Informed consent-who what when where in texas

[x4livin, ADN]

I was called upon to assist in making a decision as to who can give informed consent for blood.

This was the information I was given at the time of the call:

Pt was admitted through ER to OR, was given narcan so that she could sign her own informed consent. She was taken to OR 2 days ago. Pt has one unit of packed cells in OR. Pt now has HGN of 9.7 and surgeon was in at night and writes an order for another unit of blood. Pt has a PCA pump that the ICU nurses are pressing the button for upon asking the moaning patient if she is in pain and getting an affirmative response(Morphine 2/10/12) Pt has no blood consent.

Is the OR consent for surgery that the patient signed(with the little added circle yes or no and initial if you want blood area initialed) valid for them to give blood now, 2 days later. I say No.

Is the patient legal to sign a consent. I say no. The patient has 2 "friends" listed as contacts. She has adult children. None of which have been appointed as a proxy or durable;e power of attorney for health care. Her last hgn is 9.7-no where near "emergency". Can they call one of her children and get a second witness on the phone for valid consent for blood. I say no.

I have researched the flip out of this. If it is not an emergency and she has not legally appointed POA for healthcare-and she is not lucid enough to press her own PCA-she does not get the blood unless her doctor wants to come up with a document-able reason that it is an emergency.

This morning, I am told by the ICU manager that "this is how she has always done it", she has "never had any problems before" and she hopes that if she is in ICU and needs blood, that we will call her kids and get permission from them and get her what she needs. If 4 experienced ICU nurses didn't know for sure, they were calling me, 3 CCU nurses agreed with me before we decided to not give the blood, apparently there is a problem. The hospital policy does not define informed consent or who may give it, only that it must be obtaind. She also now states that pre-op did narcan the patient for consent, but that the daughter intimately gave consent for the surgery.

I am finding no where that this is legal. Several states have a "family act" that extends this proxy status to family members upon an acute situation, Texas is not one of them.

Where do I go to get a documented legal answer to back me, whichever the right answer may be? (Yes, the hospital has attorneys, but this has been an issue here from the time I started here 11 years ago, and so far, no one is calling it definitively, and I want something solid to go on.

[dishes, BSN, RN]

Do you you have a legal argument to justify saying that the OR consent form isn't valid if the patient is in the post operative period? What exactly does the agreement to decline or accept blood say on the OR consent form?

[Jolie, BSN]

Non emergent, patient incapable of giving informed consent, no identified proxy. I agree that the blood can wait.

I have a few questions, though. Please be gentle with me, in 26 years as a nurse, I have never cared for sick adults, so my questions may be laughable, but here goes:

1. Don't pre-op and intra-operative orders typically "expire" and have to be renewed once patient leaves the OR setting? Therefore, it seems that the intraoperative blood consent would no longer be valid, not to mention that the setting and circumstances for which the patient consented to blood in the OR are vastly different than those on the post-surgical unit 2 days later.

2. Why, on God's green Earth are nurses pushing the administration button on the PCA for the patient, causing the patient to be so highly overmedicated as to be incapable of a coherent conversation 2 days post-operatively? This raises questions in my mind of appropriateness of nursing care and patient safety that have nothing to do with blood consent.

Thanks for indulging my questions.

[Esme12, ASN, BSN, RN]

I agree with Jolie, my first question is to why after 2 days the patient is not coherent enough to give consent and the nurses need to stop pushing the button for her especially if she is snowed. Stop snowing the patient. Not all hospitals require separate blood consent if the consent for blood and blood transfusions is on the surgical consent. It would be helpful if you knew your hospitals policy on this as it is very facility specific. But there is no law requiring a separate transfusion consent unless deemed necessary by your facility.

As per Texas law..........The law places the duty to obtain informed consent upon the physician and it is non delegable. Hospitals and nurses do not have a duty to obtain consent prior to a procedure.The fact that a hospital or nurse voluntarily undertakes the duty to obtain informed consent does not relieve the physician of the duty, but merely adds additional parties that may be subject to legal liability.In other words, a nurse may be assigned the task of informing the patient and obtaining a signature, but the physician is responsible to see that it is done properly.

Informed Consent

In the state of Texas not all procedure require informed consent and have List A and List B....one for consent and one for not necessary consent. To ensure proper disclosure is given to patients, the Panel has adopted disclosure forms, in both English and Spanish, which physicians may use to inform a patient about the possible risks and hazards of a particular procedure. One of those adopted forms is general in nature and is assembled so that it will satisfy the physician's duty to disclose for many of the surgical and medical procedures in List "A." In addition to that form, there are consent forms designed specifically for the disclosure of the risks associated with radiation therapy, abortion, electroconvulsive therapy, hysterectomies, and anesthesia.

These forms, when properly used, will enable a physician to avail himself of the protections provided by the legislature through the act. Although a signed consent form is important to comply with the law and to document the patient's consent, it is not a substitute for discussion between the physician and patient about the proposed medical treatment.

If a physician has disclosed the risks to a patient as provided in List "A" (and obtained consent through the Disclosure Panel's form) or if the procedure does not require written disclosure and is in List "B", then a legal presumption that the physician did not neglect his duty to disclose.

Texas Medical Disclosure Panel

Thus, based on guidance from staff and counsel, each institution generally develops its own list of surgeries, procedures, or situations where full informed consent is needed. [Manthous 2003] In fact, the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations or JCAHO) has set a standard that hospitals must establish and follow policies that describe which procedures or care, treatment, or services require informed consent. [Joint Commission 2005] One of the first steps recommended in the next section is to clarify your institution's policies about when informed consent is required.

A Practical Guide to Informed Consent

I hope this helps some.