nursing protocol

caringchic · Feb 17, 2009

that is amazing, so the MD should have said yeah an NG is great, no worries..where does personal responsibility come in??? If the lady felt bad that is what ED's are for, does everything have to feel good? I am sorry but immunizations dont feel good but are necessary, mammograms dont feel great but are preventative, lab draws dont feel good but help diagnose and tx ... what the helll is the world coming to?? Scary to be a healthcare provider ... my best to the doc!

SunnyAndrsn · Feb 17, 2009

A couple a things stick out here:

1. The pt. called the MD at home--why? Was their relationship personal as well as professional, was the MD 'off duty'?

2. The MD advised the pt. to go to the ER for proper treatment, and from a quick search I found even offered to meet her there. This implies that the MD was indeed 'off duty'...and makes me wonder where his liability is in simply explaining the possibilities. It seems this is a bit of a "good samaritan" situation, except that the pt. called the MD at home, the MD didn't just come across someone needing help.

3. Should the MD *NOT* have explained the possibilities at the ER? If he had been vague and said "they'll run some tests" would she have been too afraid to go due to the fear of the unknown?

As for the title of this post, "Nursing Protocol" I'm confused? As nurses we're often asked for medical advice, and if I, as a nurse, had a call from someone like this, I would have responded "Please call the ER/triage nurse at your local hospital" And to the question that is bound to follow "Do you think it's serious/what do you think is wrong with me" I'd reply I don't know, this is why you need to have the proper evaluation but a physcian qualified to interpret the test results and order appropriate treatment--but as your friend/neighbor/family member, I'll be happy to hold your hand while you get checked out."

This physician also recommended the pt. to seek appropriate treatment, and attempted to avoid treating her over the phone--although he did give her possibilities he did not have the ability to have her sign a form that said she was not going to follow his advice and was aware of the consequences.

Section 8.08 of the AMA Code of Medical Ethics addresses duty of disclosure: "The patient's right of self-decision can be effectively exercised only if the patient possesses enough information to enable an intelligent choice."

Balance this with the fact that she was asking the MD to treat her over the phone and had she had gone in, with nothing worse than gas but had a full workup, she may have sued him for malpractice anyway!

i just finished reading on the internet details on a court case, marsingill v. o'malley. some things were mentioned in the discourse that i would like some clarification on. a lady (marsingil) called her physician (o'malley) at home with complaints of nausea, bloat, abdominal pain, inability to burp, and constipation. dr. o'malley said he could not evaluate her over the phone, but if she felt bad enough to call him at home at night she should go the emergency room. she questioned the doctor as to what might happen at the er? doctor stated they would probably take x-rays and insert a nasogastric tube to relieve the pressure in her stomach. she had previously had nasogastric tube inserted, and on hearing she would likely receive this procedure again, ended the call, telling the doctor that she thought she could now burp and felt better and ended the call. patient's husband later found her unconscious on the floor and summoned ems. it was discovered that she experienced an intestinal blockage which caused her to go into shock, from which she suffered brain damage and partial paralysis. when her family filed a lawsuit, one of their expert witnesses testified the doctor's actions fell below the standard of care, stating that a competent physician who wanted to encourage a patient to seek emergency room treatment would not have offered the possibility of being treated with a painful procedure of inserting a nasogastric tube. i guess the crux of my question concerns E.R. ethics and protocols. what would have occurred in the emergency room when patient got there? if she refused insertion of nasogastric tube, they could not force her, is that not correct? i know there are certain instances in er protocol where patient is considered not competent to make medical decisions, and treatment could then be forced on her. would this be one of those times? are N.G. tubes really that awful? i decided to go ahead and ask this question as it really has very little to do with the lawsuit per se. thank you very much.

kellykelly · Feb 17, 2009

I hope this gets thrown out of court. Her family should be ashamed of themselves. So, the doctor should have been dishonest and pretended all they'd do was take a look at her in the ER and send her home? Or he should have refused to answer her question with an honest answer because the honest answer led to her deciding to forego treatment?

Some people...I just shake my head at what makes family members and patients feel they're ENTITLED to money from frivolous lawsuits like this one.

kellykelly · Feb 17, 2009

...and to get back to the other part of the OP, I don't work in an ER but we have had people refuse treatment on the floor. In this case, unless the patient was a DNR, we would have treated her after she passed out (providing she was mentally competent to make the decision to refuse the NG and other threatment while she was conscious, and after we had exhausted all attempts to persuade her and her family to agree with treatment) and the family would probably be busy trying to sue us for going against her wishes. *eyeroll*

Document, document, document, CYA CYA CYA.

loricatus · Feb 17, 2009

Oh come on. This doc did everything right. He provided what consituted informed consent and should not have to suffer for providing the truth to his patient.

