Noncompliant parents. Do I have any rights to protect my license?

[RNC-NIC]

We currently have a baby on the unit whose parents refuse to allow necessary medical interventions. They refuse to allow this patient to use mist with the trach collar because they think it's too loud, they leave the floor with the patient without resuscitation equipment or even informing nursing, they refuse suctioning even if the patient is bubbling over and desatting (oh, they'll cough it up and come up, this happens a lot) and they won't allow chest PT despite the patient plugging.

They accuse staff of not responding to other patient alarms and are constantly eavesdropping on other patients and are hypervigilant for mistakes in care. They also will not allow nursing to assess the patient overnight and when this person is sleeping.

The parents have been spoken to repeatedly about at least informing nursing before leaving with the patient and to bring the BVM and safety equipment but they repeatedly state they'll be back soon and that they just suctioned the patient so bringing a portable machine isn't necessary. They absolutely will not grasp the concept that anything can happen at any moment (this patient has a critical airway), and just because they just performed suctioning does not mean the patient may not need another if they're a half hour away from the unit on a walk. The patient isn't even CLEARED to leave the unit.

Security has been involved, social work has been involved, and the parents don't care. "It's my child and I'll do as I see fit." It isn't for a lack of education as many MANY nurses and even practitioners have attempted to educate this family.

Our unit rotation is coming up and I'll be taking care of this baby. I want to make them write a statement saying I'm not responsible if something happens to their child due to their refusal of interventions. I want to put it back on them that "Okay, so I can document you're willingly risking your child's life?" if they refuse to take the resuscitation equipment.

I would actually like them to request me NOT to be their child's nurse, as I will refuse to withhold the necessary care like suctioning just because the parents don't want it done, UNLESS they are willing to release me from liability. Has anyone ever had this happen? Did you have any recourse other than documenting the parents' response?

[apocatastasis]

I would go up the chain of command. Discuss with nurse manager, higher ups if necessary. Involve the physician. Most importantly, document everything. EVERYTHING. Encourage your co-workers to do the same. You can't be held responsible for irresponsible parenting. Follow your institution's policies and procedures... and you do have your own malpractice insurance... right?

[RNC-NIC]

I would go up the chain of command. Discuss with nurse manager, higher ups if necessary. Involve the physician. Most importantly, document everything. EVERYTHING. Encourage your co-workers to do the same. You can't be held responsible for irresponsible parenting. Follow your institution's policies and procedures... and you do have your own malpractice insurance... right?

I do have my own malpractice insurance, however I don't see why I should end up paying the price for parents who will not heed medical advice about their child, yet practically threaten nursing about keeping their baby safe. It's gone way up the chain of command and then dies on deaf ears. My fellow nurses have been trying to follow policy/procedure but the parents won't allow us to do so.

[diva rn, BSN, RN]

Can you call Child Protection Services? What did the Social Worker say? What does the Pediatrican say?

I am not so sure you can refuse to take assignment...can be construed as abandonment I think, unless you make previous arrangements with manager to not get this pt as an assignment...but someone needs to take care of this kiddo....someone who will be vigilant...what if every nurse on this unit says they don't want to take care of him?

Someone needs to look out for this little kid while he is in the hospital at least--God knows what happens when he is at home.

[himilayaneyes]

The best advice is to document document document. I hate to hear these types of stories, particularly of families refusing necessary medical care. Just document the refusal and the education provided. I think if you suction their child against their will, they could potentially press charges against you. I think it would be like bathing an oriented patient who didn't want to be bathed. Be careful. Best way to protect your license is to document. Good luck.

[cherrybreeze, ADN, RN]

I highly doubt you can have them sign something like that.

Sadly, they CAN refuse cares, unless there is a court order for these cares to be done despite the parents' objections. You can think all you want that you'll suction the patient even if they refuse, but you can't do that. THAT is what would put your license at risk; it's battery.

Has your facility looked into the possibility of a court order, since it would seem that the parents' decisions are threatening the life and well being of the child?

