Refusing "Hospital Protocal"

LizzyL&DRN · Jul 5, 2007

Then maybe she should go home and have her baby or a birth center. In our facility we would vigourously explain the importance of our protocols and that we only want whats best for the patient and her baby. If she continues to decline everything I would have her sign an "Against Medical Advice" form listing everything she is refusing. This form will protect the nursing staff and hospital and the doctor if something tragic would to happen. We would care for her at that point the best we could to ensure her and the baby's safety.

Super Nurf · Jul 6, 2007

Document, Document and Document. Do hospitals usually have forms for refusal of care?

Preemienurse23 · Jul 6, 2007

Contact your legal department and ask them, or call your nursing administration and ask. They would be able to tell you what forms/documentation needed to be done.

Jolie, BSN · Jul 6, 2007

What happens if a woman refuses what a hospital considers "protocal'? What if she flat out refuses to have an I.V., amniotomy, EFM, ect.?

It is the responsibility of the nursing and medical staff to explain the risks and benefits of each intervention to the patient, document their teaching and the patient's response, and then go on and care for the patient to the best of their ability, given the limits that the patient sets.

Forcing an IV, monitor, or amniotomy on a patient who has refused is battery.

In my experience, things rarely go this far. Most patients are quite reasonable when the risks and benefits are clearly explained to them, and in a true emergency, very few refuse crucial interventions.

I have one question for those who work at facilities with rigid protocols regarding IV's, continuous monitoring, etc. How do you manage patients who come thru the door crowning? I assume that there is not time for IV's or continuous monitoring in those situations, and those deliveries probably go just fine.

I personally have no problem with placing a hep lock and doing intermittant monitoring. That is what I had with my deliveries. But if a patient wants otherwise, and there is no immediate danger to mom or baby, why try to force the issue?

fultzymom · Jul 6, 2007

Patients are allowed to refuse any treatment that they do not wish to have. Your best bet in this situation would be to educate the patient/family of the need for the procedure, ensure they the fully understand the risk vs. benefit et then document the education you did and the refusal of the patient/family.

CEG · Jul 6, 2007

If the patient refuses a procedure after having risks and benefits explained to them, why is this such an emotional problem? In reality, continuous EFM and amniotomy have been proven to actually worsen outcomes. The need for an IV is precautionary at best if no meds are given (which is admittedly a rare case, but do most women actually need pitocin to deliver a baby?). Not everyone has the option of birthing at home or in a birth center due to insurance problems. This is such a frustrating example of the lack of evidence-based practice. Practice needs to be changed in hospitals to reflect current recommendations. Patients shouldn't be forced to submit to unscientific protocols to satisfy legal concerns.

tntrn, ASN, RN · Jul 6, 2007

If the patient refuses a procedure after having risks and benefits explained to them, why is this such an emotional problem? QUOTE]
Because if something does go wrong, you're still going to get sued. Signing a disclosure that the risks were explained to you is really a worthless piece of paper. Anybody can sue anybody for anything at anytime under any circumstances.
I'm with the response that suggested that person should go home to have their baby.
(Once had a home birth patient with her lay midwife who showed at our facility after 6 hours of pushing and no baby and announced to me that she didn't want an IV. Okay. And exactly what did you come here for then, if you're going to refuse to try other methods of getting you a good baby.)
I personally think that epidurals are way overused and over suggested as well. I love a great natural childbirth. But I'm also realisitic enough and old enough to have seen perfectly good labors go right to a bad place. In those cases, I am so thankful for a hep lock at the very least. How invasive is that really. In a perfect world no labors would ever go bad, no babies would ever be lost, but the world isn't perfect. I'm also too old to enjoy the massive adrenaline rush of a crash section anymore. There was a time---

LizzyL&DRN · Jul 6, 2007

Forcing an IV, monitor, or amniotomy on a patient who has refused is battery.
In my experience, things rarely go this far. Most patients are quite reasonable when the risks and benefits are clearly explained to them, and in a true emergency, very few refuse crucial interventions.
I have one question for those who work at facilities with rigid protocols regarding IV's, continuous monitoring, etc. How do you manage patients who come thru the door crowning? I assume that there is not time for IV's or continuous monitoring in those situations, and those deliveries probably go just fine.
I personally have no problem with placing a hep lock and doing intermittant monitoring. That is what I had with my deliveries. But if a patient wants otherwise, and there is no immediate danger to mom or baby, why try to force the issue?

I agree, I don't know any nurses that would force a patient to have anything done to them they didn't want done. All hospitals have protocols but it's my understanding the doctor can change the protocols as they relate to specific patients. For example, we have Q4h vital signs for all our patients. We have a lot of long term antepartum patients that frequently complain about waking them up all the time for vitals. The docs simple write an order to change that. Why not for laboring patients who want to walk. I think all our docs will allow mom to walk as long as the patient has a reactive NST. I've never had a pt refuse everything. Even the most determined patients allow a heplock in my experience. I do wish more of our docs were more accomodating to women that want to deliver in different positions other than lithotomy.

HappyNurse2005, RN · Jul 6, 2007

you can refuse any darn thing you want! Most women don't know that, though, and if they were attempting to refuse it, i'd ask them why (to combat any misinformation), explain risks/benefits/alternatives, and document.

I've had ladies refuse iv access. then they are discussed with how if they bleed excessively after birth they might need a shot in the thigh. (one lady said no to that, too, one refused initially, but consented after she was bleeding a bit too much). one lady refused all needles of any sort whatsoever, and had even done so during all prenatal exams. ladies have refused ultrasounds, cervical exams, etc etc.

you are a patient, not a prisoner, and can refuse anything you want. i would just be sure to know the risks/benefits to what you are refusing to make sure it is an acceptable trade off to you.

mbobrn · Jul 9, 2007

Practice needs to be changed in hospitals to reflect current recommendations. Patients shouldn't be forced to submit to unscientific protocols to satisfy legal concerns.

I have to totally agree with you. I am currently working out of the USA. I here all the time..."well, that is the way we do things here!" Thanks for your comment.

Melissa

NPinWCH · Jul 9, 2007

I teach our hospital's childbirth ed class since no one else wanted it and I tell each and everyone of my students that they have the right to refuse ANY care they do not want, BUT if you choose not to have an IV/hep lock, pitocin, continuous EFM then you should bring it up with your doc before you show up in labor, better yet at your next appointment.

There is nothing worse then trying to admit someone who refuses just about every protocol in place (lab draw, EFM, IV, abx for GBS...) and when you call the doc to tell them they are totally and righteously angry. The typical statement is, "I've cared for her for the past 7 months and this is the first I've heard about any of this". Labor is the WRONG time to bring this stuff up.

In class I make sure everyone understands why we do the things we do. That being said, our docs have no hard and fast rules concerning EFM, unless they are on pitocin. I encourage intermittent monitoring, say 15-20 minutes on the monitor then 45 minutes up and about the room. If a pt refuses an IV, I find out why, and encourage a hep lock. If a pt doesn't want blood drawn because it's one more needle, I'll draw with the IV start. Usually the patient just wants their concerns addressed.

Alot of the things we do are at best useless and at worst increase the risk for C/S so...unless it's life or death I almost always side for the pt.