Patient right vs common sense

Can someone tell me where the line should be drawn. A while back we had a male patient admitted to Med/ surg with chest pains. His initial cardiac enzymes and EKG were normal. By the time he was admitted from ED his pain was gone. He was considered stable and had an uneventful night. The next AM he was still pain free. However, his AM troponin I was elevated. I believe it was in the 7.0 range. The man was up walking in the halls insisting on going for a smoke. One of our patient educators, who was aware of the situation, said that we had to let him go smoke because it was his 'right". I couldn't believe what I was hearing. Needless to say, this patient was not allowed to go smoke(common sense did prevail) and he was off to ICU. I believe he had a good outcome. Any similar situations out there? I'm sure there are.

[SharonH, RN]

I see your viewpoint. But at what point does the patient take responsibility for his own health? Just because we allow them to smoke(which is their right) does not mean we endorse their behavior. I think you should educate the patient on the possible consequences of his actions, make sure he signs the release form! and let him go.

WE HAVE PATIENTS IN OUR REHAB THAT WHEEL OUTSIDE WITH THEIR O2,TURN IT OFF, AND FIRE UP. IT'S THEIR CHOICE . WE HAD A NEW PARA ONE TIME WITH A BAD BEDSORE ON HIS COCCYX. HE HAD BEEN STAYING IN HIS CHAIR ALL DAY AND NOT LISTENING ABOUT PRESSURE RELIEF. THE MD(TOTALLY HATED SMOKING) WROTE ORDERS FOR NO SMOKING, BEDREST IN CLINITRON BED, AND REMOVE WHEELCHAIR FROM BEDSIDE. WELL, HE WANTED UP AND TO GO OUT AND SMOKE. THE NURSE REFUSED TO GIVE HIM HIS WHEELCHAIR. HE ACTUALLY THREW A SHEET ON THE FLOOR AND CLIMBED OFF THE BED(THOSE CLINITRONS ARE PRETTY HIGH) AND THEN PROCEEDED TO DRAG HIMSELF DOWN THE HALL TOWARD OUTSIDE CURSING AND FIGHTING ANYONE WHO TRIED TO HELP HIM. SHOULD A PT. BE PUT IN THAT POSITION? YES, HE NEEDED THE BEDREST BUT THE MD SHOULD HAVE SPOKEN TO HIM AND MADE SOME COMPROMISE. PTS. HAVE RIGHTS TO DO WHAT THEY WANT EVEN IF IT'S BAD FOR THEM.

Patients do have rights, BUT, my personal opinion is, YOU choose to come to the hospital for treatment, and if YOU choose to not follow the "program", then I believe YOU should get your clothes on and sign yourself out AMA. . .just my opinion

I agree with post saying if you aren't going to cooperate with your own care you may need to leave the hospital. Unless, of course, you are mentally impaired (baker act et al). There are many doctors now who will dismiss a noncompliant patient in their office practice simply because of liability. On the other hand; it is unbelievable on a respiratory floor how many docs will actually write orders allowing a COPD pt to go downstairs to smoke. I guess I'd understand if I were a smoker. Then of course, there are those end stage pt's whose outcome is already grim and I actually believe if your exit is emminent, you should be allowed to exercise your own comfort measures including smoking. In those situations I believe the pt should sign a release of responsibility. Of course, lawyers can always get around that. Then you add a family member to the mix....

Hi colleagues. I'm going to try to avoid writing my 2 cents and more on prevention and promotion. Everyone so far has made some good points. It's does not seem fair that a person willingly comes to the hospital for treatment and care, but yet demonstrates so little respect for the actual administration and compliance to care. I would be tempted to address this with them in a tactful manner if possible. On the other hand, health care professionals do a rather poor job of establishing appropriate, individualized plans of care and providing good rationales for following prescribed treatments. It goes both ways. Correct me if I'm wrong, but I thought that we have proposals or actual standards in place or to be put in place that are supposed to hold patients, families, and health care practitioners liable for outcomes.

There are many issues in defining rights and excerising those rights not only in healthcare but outside of healthcare.

Should a paient be allowed outside to smoke?

Should family members bring in food for our obese patients?

Does a diabetic have to follow orders from the Doctor or educator about their eating habits?

Should we force couch potatoes into excerise programs?

All of these are behaviors. It is the choice of the patient or person to choose their behaviors. What is "right" is not our dictate, it belongs to the individual.

Risky behaviors are not only defined by smoking, obesity, drug abuse, alcohol use and unprotected sex. It includes racecar driving, parachuting, skydiving, motorcycles and rock climbing. We should be cautious about those things we wish to regulate or we might end up regulating our behaviors.

It is hard but we must remind ourselves our job is to assist a person through a healthcare crisis and not through a lifetime crisis.

Hi RNed. I'm going to respectfully disagree with your last assessment on helping patients through a health care crisis. In fact, we both know that the effects from good or poor health spans a lifetime. In fact, health care professionals are responsible for helping patients and families maximize their quality of life as we get them through a health care crisis. Yes, it's true that they have the ultimate choice of what they do with their lives, but we have an obligation to generally protect the public's health to our best knowledge on a long term basis. This is the philosophy I use in home health. I don't push myself off on my patients and families, but I do inform them of potential short term and long term consequences of uncontrolled diseases and conditions and provide them with options for stability or improvement. This is very difficult, because most people, especially me, in my position are not experts.

RNed, I want you to keep in mind, if you work at the bedside in a facility, that what you do with and for your patient has a direct impact on how he or she fairs in the home environment and beyond. I will do my best to try to keep my patients and families apprised of what's going on with institutional care so that hopefully, they won't be so burdensome on the staff.