I'm not sure how well it would go over with your coworkers if you refused to care for this patient. The risk is the same for any staff member, so that may come off as prima donna type of behavior. If you care for this patient and family, DOCUMENT, DOCUMENT, DOCUMENT. That should be enough to protect you. If they take the patient off the unit, you could possibly ask them to sign an AMA form (we've done that for patients that insist on going outside to smoke and there is no order allowing them to do so). However, they can still refuse to sign THAT, and if that's the case, two staff members who witnessed the refusal can/should sign it. Bottom line, though, is that you need to make sure to document what you did, wanted to do (ie, suction the patient), the patient's condition at the time (objectively, of course), the parents' response, and the outcome (either way, if their condition improved as a result of something you did, or if resolved itself because you weren't allowed to, etc etc etc). If there was a large amount of mucus/bubbling that you felt required suctioning, but the parents refused it, how long was it before the patient was able to clear it themselves? That sort of thing.

It sounds to me, though, from what you say, that social services and risk management need to be MORE involved. If it isn't enough to get a court order for treatments, there isn't anything else you can do (which yes, I find terribly sad, that poor child). You can't have them sign a form that you just create, that's not legal. Doesn't sound like they'd sign it anyway, and all the attempt to do so would result in is further alienation between these parents and the staff.

Best of luck, and keep meticulous notes and records in the chart when this patient is under your care.

[RNC-NIC]

The best advice is to document document document. I hate to hear these types of stories, particularly of families refusing necessary medical care. Just document the refusal and the education provided. I think if you suction their child against their will, they could potentially press charges against you. I think it would be like bathing an oriented patient who didn't want to be bathed. Be careful. Best way to protect your license is to document. Good luck.

This really bothers me to hear. I have been a NICU nurse for almost 10 years and have never had this problem. Recently our unit has been taking readmits that were discharged from our NICU and retaining chronics for a ridiculous amount of time instead of graduating them because of a steady decline in census, and it has opened doors to things we haven't had to experience before, such as a situation like this. I don't understand how parents don't have the right to refuse a blood transfusion on their child for religious reasons, yet I can't suction a baby who is demonstrating signs of respiratory distress such as audible secretions and low sats (keeping in mind the baby has a critical airway with a neo tracheostomy tube. It doesn't take much for a trach that size to plug off).

[mikesgirl1]

I dont really know how it works in the hospital.... in homecare we call child protective services to deal with the non compliant parents, and document everything also we are privelaged enough to refuse to provide service

[Chico David, BSN, RN]

It's stupid on the part of the parents, and sad for the child, but as long as their repeated refusals to abide by reasonable rules are documented, I think it's overkill to worry about this reflecting on the nurse. Document everything, do your job as best you can and don't fret about it coming back on you - there are some reasonable limits to what you have to worry about.

[RNC-NIC]

This is what I don't understand though. I could understand battery if it was an A&O adult refusing a treatment, however this is an infant who cannot communicate their needs or advocate for themself. The parents have this baby as a full code with no restriction on intervention. With that form signed, how can they refuse care in a situation that has the potential to lead to a code?

[apocatastasis]

I do have my own malpractice insurance, however I don't see why I should end up paying the price for parents who will not heed medical advice about their child, yet practically threaten nursing about keeping their baby safe. It's gone way up the chain of command and then dies on deaf ears. My fellow nurses have been trying to follow policy/procedure but the parents won't allow us to do so.

I agree, but in a situation like this, all it takes is a dead baby and a lawsuit brought against you to cause you serious trouble. You don't need to be guilty to have to shell out a ton of money for a lawyer. And any nurse that relies solely on his or her hospital for legal counsel and representation is foolish. Document and have backup. Like others have said, I would also discuss refusing the assignment with your NM. You're definitely in a difficult situation, I can't imagine how you must feel. :hug:

[linearthinker, DNP, RN]

Just document. Encourage your colleagues across all services to do the same. I'm surprised the hospital agrees to admit them, considering they bear the most liability in this scenario.

I would be obnoxiously clear with the parents. I would say, "Let me be clear, you are refusing to comply with potentially life saving suctioning" or "safety protocol regarding _______________" "Let me be clear: You understand that failure to comply could result in little Susie Q's death?" And document that and their response word for word.

Ugh. Sorry you are dealing with this. Take care.