Obtaining circ permits (long...)

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Specializes in Community, OB, Nursery.

Before I get to the point: This is NOT a debate on whether circs are right or wrong, not an opinion debate. Don't want to get into it here. Anyone who's read any of my other posts on the subject knows how I feel about it. I am asking for help in streamlining a process that is not working at our facility. Also, I am not doctor-bashing, although it may seem that way.

Ok, now to the point...

Here's how we do it at our hospital: When mom comes to the hospital, the triage RN completes the pt profile and asks if mom would like her baby (if male) to be circed. She then puts a sheet in mom's chart for the OB doc to sign stating something like this: "I acknowledge that I have discussed circumcision with the male infant's mother, blah, blah, blah risks/benefits/alternative." Once doc has signed this, the charge nurse in NBN can then fill out the permit and take it to mom's room to have her sign the consent. Afterward, baby is put on the 'circ list' for circ in the AM.

Here are a few problems I have with this:

1) Docs are not signing the stupid risk/benefit/etc. sheet. So we in NBN while doing chart audits find that mom wants a circ & doc hasn't signed the sheet, so we take a sheet out & put it on mom's chart for doc to address on rounds in the AM.

2) Once docs do sign the sheets, the sheets have trouble finding their way back into the NBN. So often it's day of discharge and baby is circed 2 hours before walking out the door. (ok, being carried...)

3) When the docs DO sign the sheets (a lot of BS surrounding one stupid piece of paper!) they are just signing them. They do not actually discuss c Mom the risks/benefits etc. Before I have Mom sign the consent I ask her if the doc discussed any of this with her. Inevitably she says "No, s/he just asked me if I wanted him circumcised." This is NOT informed consent and I have a huge problem with having her sign it. I think if the MDs were more upfront with parents about this, there would be fewer circs. That's JMO.

4) Baby does not have to have been seen by peds before circ. Normally peds sees them before circ just by virtue of timing. But we had an OB wanting to circ a baby at 0600 that was born at 2214 the night before! Of course peds hasn't seen him! I felt that that was unsafe and the so did the couplet nurse, who refused to have mom sign the consent...so the NBN charge consented Mom herself. "OB wants to do it now" is NOT a reason to circ a baby that hasn't been seen by peds.:angryfire

5) Some of the OB residents want to circ babies at 0130 or some other ungodly hour of the night because they have 40+ patients to see the next day. It 'works better that way.' I understand that they are busy and all, but if you don't have anything else to do at 0130, for pete's sake GO TO SLEEP!

Personally, I don't care if no one ever got circed from now until eternity. But assuming that circ is not going to be outlawed here any time soon, I am looking for things that work for other places and just might work for us. How do things work where you are, and how do you feel it works for you and the patients?? Thanks for listening.

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Specializes in ER.

If the risks and benefits haven't been discussed I would not witness the signature, whether that would stop them from doing the circ- who knows?

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I always take in a circ information sheet prior to the docs rounding the morning so the patient has education prior to the doc coming by to discuss the risks/benefits (especially about pain relief). :devil: I'm just a little devil. ;)

Our OB docs do the circs - we don't have pediatricians. Our OB docs are also the ER docs and the clinic docs and the surgical docs . . (rural medicine).

We do our circs about 6 a.m.

steph

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Specializes in Community, OB, Nursery.
If the risks and benefits haven't been discussed I would not witness the signature, whether that would stop them from doing the circ- who knows?

What would happen is that the nurse who refused to witness would get in trouble, I'm afraid. I have no problem talking c patients about risks/benefits etc. but if the MD is signing a part of the patient's medical record saying that s/he has discussed it and really hasn't, that's falsifying information. Besides not giving Mom informed consent.

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Specializes in Community, OB, Nursery.
I always take in a circ information sheet prior to the docs rounding the morning so the patient has education prior to the doc coming by to discuss the risks/benefits (especially about pain relief). :devil: I'm just a little devil. ;)

Our OB docs do the circs - we don't have pediatricians. Our OB docs are also the ER docs and the clinic docs and the surgical docs . . (rural medicine).

