Informed Consent

[tolerantgirl]

I was taught in nursing school as well as a new nurse in a residency program that physicians are the ones who obtain the consent and as nurses we witness the consent. I follow this rule; however, I receive a lot of grief in doing so. I continue to have physicians call and tell me to get consent for a procedure and there is not even an order on the chart and the patient has no clue what is going to happen or that a procedure is going to be done and when I tell the physician they need to speak to the family or patient to obtain consent, I am told that I am the only nurse that makes them go through all this. And no one seems to be doing anything about it and I have seen nurses get consent before the physician has spoken to the patient or even placed an order in the chart. I refuse to do it.

Another issue is drawing up medications for sedation before a procedure when there is not an order and when you do not know how much they want drawn up. I was told that according to JHACO, the medications are not to be drawn up before the procedure, they are to be drawn up from the vial right before you give them. I also follow this rule, but was yelled out infront of a patient for not drawing up medications beforehand and the physician walked out of the room because he said I wasn't ready after he told me how much he wanted and as I was drawing up the medications. First of all, patient safety comes first before the physician's wants. I just wish management would back us up and I wish the physicians would be spoken to and educated. Before, I was scared to death to make a physician upset, but now I know that I have a right to stand up for my patient and practice safely according to the rules and regulations. And I think it is so unprofessional to act that way infront of a patient who can hear and understand everything. I was so embarrassed.

[Virgo_RN, BSN, RN]

You are correct, the physician needs to speak with the patient and explain the procedure, its benefits and risks, and answer the patient's questions, before informed consent can be obtained. You can have the patient sign the form and witness their signature without the physician present if you are reasonably certain that the physician has done this. I ask them, point blank, if the physician has explained the procedure and its risks, and if the patient has any question, and whether they feel comfortable giving consent. If the patient doesn't seem to really "get it" or still has a lot of questions, I will just leave the consent form on the front of the chart for the physician. If they don't like it, too bad. It's their job to make sure the patient understands what they are consenting to and what the benefits, risks, and alternatives are. That's why they are called "doctor" and not "nurse".

As far as drawing up meds, you can have the meds you anticipate the doctor will want present, along with syringes and flushes, and draw them up as ordered. One exception to this is when the doctor writes something like "set up for cardioversion with thiopental". In that case, I would set up for the cardioversion, then when everything is ready, go ahead and mix/draw up the powdered thiopental in the graduated syringe and call the doctor to alert them that everything is ready.

If you're using something like fentanyl and versed, I personally do not like to draw up the entire vial, since you don't know how much the doctor is going to order, and there is the chance of a brain fart and pushing the wrong amount. I prefer to draw up those premixed meds in the amounts ordered at the time they are ordered.

Even in the rapid sequence inductions I've been present for, the meds do not get drawn up until the physician orders specific drugs in specific doses.

Sounds like that physician is just lazy or in a hurry. I'm sorry you were embarrassed. I know what that feels like, to have a doctor talking to you like you're the biggest moron that ever walked the face of the planet. Not fun.

[rghbsn, BSN, RN]

I'll back you both up on these rules. I have had to tell physicians to get their own consent as well...and you're right, they don't like it. But let's not put all the blame on them. We have to look into the nursing mirror as well; the nurse that gets consent for them is doing something illegal and immoral. They are also becoming an enabler. The nurse that draws up all the meds in (most likely) unlabled syringes prior to a procedure is both enabling and rolling the dice. If you mix up your meds you can hurt someone, kill someone, and lose your license. Not worth the risk in my opinion.

I, too, am sorry that you got mistreated in front of a patient. Don't be afraid to call them on it, either. Tell them, "this isn't really the appropriate time or place for this. We can discuss it outside the room if you'd like." I have found that this usually has the profound effect of shocking them, and also of showing them that they're being an ass. If they don't like practicing under JACHO regulations, there are a few hospitals around that have lost their accreditation...they can go practice there.

[PostOpPrincess, BSN, RN]

You don't need your management to back you up. Check out your policies, and if they still give you grief...tell them about the BON and JCAHO.

Trust me, they won't bug you then.

You are doing the right thing--don't let their lateral passive-aggressiveness compromise you.

Keep chugging along, and as you get more experienced, you'll be able to tell them to "stuff it."

[tolerantgirl]

Thank you so much for your support. I know how easily that the patient could have received the wrong dose in my situation especially when I was nervous. I know that it is my job to protect my patient and offer safe care. I am going to continue to follow the policies and rules that are set in place to protect the patients even if that means the physician is going to be upset.

[Nurserton]

The consent is the physician's responsibility entirely, period. They are the ones doing the procedure, they need to explain it. If you want to get a consent go right ahead but if something happens you know you're losing your license before the doc's losing theirs.

[tolerantgirl]

Maybe you misunderstood me, I have no desire nor have I ever obtained consent. I tell the physicians they need to obtain the consent and that is why I am frustrated with being treated like an idiot because the physicians always say " I have never heard of that. You are the only one that makes me go through this." I was posting in hopes to hear some advice on how to deal with this problem because the physicians continue to expect nurses to obtain consent and I have seen nurses over and over obtain the consent. I am not going to jeopardize my license for a physician who is lazy. I am not sure where you got the impression that I want to obtain consent. Maybe you should read my first post.

[tewdles, RN]

Just for the record...there are certainly instances where it is appropriate for a RN to obtain informed consent. For instance...I frequently obtained informed consent for election of hospice benefit. That (probably unnecessary) comment aside, I completely agree with previous posts. It is entirely up to the practitioner who will be completing the procedure to insure that all appropriate information has been provided the patient and all questions have been answered. Who actually witnesses the signing of the consent is less crucial. I have been in situations where (in the ICU and in L & D) I was present during the discussion of the procedure between the MD and the pt/family. At the conclusion of that meeting, I witnessed the signing of the consent being careful to insure that they had NO UNANSWERED QUESTIONS while the surgeon went off to scrub.

[rghbsn, BSN, RN]

tewdles

That is 100% appropriate. As long as there is a witnessed discussion or even an order written such as: "Nurse to obtained signed consent for EGD in A.M., risks and benefits discussed with patient by me." then the nurse should feel comfortable in getting it signed. If I get a consent form signed without the Dr. in the room, I will always ask if all of their questions have been answered to their satisfaction. If the answer is no, they don't get to sign. Simple as that. If the MD doesn't like that, then I'm sorry. They need to make sure everything is done right while they're there.

[elkpark]

Maybe you misunderstood me, I have no desire nor have I ever obtained consent. I tell the physicians they need to obtain the consent and that is why I am frustrated with being treated like an idiot because the physicians always say " I have never heard of that. You are the only one that makes me go through this." I was posting in hopes to hear some advice on how to deal with this problem because the physicians continue to expect nurses to obtain consent and I have seen nurses over and over obtain the consent. I am not going to jeopardize my license for a physician who is lazy. I am not sure where you got the impression that I want to obtain consent. Maybe you should read my first post.

I would suggest that you check with your nursing administration and facility risk management/legal department. Also the medical staff by-Laws (they should spell out the professional/practice responsibilities of the physicians practicing there).