Ethical Dilemma

  1. I had an incident come up recently, but I wanted to see what you all thought. I don't remember all the specifics, but I'll give you the scenario as best I can. I had a patient who had surgery a few days prior. Some kind of Ortho surgery. The patient had been draining from his incision and had been monitored for a few days. I had the patient for night shift. If his drainage was improved in the morning, he was going to be discharged. However, in the unlikely scenario his drainage increased, the plan was to take the patient back to the OR. He was therefore NPO at midnight. At midnight, I removed the food and fluids from the bedside and told the patient he couldn't eat or drink. He basically said he'd tolerate while he was sleeping but there was no way he was agreeing to go the OR and in the morning he was eating. Everything was fine until the residents rounded at 5am. They didn't give him a definitive answer (they were waiting for the attending) and the man began to demand something to drink and food. I told him he was still NPO, but I'd check with the doctors. The residents refused to change the order, even if he was refusing the OR and also refused to come see him and speak with him about it. I tried to keep stalling the patient, but at this point he was becoming quite angry. He was physically not really capable of walking to the ice/water machine. I gave him some ice chips to tide him over. I personally felt like I should give him what he wanted. After all, he can refuse anything he wants to, including being NPO. But my manager said that if I gave him the fluids it was legally questionable. I managed to stave it off till I left at 7am and I'm not really sure what happened after that. Was I right or was my manager right?
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    About cjcalimer

    Joined: Sep '07; Posts: 33; Likes: 38


  3. by   Daisy_08
    Not really an ethical dilemma, more like what to do with a stupid pt dilemma.

    As long as he is a mentally fit adult, then you can’t do anything to stop him, and even then? Make it clear he is eating against medical advice and make him aware of the consequences. It needs to be an informed decision. If he still wishes to eat... Bon-appetit! Let the doc know, document it all, and depending on you environment even get a witness.

    I feel like a read somewhere on here about a nurse being charged with something for not giving an NPO pt food when asked? I don’t think it stuck though.
  4. by   Orange Tree
    If he wanted to get food himself or ask his family to bring it for him, I would document teaching, but not attempt to stop him. I wouldn't involve myself by hand-delivering a cheeseburger, though.
  5. by   CharleeFoxtrot
    I'd have advised the Pt that this was against medical advice, gone and got the ice chips, called the charge and have them stat page the attending then document-document-document!
  6. by   classicdame
    has nothing to do with ethics except that it made you feel bad, and you had a conflict between doing what the patient wanted and what the MD wanted. It makes it even harder when you realize that most surgeries do not require more than a few hours NPO, not 12-18 like we sometimes submit our patient to doing. We have all gotten into the routine of NPO after midnight, even though it is not required and, for diabetics and some other patients, is a detriment. Regardless, you did the right thing. Too bad the resident could not make a decision without the attending. Too bad the attending was not around. Too bad the patient was irate and you were caught in the middle. But in this instance, you could not serve as the pt advocate. You had to be your own advocate and document carefully. I agree that AMA forms and calling the attending are all good options, but none replace documentation.
  7. by   Roseyposey
    At the end of the day, our patients have free will. This doesn't mean that you have to order them a pizza, but just be sure to document the teaching and inform the appropriate people that the patient is not npo (and document that too).
  8. by   nurseprnRN
    The patient is absolutely free to refuse any part of the treatment plan -- including NPO. Just because they call them doctor's "orders" (a leftover from the military past) that is not how we look at our intercollegial relations now.

    There's a difference between an ethical conflict and something that makes you feel uncomfortable or unclear. There is plenty of opportunity for the resident to learn about that, too. The patient can refuse; he is not in jail, was not declared incompetent by a court, and was not under guardianship. If he were so inclined he could make life uncomfortable for the hospital because he was denied a reasonable request for food and liquid, stated that he knew he couldn't have surgery in the morning if he ate and drank, and didn't want it anyway.

    There's no ethical dilemma here. What there is is a problem with staff who don't know enough about patient rights. What's "legally questionable" is the idea that your manager gave you, that giving him fluids would be risky for you or her. Not so. Do what he wants, chart the heck out of it, notify the attending or chief resident since the underling doesn't have any authority, and have a good night's sleep.

    Might be fun to run an inservice on this for the house staff and nurses.
  9. by   lhflanurseNP
    Had the patient signed a consent for surgery? Even if he had, the patient has the right to refuse and according to what you have written, that seems to be the case...changed his mind? never agreed?
  10. by   RNperdiem
    Oh the aggravation! This is the kind of patient who will not listen to medical advise, and then when bad things happen will be the first to say "they are trying to kill me!" and complain about the bad care they received.
    It is never their fault
  11. by   BrandonLPN
    The pt has a right to eat and drink. But in violating doctors orders, I feel the hospital is within their right to discharge his butt and let him seek treatment elsewhere.

    What's the point of being in a hospital if you're going to refuse doctor's orders? It's the doctor's job to dictate the treatment plan.
  12. by   BrandonLPN
    And if the OP were to give food or water against doctor's orders, isn't that a breach of the nurse's duty? We cant physically stop the pt from getting food or water themselves or from family giving it. But if NPO is ordered that means we are forbidden from giving it ourselves.
  13. by   nurseprnRN
    Quote from BrandonLPN
    And if the OP were to give food or water against doctor's orders, isn't that a breach of the nurse's duty? We cant physically stop the pt from getting food or water themselves or from family giving it. But if NPO is ordered that means we are forbidden from giving it ourselves.

    Not true. We don't work for the physician. Our first duty is to the patient. You can look it up. ANA Scope and Standards of Practice apply to all nurses in all settings.
  14. by   Roseyposey
    Who are the doctor's orders written for???? The name on the label is not Brandon LPN, it is Patient Doe, John. This is what doctors and nurses alike tend to forget. The doctors are absolutely NOT giving ME an order!!!!! I do not take orders from anybody. I, as a nurse, FOLLOW orders. The order is FOR the patient. I carry out the orders. We are doing for the patient what they cannot do for themselves. If they were at home they would either take their Lisinopril or they would not....the order is for their care. In my world, we do not call them "doctor's orders," we call them "suggestion sheets." A patient can choose to selectively follow THEIR orders. We document which orders are carried out and which are not.

    ....sorry guys, hot-button issue.