Obtaining Consent and Confrontation With Physician

[rn21191]

I've been a nurse in the same specialty for almost 4 years and have worked at a few different hospitals in a large city. I like to think I have learned to communicate effectively and respectfully with my coworkers and our doctors. Super long story short, my patient had been refusing surgery since admission. She was on the fence about pursuing treatment as her symptoms weren't too bad. It actually came to the point where they had decided to transfer her to a medicine service and transfer her out of the ICU because she was so adamantly refusing everything they were recommending. Psych was consulted and deemed her capable to make decisions for herself. The attending surgeon came and spoke with the patient, explained the importance of treatment and got her to agree to the pre op MRI. They scheduled her surgery for the first case of the next day. When I took over, she hadn't yet signed the consent form. At the beginning of my shift the resident came by and said he'd go in and consent her before she went to sleep. The unit went crazy and he wasn't able to come back until late at night. He went in to talk to her and immediately came back out of her room. He told me she was seeing things and not very awake and that he didn't feel comfortable getting her to sign then. He thought it would be best to let the attending come in the morning and do the consent form. I agreed with this and really respected him for knowing when to take a step back. I had kept her NPO just in case and she was ready to go as soon as that form was signed. Anesthesia came to get her at 645 and I told him I didn't think she had signed yet. He grabbed the chart and said that she had indeed signed the form. I was confused but figured I just missed the doctors rounding and the attending's conversation with her. Something didn't feel right but she wasn't refusing at the moment so I packed her up and brought the day shift nurse in to do report at the bedside before she went down for surgery. I briefly explained the situation and the day shift nurse asked the patient right away if she wanted to do this surgery. The patient said no she did not want to go so the day shift RN called the team and the day resident came in and immediately started pressuring the patient to go right then. He told her she would die without the surgery and that everyone was waiting for her so they had to go downstairs NOW. I politely asked the resident to call the attending as this is what the night resident said would happen. He called the chief resident instead and asked me why this was a problem as the consent for was signed the day before. I explained it had not and that the night resident felt more comfortably deferring to the attending. He got the chart and said that there was a signed consent form so he was still confused as to why I was being difficult. I told him his own resident didn't feel comfortable consenting her when she was half asleep and delirious. He went to call the resident and asked him what happened, and came back and started asking her orientation questions which she answered correctly. He asked if she knew the severity of her situation and she said yes but that she still didn't want the surgery. The chief came out into the hall and started yelling at me about how this was ridiculous and that it was inappropriate for me to let her say no. I believe he said "do you want her to die? That's what you're saying if you keep pushing this". I calmly stated that I was in no way telling her not to do it, but I was just reporting to them that she did not want to go. I said I was advocating for my patient and he got so angry at that phrasing. He said "Oh so you're the only one in this whole place who is advocating for her? I'm trying to save her life. I'm personally offended that you think I'm not advocating for her as well. I didn't really know what to say so I just let him walk away and call the attending. I went straight to my managers office and told her what was going on. She's great, and she called the chief to her office to talk. She actually said "why are you being mean to my nurses" and I loved her so much for that. He started to talk and then they saw the attending so the three of them talked in the hallway. My manager came back in and said the attending was telling the chief to be nice and listen to us, and that he wants us to know we can always come to him directly. The chief came into the office and apologized for the way he handled our interaction. He said he was frustrated because the attending was waiting on him and he felt like I was insinuating we weren't all on the same team. He said he hoped we could go forward working together in a positive way and I agreed. He left and I did feel better that we handled it right then and there. However, I have several concerns with the overall situation. First and foremost I was disappointed that the team felt they had the right to pressure her so much to have a truly risky surgery. Patient's can always revoke consent and they were acting like she could not do so. I was also worried that there was a chance she didn't even remember signing the consent and that it was obtained inappropriately. Lastly, I felt frustrated that the chief was trying to manipulate my feelings to get me to do what he wanted. I obviously want the best for my patients but I also have to look out for their best interests and listen when they're saying no. Lastly, I don't think any of the residents understood that I was trying to protect the patient's wishes, my own license, as well as the whole team. If something went wrong in surgery and there was any question of consent, we would all be dealing with a difficult situation. Any comments, similar experiences, or advice on how to handle this team going forward? After this situation and a few others with the same team I truly feel like I need to escalate this to someone above myself. I know I can't change a whole lot, but I feel like this is as good a time as any to express concerns.

[NurseCard, ADN]

I honestly just say, keep doing exactly what you are doing. EXACTLY.

I mean, you make sure the surgeon has explained the procedure and the

risk, you make sure that the patient understands... you make sure that

the patient is of the proper mind to consent to the procedure. You

properly let the surgeon and team know that you did not feel that the

consent was signed properly. You let them know that the patient did

NOT want the procedure. What else can you do? You did

EVERYTHING that you needed to do. Yes, the chief gave you

a hard time. So? Surgeons have been known to do that.

You stood your ground, in the end he apologized, the

patient did not get the surgery that she did not want...

