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?
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).
Parents absolutely have the right to refuse a blood transfusion on behalf of their child for religious reasons. The only way for a transfusion to be legally administered in this case is to get a court order that temporarily suspends the rights of the parents.
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?
It is battery because the parents are the legal guardians of the child. In the eyes of the law, the parent's decisions for the child are equal to that of a competent adult. The fact that they signed a full code document doesn't mean that they forfeit the right to refuse other interventions. Though the respiratory distress may lead to a code, it is not a code situation at the time.
It sounds like nothing has made an impact on these parents' decisions regarding their child's care. It looks like the only way you will be able to get them to comply with the advice of the hospital is to have the ethic's committee bring the matter to court and get a temporary guardian appointed for the patient.
Maybe they are picky, maybe they dont want the child suctioned every 10 minutes because they have cared for them at home just fine, maybe they are not complete idiots just because they requested their child be able to rest at night. Sadly this whole thing probably could have been avoided if proper Interpersonal Communication was utilized instead of drawing lines in the sand and isolating the parents. Sad that a whole unit of professional nurses can't resolve something like this without threatening to call CPS. Lee
This is obviously more than a miscommunication between the patients and staff. According to the OP, the parents have been educated several times and spoken to by many staff members. This is obviously blatent disregard for the child's welfare. Asking the the child sleep without being disturbed is one thing. Refusing to allow suctioning when the child is desating or taking the child off the unit without proper medical equipment is quite another.
Do you know how small an infant's airway is? About 1/2-3/4 the size of a standard straw. How long do you think it would take to close that airway off? Infants breath 30-60 times per minute because they have such small lung capacity and need the extra breaths to get adepquate oxygen to their bodies. If that oxygen is compromised, even for a few minutes, it can lead to irreversible brain damage. Whose to say that this child hasn't already suffered damamge and it won't be noticed until the child gets older?
At this point it really sounds like it is more about protecting the patient than protecting your license. And while you can at some level protect yourself by documenting, if anything were to happen to this child you would still be asked to account for the fact that you didn't get social services or CPS involved. Also, the whole thing about living with yourself if the child dies because no one intervened.
Of course management isn't going to listen, they adhere to the whole "customer service" module of health care and so only believe that at all times the "customer" is always right. I think that it is that module that accounts for a lot of the system errors and flaws and catastrophic mistakes that occur in health care. So you're not going to get any support from them because they do not see anything here except dollar signs.
This is not an easy scenario. It will not be easy to fix, it will not give anyone warm fuzzies to fix, it will involve a lot of uncomfortable and disagreeable feelings and unpleasant conversations, and some degree of self examination. That is why we have rules and systems of ethics to guide our behavior -- ethics isn't for the easy cases, it's what helps us deal with the really hard ones.
Has anyone involve the Risk Management department, or the hospital's Legal Counsel? If parents are refusing reasonable/nessary care, for their child, I believe that the hospital/treating physician, can notify CPS. Children have been removed from their parents due to bad choices by parents. A judge can do this.
As I stated above, I would document and call Risk Management ASAP. and involve the hospital's Legal Department.
I would also like to remind you of my usual mantra in cases like this- MAKE COPIES OF ALL OF YOUR NURSES NOTES, CONSENTS, DOCTORS' ORDERS/PROGRESS NOTES CONCERNING THIS SITUATION. Make the copies when no one is around to see you, and do not tell anyone you have done so. These notes/documentation WILL DISAPPEAR, if this becomes a legal issue.
You could find yourself "up the creek..... and hung our to dry", if these notes disappear in sticky situations like this. If the management is letting the parents get away with this stuff, they WILL turn on you, as the at fault profession. They will shift blame to you!!!
Specializes in Acute Care Cardiac, Education, Prof Practice.
I'll reiterate others' suggestions to get risk management and ethics involved.
It might be necessary to have the parents evaluated for their fitness to make medical decisions.
How are they with the child otherwise? Do you see a normal give and take of affection? Do they ask appropriate questions? Are they involved with the child's care? Does this child have siblings? If so, how are they treated?
If normal behaviors are missing, it would make me wonder if this baby is being looked at as expendable in the name of reaping a settlement. The documentation that has been recommended will be your saving grace if it comes to that.
But I would hope that the combined efforts of docs, nurses, risk management, ethics and social services can head off a tragic outcome.
Thanks for advocating for this poor kid.
Sadly this is exactly what I was thinking. Poor tiny human.
Sadly this whole thing probably could have been avoided if proper Interpersonal Communication was utilized instead of drawing lines in the sand and isolating the parents. Sad that a whole unit of professional nurses can't resolve something like this without threatening to call CPS.
Lee
When in doubt, blame the nursing staff for having poor communication skills. Obvious you've not done peds. It's amazing how many parents care more about their own comfort than their child's safety. Refusing humidity for the trach, ugh. Not only does it keep the secretions mobile, but who wants dry air going straight into their lungs? Who cares how loud it is!!!
Management rarely is much of a help in these situations because management is most concerned with customer service. Risk management is who needs to be involved. They're the ones that want to avoid lawsuits.
We deal with this kind of stuff all the time, but we are not nice when it comes to parents like this....niceness only gets you so far.