We do our circs about 6 a.m.

steph

I do like that idea. I found our circ info tucked away in a storage room behind the nursery. Who knows when it last saw the light of day. I'm going to take it with me from now on every time I go to get circ permits signed.

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I do like that idea. I found our circ info tucked away in a storage room behind the nursery. Who knows when it last saw the light of day. I'm going to take it with me from now on every time I go to get circ permits signed.

Yeah, especially for the doc who does not use lidocaine. :madface::nono:

We sent out a newborn yesterday whose parents did not want him circ'd . . . that is the first in a very long time for me personally. Hispanic family.

Recently had a young couple, I knew the girl when she was in elementary school and she is best friends with my niece. I talked to them about circumcision and gave them the info and told them that their doc (the above doc) does not use pain relief. They were appalled. Well, I guess he convinced them not to use pain relief and they bought his story about penile dysfunction due to lidocaine shots . . and they had the circ done sans lidocaine. sigh . . . . . :o

steph

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Specializes in Community, OB, Nursery.
I guess he convinced them not to use pain relief and they bought his story about penile dysfunction due to lidocaine shots . . and they had the circ done sans lidocaine. sigh . . . . . :o

:uhoh3:

It amazes me how many very intelligent, progressive people will take something like what that doc says at face value and not question it. I realize we (nurses, docs, sometimes anyone in scrubs) are authority figures, which is why I make it a point to let folks know they can indeed ask why things are being done and continue to ask questions if they continue to be unsure.

Which is why it bugs me to no end that most of our docs don't talk c these patients about circing other than to ask them if they want it or not.

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It is the doctor's responsibility to obtain informed consent. Get some help from your Risk Management people. Involve Management and Admin. Be prepared to lose your job if you meet with too much resistance and do not stop. But it is not your job to obtain IC and I think you are probably liable to a degree if anything goes wrong. You will then wish that you had a taken a stance.

It's hard to believe that doctors are so lazy that they don't want to inform their patients at some point during the 9 months preceding having to make this decision.

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This is a huge issue in our NICU. Mom is often d/c'd without signing consent. When it's about a week before thebaby is d/c'd we then have to track down the on call OB to come when mom is there to have her sign the consent. There is an awful lot of drama and eye rolling involved and depending on the type of day they are having, the on call won't go over the procedure.

Then they put it off and put it off until the kid is on their way out the door and then they circ them. So that is one more thing for mom to worry about when she brings her baby home from NICU.

I wish our OBs would do circs during night shift. I have no problem with that. Thngs are a little more laid back and we can give extra cuddles to a just circ'd little guy.

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Yeah, especially for the doc who does not use lidocaine. :madface::nono:

We sent out a newborn yesterday whose parents did not want him circ'd . . . that is the first in a very long time for me personally. Hispanic family.

Recently had a young couple, I knew the girl when she was in elementary school and she is best friends with my niece. I talked to them about circumcision and gave them the info and told them that their doc (the above doc) does not use pain relief. They were appalled. Well, I guess he convinced them not to use pain relief and they bought his story about penile dysfunction due to lidocaine shots . . and they had the circ done sans lidocaine. sigh . . . . . :o

steph

OMG...that's horrible

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I think all Docs ought to be responsible for consents.

I have never felt comfortable having pts sign consents when I have no knowledge of what the Doc and pt have discussed.

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Specializes in Critical Care.

We have recently gone through the whole consent thing here. Not related to circs, but consent in general and our in-house legal dept. has said that as a witness you are NOT obtaining the informed consent. All you are doing is witnessing a person signing a piece of paper. It's the doctors responsiblity to talk with the patient and inform them of their choices.

So, what we do if the consent isn't signed is talk to the patient, ask if they have discussed it with the doctor and if they have any questions. If they haven't discussed it with the doctor or if there are questions, then we don't have them sign. The doctor is called and they have to talk with the patient before the nurse will witness a signature.

tvccrn

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