This customer service mentality has gone too far. It is time that some patients take responsibility for the informed decisions they make.

suanna · Feb 17, 2009

I hope they don't get a dime. Patients make stupid decisions, refuse to follow doctors instructions, and get sicker- but it is somehow the doctors fault. Why in the world was this lady even on the phone with her doctor- call the office- can't get in- go to ER if you feel really sick. People who think they have a private doctor at thier beck-n-call are as bad as the ones who think the ER is for every minor complaint they were too busy to make an appointment for during the day. If we are going to resolve the health care crisis in America one of the biggest changes is the public has to have a major attitude adjustment. If you have a family member die- it isn't a hot ticket to the malpractice lottery. How about this-you pay the hospital and doctors legal costs if you lose! After all, they are going to be paying yours out of the settlement if you win! If you had a chance of losing $50,000 you are less likely to throw the dice over this sort of thing. Second, people also need to learn that just because 3-4 attending specialists are starting your IV and doing your bath on "House" dosen't mean you are going to get that kind of care outside of the TV. Thirdly, doctors are not God- even if they sometimes act like it. If a 95y/o dies of pneumonia in a nursing home- sue the Pope, not the doctor that got them to 95 years old. Sorry-I'm ranting again:uhoh3:

iluvivt, BSN, RN · Feb 17, 2009

This case should not even get to court. this is standard advice. The md was correct you cannot diagnose over the phone and instructed the patient to go to the ED and the patient could have called 911. Had I been the MD I would have thought it suspicious that SUDDENLY her symptoms were magically gone and urged her to go to the ER and stressed the reason why. Regardless.the patient is ultimately responsible for her decision.

Flare, ASN, BSN · Feb 17, 2009

Talk about frivilous law suits. I am so tired of people not taking responsibility for thier own actions. Sure - an NG tube is probably not the most pleasant feeling, but ask the guy who just got his painful gut decompressed if he thinks it's worth it (especially with the concurrent use of analgasics while in the ER) and he's sure to say yes. The patient called the doc (assuming she either called his answering service, or had his home number (caller id from a previous call back could provide that)) and he obviously either was not on call or thought that this was something out of his range of services. The doctor shouldn't have lied - then we have an ethical dilemma. He certainly was truthful in saying that he can't evaluate that over the phone and was more than correct in refering her to the ER. Of course, you can lead a horse to water but you can't make it drink.

CoffeeRTC, BSN, RN · Feb 17, 2009

So if the doc lied and said..you will be getting an NG, but it it easy...they would probably sued over that one...pain and suffering. Geesh.

Like telling a kid..it isn't going to hurt a bit then bam!!!

J.R.theR.N2b · Feb 20, 2009

it seems quite a bit of the family's argument is based upon the effects of the doctor telling the patient that she most likely would have a nasogastric tube inserted. it was still the patient's choice however. the doc told her on the phone that if she felt bad enough to call him at home afterhours, she should go the emergency room. she chose not to, and for the family's argument to have any validity they must have expected the doc to lie to his patient. if the lady would have elected to go the ER and they told her of the necessity of the NG tube, she would most likely have refused. then to the best of my knowledge they could not have forced the tube on her. i admit that i too would certainly not want a NG tube, or a foley, or an IV because they do hurt. but if you are feeling as this lady says, it seems like a little (even quite a bit) of acute discomfort would be preferable to hurting. if this patient entered your ER with the symptoms she described, and then refused, would any attempt been made to consider her as "not competent" thereby gaining a type of consent?

sharkdiver · Feb 20, 2009

J.R.,

A competent patient has the right to refuse any procedure or treatment, even if the result of that refusal may be life threatening. Patients are also assumed to be competent until it is proven otherwise, and the refusal of care in and of itself is not considered an indication of incompetence to make medical decisions. If a patient can demonstrate that they understand the potential risks of refusing a recommended procedure or treatment, they are willing to accept those risks, and can state the reason(s) for their refusal, they have met the basic standard of competence in making what I like to call an "informed refusal". Whether you agree with their specific reason(s) or not is irrelevant.

Any attempt to force a procedure or treatment on a patient that they have refused is a criminal act (assault and/or battery depending on the laws of your specific state).