In the absence of a court order (usually 72 hours for observation), the doctors and nurses should not be trying to hold her against her will.

If she did have a substance abuse problem and was experiencing DT's, this should have been explored before it was assumed (if in fact it was assumed). Even if she had been experiencing DT's, she is still allowed to make her own decisions about her care, absent a court order. An alcoholic who enters the ER has the right to refuse treatment, so why should it be a factor (if it even was a factor) to justify holding her against her will.

With regard to the hospital's legal liability, it is common to have the patient sign something saying that they are leaving against medical advice. That, I believe, is essentially the hospital's assurance that they cannot be successfully sued later if complications should arise.

I absolutely agree that every effort should be made to educate the patient in a kind way as to why it is important that she stay, regardless of her ability to afford an extra day or two in the hospital. It is not as if she would have to pay it up front in order to stay, and she would certainly be allowed to make payments for any "additional" days spent in the hospital. If the patient still refused and wanted to go home despite medical concerns, she has that right! You don't have to be intelligent in order to assert your rights as a patient after all. LOL.

Sounds like you had a great learning experience.