1. If they are leaving the floor without a dr. order to allow it, everytime they step out of the unit, you call security. We have a locked unit, so they wouldn't be able to get out with the kid anyways and they would set off the alarms.
2. If the baby is in obvious distress and they won't let you suction or they won't suction, again, call security, this is patient safety.
3. The advice above to copy nurse's notes...don't do it. If the hospital finds out you hae done that, you will be fired and if something happens and it goes to suit, you will be on your own and the hospital, and most likeley your malpractice will not cover you....this is a HUGE HUGE HIPAA violation. EDIT: and if the originals go missing and you have copies, it is not admissable, not in the chart, not there at all. It doesn't matter if you have copies...if they aren't in the chart, legal does not consider it at all. The other side could say that those were written a day ago. It is a slippery slope.
4. DCFS will not do much of anything while the kid is hospitalized. Your social worker and management and risk management need to be on board with all this. Have they sat down with this family and spelled out the care, etc? If not, this needs to be done and a POC documented in the chart. We have had parents that are only allowed to visit with security, but this was only okayed by risk management. We have also had a care contract drawn up and the parents have to sign it....they deviate, we call security.
5. Document, document, document and try to have witnesses in the room who will sign your notes also.
6. If this is happening during the day when management is there, call them to the bedside. If it is off shift, have the charge nurse co-sign you notes on this family or if need be, call the nursing supervisor about problems since they have to log it.
It is a tough situation, but it is something you run up against a lot in the peds field...parents who dont' get it and feel a lose of control over their kids lives get this way. Most of the time it is just plan being ignorant, no matter what you do or say, this is how they are and you have to go in and do the best job you can.
Specializes in Spinal Cord injuries, Emergency+EMS.
incident forms , raise your concerns with your nurse manager and the Senior doctor responsible for the child and the clinical director, if necessary (and as a joint MDT decision ) you may have to go legal on it all.
Maybe it is just me but this seems like a super easy fix. Anyone can call CPS at any time without giving their name or information. No matter the outcome of their investigation at least you can have the piece of mind that you did everything you could to protect the child.
Maybe it is just me but this seems like a super easy fix. Anyone can call CPS at any time without giving their name or information. No matter the outcome of their investigation at least you can have the piece of mind that you did everything you could to protect the child.
CPS will typically not get involved until the child is near discharge, at least where I am
For the issue in my unit we currently have the parents banned, it started out with a behavior contract, then one parent was restricted to 1hr visit w/security, then the other ended up restricted to 1hr w/security, now neither can come, we have a security guard sitting outside our locked unit now 24/7. It's unfortunate but they became not only a danger to staff but to the baby as well. Legal, risk management and unit management are all in on this.
* not to mention we have had other patients with MULTIPLE calls to CPS who still go home with those parents and die in a car seat attached to an empty oxygen tank with no apnea monitor on CPS is not all its cracked up to be all the time
CPS will typically not get involved until the child is near discharge, at least where I am
For the issue in my unit we currently have the parents banned, it started out with a behavior contract, then one parent was restricted to 1hr visit w/security, then the other ended up restricted to 1hr w/security, now neither can come, we have a security guard sitting outside our locked unit now 24/7. It's unfortunate but they became not only a danger to staff but to the baby as well. Legal, risk management and unit management are all in on this.
* not to mention we have had other patients with MULTIPLE calls to CPS who still go home with those parents and die in a car seat attached to an empty oxygen tank with no apnea monitor on CPS is not all its cracked up to be all the time
Poor tiny human.
Obvious you've not done peds. It's amazing how many parents care more about their own comfort than their child's safety. Refusing humidity for the trach, ugh. Not only does it keep the secretions mobile, but who wants dry air going straight into their lungs? Who cares how loud it is!!!
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CPS is not all its cracked up to be all the time
Double-Helix, BSN, RN
3,377 Posts
Parents absolutely have the right to refuse a blood transfusion on behalf of their child for religious reasons. The only way for a transfusion to be legally administered in this case is to get a court order that temporarily suspends the rights of the parents.
It is battery because the parents are the legal guardians of the child. In the eyes of the law, the parent's decisions for the child are equal to that of a competent adult. The fact that they signed a full code document doesn't mean that they forfeit the right to refuse other interventions. Though the respiratory distress may lead to a code, it is not a code situation at the time.
It sounds like nothing has made an impact on these parents' decisions regarding their child's care. It looks like the only way you will be able to get them to comply with the advice of the hospital is to have the ethic's committee bring the matter to court and get a temporary guardian appointed for the patient.
This is obviously more than a miscommunication between the patients and staff. According to the OP, the parents have been educated several times and spoken to by many staff members. This is obviously blatent disregard for the child's welfare. Asking the the child sleep without being disturbed is one thing. Refusing to allow suctioning when the child is desating or taking the child off the unit without proper medical equipment is quite another.
Do you know how small an infant's airway is? About 1/2-3/4 the size of a standard straw. How long do you think it would take to close that airway off? Infants breath 30-60 times per minute because they have such small lung capacity and need the extra breaths to get adepquate oxygen to their bodies. If that oxygen is compromised, even for a few minutes, it can lead to irreversible brain damage. Whose to say that this child hasn't already suffered damamge and it won't be noticed until the child gets older?