Liability and giving opinions

classicdame, MSN, EdD · Jun 19, 2008

oh yeah. We all would be rich if paid for every inappropriate remark ever made. At least you learned from yours. Keep us informed. Don't beat yourself up. Maybe you were the catalyst that got everything rolling. And if she DOES have a brain tumor you did not give it to her.

gonzo1, ASN, RN · Jun 19, 2008

I for one don't think you did anything inappropriate, and the conversation did lead to learning more about the pt and her history.

When asked what "could be wrong", I don't think running down a list of possibilities is diagnosing at all. These are things the person could have found for herself if she did a google search for ear pain and falls.

LTC doctors seem to be notorious for trying to keep nurses "in their place"

You have a duty and a right to educate your patient and her family, and to advocate for them.

Don't be bowled over by arrogant fools.

PMHNP10 · Jun 19, 2008

I recently was in a tough situation, and made a comment I now regret but still feel a bit of fustration! I take care of a 86 year old lady with multiple chronic illnesses, she has some dementia and anxiety issues. The RP is her daughter, who is very sweet and I have established a wonderful repor with over the last year or so that I have taken care of her mother, I have built a relationship of trust and respect, (which is not always easy in LTC). The resident has recently had c/o her ears "not feeling right", they "feel funny", she c/o of not being able to hear from time to time. I reported to MD and requested he check her ears...after more than one request the NP writes an order for a ENT referral, our SW contacts the daughter, who questions why? Daughter fears the out trip and visit would cause her mother alot of duress as her mother doesn't even like to leave the floor for the ice cream parlor! SW calls me and states she called MD to clarify for the daughter and MD requested the nurse look in resident's ears, so SW was asking me to do so!! I felt this was inappropriate. Daughter also asks me why the ENT referral and does she really need to see a ENT? Seems there is no communication going on between MD and RP...I am once again the middle man! I told the daughter I can not make the determination if resident needs ENT, daughter really struggled with decision, she kept putting it back on me..finally I said it....the words I deeply regret but then again I don't. Resident fell x3 in short period, I called the daughter to report, daughter asks me if I think it could be related to ear c/o, again asks if I think she needs to see ENT..I replied that we colud not know until evaluated because it could be anything..she continued to ask questions and ponder decision, I stated her ear c/o could be from nothing or something very serious, I gave example of either wax build up or God forbid, a tumor. The daughter then states, "My mother does have h/o a brain tumor in the base of her brain, didn't you know?" Nowhere is this in the resident's medical record, I even checked with medical records, I called MD, who was furious and scolded me up and down for my comments....he said NEVER should I mention a diagnosis, we can be sued. But I found out my client has a brain tumor..I was asked my opinion and put in the middle of a situation, I said the problem could be anything, trying to get out of makng the decision myself. I am usually very careful about what I say, and I am always asked my opinion and for advice from family members. I was trying to help this daughter make a decision and learned something of my resident past medical history. But I made a huge, "No No" and am feeling very uneasy. Anyone ever done something like this??

I'm really confused here...what was the inappropriate remark--the possibility of her ears "'not feeling right'" resulting from anything from wax buildup to a tumor?

If so, IMHO, there was absolutely nothing wrong with saying that. Now had you said "it's a tumor", then yeah, you just made a Dx; but you gave a range of possibilities and stressed that only a ENT could truly determine what (if anything) was wrong.

Once again we have a situation where a nurse is criticized needlessly and you allowed the doctors misguided statements convince you that you are in the wrong and if you read your own words, you aren't even sure why you feel this way. Your comment was not at all inappropriate. It's unfortunate that this situation turned in that direction.

I'll be honest, when I read the post, I immediately said...what's the problem here, but then started thinking...well maybe there is one because after all, you kinda acknowldged there might coulda sorta maybe been one or maybe not; then I was like...O good grief. The doc is absurd.

RN1989 · Jun 19, 2008

You were trying to educate the daughter by giving her a range of things that could cause a problem. You didn't say she had a tumor or any other problem, you were merely demonstrating that it could be one of a thousand things or nothing at all.

This woman took the comment way out of context because she is one of those irritating families that gets fixated on one insignificant thing and flys off the handle.

Now you know that you should just limit any conversation with this woman and when this type of thing comes up, give her a choice of what SHE wants done. Say "Diane, you complained that your mother's ears might have something wrong. I've contacted the doctor and we have an order for a consult. Now you say you don't want the consult. You need to decide whether this is a true problem that needs to have a dr check or if you'd rather not do anything. Please let me know when you have made a decision." Or something to that effect and just leave it.