There is NOTHING different, in my opinion, that you could

have done.

Kudos to you.

One thing I will tell you to do differently... use paragraphs.

Makes your post much easier to read. :)

[akulahawkRN, ADN, RN, EMT-P]

OP: you did exactly what you should have done. Your actions protected the patient's wishes, your license, the surgical teams licenses, and potentially avoided a lawsuit and potential criminal charges for committing battery upon a patient that was of sound mind and has capacity to consent/refuse care.

Other than that, please use paragraphs. It does make it easier to read longer posts.

[morte, LPN, LVN]

perhaps reporting this to risk management? and definitely have a conversation with the attending.

[JKL33]

You did a wonderful job! I think you should feel really good about the fact that, although it didn't feel great in the moment, you kept your cool and followed through.

It sounds like the other involved parties have apologized and even the attending supported a reconciliation of this situation. I would look for opportunities to continue to facilitate a good relationship with this team. It's not uncommon that incidents like this, when handled well as this one ultimately was, tend to strengthen working relationships. Everyone has just a little bit better idea of where others are coming from and that tends to be a good thing. Sometimes we need to move on, trusting that others have learned what they needed to learn.

One particular point (in which I babble yet again about past experiences). Although the CR kind of came out of the corner swinging with his intial comments to you, you handled it very well. I too, have responded, "I'm just trying to advocate for my patient" - but after a couple of instances and some time to think it all through, I do believe that those are kind of notorious "fightin' words" when speaking with other members of the health care team who are also trying to help the patient. I haven't said that phrase for years just because, regardless of anything else, it is rarely productive; it contributes nothing to the actual position I am advocating. Calmly and neutrally continuing to hammer away with facts is usually more productive - if you can phrase it as being on the same "side"...even better. ("It's hard for us because we want her health to improve, but she has a right to make her decision whether you and I agree with her or not" and "there is a process we must follow if we don't believe she has the capacity to make this decision" and "...just the same, I know you know that legally she can revoke her consent", etc).

I personally don't think you should escalate this. We need to be careful with the idea that every difficult situation in life needs to be "escalated" because "it shouldn't have happened in the first place." All of us are learning every day, with every patient and co-worker interaction, how to be better at what we do. The residents are learning too - - they are right in the thick of their formal education. I have no doubt a lesson was learned here based on your tenacity and your advocacy! When a situation such as this occurs and then has a positive outcome, IMO the right thing is to move forward in a collegial manner, allowing this incident to ultimately build the working relationship. You can keep your eyes open for evidence of change, but for right now you should have faith in the learning process. Expect that interactions with this surgery service will be better next time around and seek to make it so.

Very, very good work on your part. That was solid nursing work you did. :)

[brillohead, ADN, RN]

Agree with everything that has been said so far, including the use of paragraphs!

One thing I would recommend, is telling this story to others. Your colleagues on the unit, and especially any new nurses that you precept/meet. We nurses need to stick up for one another and our patients, and hearing from another nurse about how important it is to keep at it and take it to your leader and press on with the surgical higher-ups can give a newer nurse the fortitude to do the same in the future.

Certain personalities don't feel strong enough to push back, no matter how experienced they are. Newer nurses or newer employees (even if they're not new nurses) may not feel comfortable pushing back. It's important to share your story, including the fact that once calmer heads prevailed, everyone was on board with the idea that the patient DID have the right to refuse the surgery at the last minute, regardless of whether or not it had been consented to previously.

Five years from now, keep telling this story to new hires. When you float to other units, share this story. People need to know.

[MunoRN, RN]

I find it a little hard to believe that the physicians behavior was tolerated as much as it was, if the patient was capable of making decisions, and at every opportunity had refused the surgery, then the physicians actions should be reported to the state.

[KatieMI, BSN, MSN, RN]

I find it a little hard to believe that the physicians behavior was tolerated as much as it was, if the patient was capable of making decisions, and at every opportunity had refused the surgery, then the physicians actions should be reported to the state.

Unfortunately, it is a common situation, especially in teaching hospitals of overall low standing. In my previous-to-nursing life, I saw the same thing happening. Residents were taught to ask relatives for consents for things which were ridiculous to ever dream of, using the fact that in the surrounding population the prevalent idea about "good medical care" was to get everything done and then some more. Nobody was ever reported.

Attendings and especially residents have very vested interests in procedures. Part of it happens because of "compensation", another part is here because residents compete with each other for the positions in the team and, since they have certain numbers of each procedure to be done in order to graduate, the competition might become really stiff; and, last but not least, comes the infamous "God's mentation". For quite a few physicians, the idea that the patient might know better what to do with his own life is still pretty much a foreign one.

My deep mental disagreement with participating in such "decision making" was one reason why I chose nursing over medicine. Kudos for the OP for standing the ground and protecting the patient!

[Argo]

First things first, you didnt make the long story short...

You did what your supposed to. I have had this happen plenty working in surgery. Im just very "matter of fact" about it, cases usually end up cancelled.