[CEN35]

We go through this type of stuff regularly. Patients have rights, and as much as I hate it they can do whatever they want to do. The thing is..........to explain to them why they shouldnt be doing whatever it is, that might cause a health risk/compramise. Then document what it is they wanted to do, and that you advised them they should not. Then document the outcome, did they listen or did they ignore your advice and reason.

We don't disagree Mjourney. I believe the patient nurse relationship has continued obligations. However my educational, teaching work on the interpersonal level has detached and the patient is expected to be more responsible for his health care upon discharge Hopefully, with new learned health care teaching.

Home health, community nursing, diabetic classses and other programs should be referred and made knowledge to the patient and community. Not only for the patient's good health - for the communities good health.

As an ICU nurse, I see a distinct seperation of the nurse-patient relationship. My friend, a home health nurse, does not and sees the long term relationship, education, community teaching and its positive effects. I support both patient teaching and community or out-reach teaching.

Detachment and engagement, We agree both are vitally important and should be in balance with the patient's and communitie's health and rights.

As a nurse how do we defend and advocate patients' rights and not by default defend their individual rights? I don't see how we can do one and not the other.

I think we agree.

[canoehead, BSN, RN]

At our hospital the pt can want to smoke, the doc can write the order but the nurses are under no obligation to go outside with the patient, or offer any assistance as they will be exposing themselves to second hand smoke and a 1-1 situation without back up with a sometimes unpredictable patient. (medically and emotionally) So nurses are able to tak the pt out if they feel OK with it, or to refuse if not. Also a pt that can go under their own steam can go with a family member, and a specific order, and a release form.

I see no point in not allowing patients (who are able to go outside) go and have a smoke. Of course I agree with education and helping them quit if they are interested, but I think they are only in the hospital for a short time, and will be smoking once they leave anyways. I won't help someone get a cigarette, but I am not going to babysit them either.

[Zee_RN, BSN, RN]

My facility has a no-smoking policy, period. Patients are not permitted off the nursing unit to smoke. It is explained to us to be a liability issue. Nursing does not have the time nor the staff to stay with a patient outside while they smoke; and if something happened while the patient was outside, the hospital would be liable. If a nurse let a patient go outside and his IV came out and he bled all over the place (or whatever!), we are told the nurse would be held liable for her poor judgment in letting the patient off the floor, unattended, regardless of doctor's orders. So it just doesn't happen.

Had a patient in ICU who was admitted with carbon monoxide poisoning from bad exhaust in his truck. His respiratory status was terrible! He signed himself out AMA, however, which required many phone calls to MDs, house supervisor, etc. He went outside, smoked a couple cigarettes and came right back into the hospital, got on the elevator and put himself back into his just-vacated ICU bed...he wanted to come back now, wheezing and puffing. Just amazing.

[RNforLongTime]

I too have encountered the same situation with one of our frequent flyer COPD pts. Said pt was just in a week and a half ago. Her doctor was well aware of the fact that this pt went outside to smoke and refused to write an order! I even left him a note asking him to write an order just so the hospital wouldn't be held liable if something happened to this pt while he was off the unit! But he never did and our hospital doesn't have a form for the pt to sign that would not hold the hospital liable if something would happen to her while she was out smoking.

One of our staff nurses was gonna have her sign AMA if she was taking care of this pt but she never was assigned to care for this pt. And I frankly did not have time to "baby-sit" this pt while she was under my care. I documented each time I cared for her that the pt went outside to smoke against medical orders and that the pt would reply that she was gonna do what she wanted to do regardless of whether she had an order or not.

It just makes me angry that this doctor would allow us nurses to be held liable. His reply was " I have no control over what she does when I am not here"

Pt's have a right to smoke if they so choose but if they come to the hospital then they are bound to comply with their treatment plan and smoking was definitely NOT in this pt's treatment plan.

i don't know about being bound by a treatment plan. a patient can be in the hospital and refuse anything they don't want where i work including meds, refusing to adhere to non smoking even though their o2 sat is 76%, intermittent catheterization, dressing change, shower, you name it... it is a patients right. if you force something on them against their will then i think they have a right to sue. just document everything. if a pt. is in their right mind it is their choice.

[RNforLongTime]

Ok--they don't have to do ANYTHING they do not want to do! They can refuse whatever they want but then I am not doing them any good either by allowing them to go outside to smoke plus should something happen to them while they are outside smoking--they could sue the hospital and my self and I could lose my hard earned license. If that doctor would just write an order allowing the pt to smoke then there wouldn't be an issue but he refuses to do so each and every time this pt is admitted which is usually about 4 to 6 times a year.

It is her choice but on the other hand if a person were a druggie--and he wanted some crack or whatever then he should be allowed to have some, right? After all it is their choice.

smoking is not illegal like crack, etc... if the doctor writes an order for no smoking and you follow it then you are infringing on the pts rights as well as the doctor. all about choice. what if a pt refused you to touch him, clean him up or whatever, would you document but still be worried you could be sued for neglect?????

My two cents on this subject.

Patients who can take themselves outside on their own and smoke will do so, regardless of whether there is an order written or not. A doctor's order isn't going to do much liability wise anyway if something happens. You simply need to document, document, document!

I agree with not needing to assist or babysit pts who smoke. That's what family members and friends are for. In hospital we are quite able to control a lot of factors but at the same time we can't infringe upon pts rights. As others have said. pts have the right to refuse any care or restrictions placed upon them. Unfortunately as front line health care workers, we get to pick up the pieces afterwards. I try to make sure my patients know the short and long term consequences of their actions and enable them to make their own decisions...