Ethical dilemma: Informed consent

[Rose_Queen, BSN, MSN, RN]

As OR nurses, we can occasionally run into ethical dilemmas. How do you deal with them? This is an actual event that occurred. I'll share the details of how it was handled after a few posters weigh in.

You are the nurse who is circulating in a general surgery OR. Your next case is scheduled to be a right below the knee amputation (BKA).

Patient information relevant to the surgery:

76 year old Vietnam vet who was injured in combat, requiring amputation of left leg.

Noncompliant diabetic with routine blood glucose levels in the 400s.

Gangrenous right foot that requires amputation for definitive treatment.

Declared incompetent after family's request for competency review.

Family has previously signed surgical consent but is not present at the bedside.

When you arrive in preop to conduct your pre surgical interview, the patient states that he does not wish to have the surgery and is ready to die with all of his remaining limbs intact. In fact, he is able to succinctly describe exactly what is going to happen to him if the gangrenous limb is not amputated: the fact that he could become septic, go into shock, and die.

How would you proceed in this scenario?

[ED Nurse, RN]

Dependent on several things- who performed the competency review? Who, if anyone, has POA and medical POA. If the patient was lucid and answering questions appropriately, you don't do the surgery- postpone it. If the family was so concerned, why were they not present for the surgery? Bottom line, I would postpone/cancel.

[RiskManager]

After consulting with the attending surgeon, I would probably recommend to postpone the case until the issues of the patient's wishes and competency to make them were sorted out. This could be someone with a temporary return to competency and if you asked him the next day, would agree to surgery. I would also determine the nature of the incompetency declaration: for financial purposes only, or did it include healthcare as well, and is the family comfortable with over-ruling the expressed wishes of the patient?

In these situations, the problem with being the OR nurse is that you may not know the whole story. But based on this scenario, you know enough to stop the line and involve the surgeon in the shared decision-making.

You could also call your friendly local facility risk manager, who lives for this sort of thing.

[Rose_Queen, BSN, MSN, RN]

Both the circulating nurse and the anesthesia provider refused to do the case. After discussion with the (unhappy) surgeon, the case was cancelled and referred to the hospital's ethics committee. The patient did not have his surgery, and died a few days later with his remaining limbs intact as he wished.

[ChrisNZ]

Thank you for your excellent case study! I work in a facility where I don't often come across such ethical dilemmas as this. It was very interesting to think about and reflect upon how I would have handled this and then compare to the actual outcome.