[DowntheRiver]

You just Wubbeled :) or just pulled a Wubbel?

[Boomer MS, RN]

I've been a nurse in the same specialty for almost 4 years and have worked at a few different hospitals in a large city. I like to think I have learned to communicate effectively and respectfully with my coworkers and our doctors. Super long story short, my patient had been refusing surgery since admission. She was on the fence about pursuing treatment as her symptoms weren't too bad. It actually came to the point where they had decided to transfer her to a medicine service and transfer her out of the ICU because she was so adamantly refusing everything they were recommending. Psych was consulted and deemed her capable to make decisions for herself. The attending surgeon came and spoke with the patient, explained the importance of treatment and got her to agree to the pre op MRI. They scheduled her surgery for the first case of the next day. When I took over, she hadn't yet signed the consent form. At the beginning of my shift the resident came by and said he'd go in and consent her before she went to sleep. The unit went crazy and he wasn't able to come back until late at night. He went in to talk to her and immediately came back out of her room. He told me she was seeing things and not very awake and that he didn't feel comfortable getting her to sign then. He thought it would be best to let the attending come in the morning and do the consent form. I agreed with this and really respected him for knowing when to take a step back. I had kept her NPO just in case and she was ready to go as soon as that form was signed. Anesthesia came to get her at 645 and I told him I didn't think she had signed yet. He grabbed the chart and said that she had indeed signed the form. I was confused but figured I just missed the doctors rounding and the attending's conversation with her. Something didn't feel right but she wasn't refusing at the moment so I packed her up and brought the day shift nurse in to do report at the bedside before she went down for surgery. I briefly explained the situation and the day shift nurse asked the patient right away if she wanted to do this surgery. The patient said no she did not want to go so the day shift RN called the team and the day resident came in and immediately started pressuring the patient to go right then. He told her she would die without the surgery and that everyone was waiting for her so they had to go downstairs NOW. I politely asked the resident to call the attending as this is what the night resident said would happen. He called the chief resident instead and asked me why this was a problem as the consent for was signed the day before. I explained it had not and that the night resident felt more comfortably deferring to the attending. He got the chart and said that there was a signed consent form so he was still confused as to why I was being difficult. I told him his own resident didn't feel comfortable consenting her when she was half asleep and delirious. He went to call the resident and asked him what happened, and came back and started asking her orientation questions which she answered correctly. He asked if she knew the severity of her situation and she said yes but that she still didn't want the surgery. The chief came out into the hall and started yelling at me about how this was ridiculous and that it was inappropriate for me to let her say no. I believe he said "do you want her to die? That's what you're saying if you keep pushing this". I calmly stated that I was in no way telling her not to do it, but I was just reporting to them that she did not want to go. I said I was advocating for my patient and he got so angry at that phrasing. He said "Oh so you're the only one in this whole place who is advocating for her? I'm trying to save her life. I'm personally offended that you think I'm not advocating for her as well. I didn't really know what to say so I just let him walk away and call the attending. I went straight to my managers office and told her what was going on. She's great, and she called the chief to her office to talk. She actually said "why are you being mean to my nurses" and I loved her so much for that. He started to talk and then they saw the attending so the three of them talked in the hallway. My manager came back in and said the attending was telling the chief to be nice and listen to us, and that he wants us to know we can always come to him directly. The chief came into the office and apologized for the way he handled our interaction. He said he was frustrated because the attending was waiting on him and he felt like I was insinuating we weren't all on the same team. He said he hoped we could go forward working together in a positive way and I agreed. He left and I did feel better that we handled it right then and there. However, I have several concerns with the overall situation. First and foremost I was disappointed that the team felt they had the right to pressure her so much to have a truly risky surgery. Patient's can always revoke consent and they were acting like she could not do so. I was also worried that there was a chance she didn't even remember signing the consent and that it was obtained inappropriately. Lastly, I felt frustrated that the chief was trying to manipulate my feelings to get me to do what he wanted. I obviously want the best for my patients but I also have to look out for their best interests and listen when they're saying no. Lastly, I don't think any of the residents understood that I was trying to protect the patient's wishes, my own license, as well as the whole team. If something went wrong in surgery and there was any question of consent, we would all be dealing with a difficult situation. Any comments, similar experiences, or advice on how to handle this team going forward? After this situation and a few others with the same team I truly feel like I need to escalate this to someone above myself. I know I can't change a whole lot, but I feel like this is as good a time as any to express concerns.

Yahoo!!!! Well done and keep up the outstanding work. You are not the first nurse who has faced this kind of situation, and it would be valuable to share with colleagues as a discussion in a staff meeting perhaps, with your manager's blessing, of course. Working through this with the residents is a learning experience for them too. Please do use paragraphs when you post such a long one.

[LovingLife123]

Why did they keep the signed consent if nighttime doc did not feel it was obtained properly? Why did he put it in the chart?

You did the right thing, but I totally understand the confusion on dayshifts part as there was a signed consent in the chart. It should have been destroyed.