Yes, she might notice at the beginning that you are pulling away from the relationship you had, but as her mother ages and becomes more debilitated, this type of thing will happen more and more. Save yourself the headache, do the best you can for the resident, and put some boundaries on the daughter's behavior when you can. Always put it back on the family, after all it is their choice and without their permission, there is nothing you can do. That whole "momma is getting older and going to die and I feel guilty" thing really makes people do some annoying things to the staff.

CapeCodMermaid, RN · Jun 19, 2008

What did you do wrong? You attempted to act on the information you had been given. It is the RP's choice to send or not to send to the ENT. Chart that she was given the info and refused an ENT visit. Don't beat yourself up...seems like you had the patient's best interests at heart. And tell that doc to get......

Furwillfly · Jun 20, 2008

I don't see where you said anything wrong either. I had to read your post 3 times to see if I was missing something!

You gave an opinion of possibilities, not a dx. Your MD is being anal retentive (ooops did I just say that???):chuckle

I have had close family members act a little odd when they have been stressed out, so don't think your repore(sp?) will be jeapordized.

Have a 99 year old resident whose family flew in to see him, which they do every year. Great people, I have a great repore with them. The daughter just critisized employees up and down this time. At first I was offended, but the more I got to thinking about it.........she knows she probably won't be coming back to visit him next year. He has declined greatly...imagine that... I had a heart to heart with her so I could help her on a more emotional level. :twocents:

Daytonite, BSN, RN · Jun 20, 2008

i don't think that your conversation with the daughter was inappropriate at all. you must understand that as a charge nurse you are responsible and entrusted with the management of the patient's care. fyi. . .a fall can be related to an ear problem, specifically dizziness caused by a possible inner ear problem, and i would have mentioned that to the daughter as another reason to get an ent consult. also, i worked in ltc. it is very appropriate for nurses to know how to use an otoscope and check the resident's ears. i learned how to do this in nursing school. in ltc did ear irrigations and wax removals (after getting doctor's orders) all the time. you can see how ear examination is done on this thread in the student forums: https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - health assessment resources, techniques, and forms

CoffeeRTC, BSN, RN · Jun 20, 2008

I agree with everyone here. You did nothing wrong. Does your facility have an otoscope? We have one, no batteries and no ear pieces. You will be surprised at what you will find. At another facility...it was a regular part of the assessments and also done after falls etc. Again...you would be surprised.

Often in LTC, we nurses are put in that hard spot. You have docs that don't come in unless they have to then you have families that think the docs are in the facility rounding just like a hospital then you have the families that want everything done or just a few treatments....

document, document, document.

suanna · Jun 20, 2008

Your comments may have resulted in an escalation of the daughters anxiety but they were not unfounded or unsolicited. The daughter asked your professional opinion about the need to see a ENT- you gave it. The doctor is an A** for chastising you for doing your job. Just because the doctor is a jerk don't feel bad about performing you duties by explaining the rationale for seeing an ENT. If a patient or family member doesn't want to know the answers they shouldn't ask the questions! A Hx of a previous lesion is an improtant piece of data you should have beed told long before this. The fact they you weren't given this history is the only thing I find fault with. If you had known this you would have been a bit more diplomatic in reviewing the possible reasons for seeing the ENT- but the answer is still the same- even more so with this history.

nowinsituation · Jun 22, 2008

My relationship with the resident's daughter was not effected at all, daughter is a sweety, she was not upset at all, she just wanted to know why it was worth putting her Mom through a out visit, remember this is a client with alot of anxiety. It was the MD and the NP who chewed me out and lectured me about how inappropriate my saying "tumor" was, MD yelled I should NEVER say anything like that, NP asked if I read nursing journels?why I didn't know better??, NP also stated that I was lucky that the client does have a brain tumor because if she didn't and then was diagnosed, we could be sued. Which I thought was a awful thing to say. I can't figure out how we would be liable?? I also don't feel like I did anything wrong but didn't know if that was from my own ignorance?? We do have a otoscope, but no way would I take on the responsibility of determining whether a ENT consult was indicated and worth making transportation arrangements, private duty, putting the resident through tons of anxiety..I feel that is the physician's responsibility. BTW the evening shift nurse told me that the NP never looked into the ears herself as she said she would. The tumor was diagnosed as benign, inoperable, and on the brain stem back in '02, MD and NP were also unaware and added to progress note ASAP!!! Daughter has agreed to a ENT consult. I was wondering if true if a lawsuit could occur as physician and nurse practitioner have claimed for something like this?? I was really upset when physician chewed me out and had thought I was doing what was in the client's best interest.

aloha551 · Jun 22, 2008

I read your post carefully. You did quite well as a matter of fact. Maybe the Doc was having a bad day and you were there at the right time and an easy target. Please don't loose any sleep over it....Aloha