Procedural Consent Problems

[bubblern90]

Hi all- I'm new to the hospital I'm currently working at in CA and I've had an issue with the way this place does next of kin consents. A lot of the doctors will call a family member on their own time, then put in an order for RN to get consent, at which point it is then the nurse's job to call the NOK and ask them that the MD spoke to them about surgery and if they have any questions and then have a second RN there to verify. I got in some trouble because I didn't feel like this was adequate consenting as I wouldn't know the appropriate questions to ask or answers to expect to ensure NOK knows the risks/ benefits/ other options and it feels wrong to put my name on a legally binding document saying I was witness to something I wasn't present for. I got a lot of heat from the House Sup and Charge Nurse telling me I couldn't refuse to do it and them going to other nurses and asking them how they do it to "prove" it's okay. I just want to know am I out of line or saving my license? Thanks!

[klone, MSN, RN]

If they are asking you to state, by virtue of your signature, that you witnessed something you didn't actually witness, I would politely decline. "I understand that is how you do things here, but I cannot sign the consent, stating that I witnessed the consent process when I didn't witness it." 

[MaxAttack, BSN, RN]

I wrote this whole long answer that no one was going to read to basically say consenting isn't an area I've heard of people losing licenses over. 

It's your job to ensure they understand what was told to them. If they have questions, refer them back to the physician. 

bubblern90 said:

I wouldn't know the appropriate questions to ask or answers to expect to ensure NOK knows the risks/ benefits/ other options

"Did Dr. X explain to you the risks, benefits, and alternatives?"

Don't put a target on your back over semantics. You're not necessarily witnessing a conversation. You're witnessing that they understand to their satisfaction (I'm not expecting them to understand at the same level as the physician performing the procedure) and are giving voluntary consent.

[adventure_rn, MSN, NP]

bubblern90 said:

The problem is that I'm not witnessing a signature because it's interactions done over the phone. 

I understand what you're saying. In the NICU, we were only allowed to 'consent' a family over the phone for emergent procedures where they couldn't physically come in; to perform a phone consent where the family couldn't physically sign off, two healthcare providers had to sign off, the physician/APP doing consent and the witness. I was always taught that I had to be present and hear what was said on the line, since you as the 'second witness' are attesting that the family member on the other end of the phone heard the consent process and then verbally agreed (not that you're witnessing the physician/APP sign). I would also feel uncomfortable doing what you're doing without clarification.

I wonder if it varies by state. You could look state Nursing Practice Standards online to find out. Your safest bet may be to ask your Board of Nursing directly, but you might alienate yourself (or get yourself fired) if it turns out it's again BON policy and you tell the facility that.

Could you (or whoever it is witnessing) be dialed into the initial call? That would solve the problem.

[subee, MSN, CRNA]

JKL33 said:

Also as a side note, we (nurses) generally need to tighten up the verbiage we use about all of this.  We are NOT "getting consent."

The one who wants to perform the procedure is the one who legally needs to get/obtain the consent. They do this through the informed consent conversation. This is only done by the proceduralist/surgeon, NOT the nurse.

We should describe our part in it as "making sure the consent forms are signed," not as "getting consent."

??

IMHO, we need to start from the ground up on "consent".  All consent signatures done immediately before surgery are coersive.  Secondly, we have no idea what a surgeon told a patient and how much of it the patient heard or understood.  It should be pre-printed on the form that the nurse is witnessing that the patient is who they say they are because that's the only truthful thing we can attest to.  No one should have to write that in.  We aren't accounting for individuality among the patients.  Doing time outs in the room is also largely a waste of time and just cruel, in my book.  The hospital doesn't want the patient to get any pre-meds before they go into the OR so that they can "participate" in the time out.  My experience is that patients are usually so anxious they will agree to anything, even if it's the wrong side.  And the cases where the wrong side is done, it's mostly heads and they do it after all the drapes are on and no one can even see the head!  If the x-rays are displayed backwards, no one in the room was wiser because the mentality is "Let's get going!" because it's taken a good 45 minutes to even get to the point of doing a time out.  Surgeons are the rain makers for the hospitals and we have to cut them down a notch to create a culture where safety, not the schedule, reigns supreme.  The system is set up against us from the start because of production pressures.  We should be trained in school about the philosophical and organic meaning of the word "consent".  

[mmc51264, BSN, MSN, RN]

Nope nope nope. Their job to get consent and get them signed. Out of my scope. 

 

[subee, MSN, CRNA]

mmc51264 said:

Nope nope nope. Their job to get consent and get them signed. Out of my scope. 

 

Who is this for?  Who said you were supposed to do anything besides getting the consent signed?

 

mmc51264 said:

Nope nope nope. Their job to get consent and get them signed. Out of my scope. 

 

Who said nurses should do anything else except witness the signature?  Who are you responding to?

[vampiregirl, BSN, RN]

A couple of thoughts...

Have you looked at said policy yourself?

 

I've found situations where "everyone" thought something was an actual policy and we were all wrong! One person taught another and eventually everyone were all doing whatever it was incorrectly and thought they were "following" policy.

 

If so and this is the actual policy, do you have a unit or hospital educator?

 

I've found that educator's can be sometimes be helpful in either situations where I'm concerned about a policy/ procedure/ process (or don't understand it).

 

Sometimes either legal requirements have changed since a policy was implemented. (Or new evidence based practices have been updated in other situations). Or a policy was a temporary workaround to address a new requirement at some point and never got reassessed/ researched.

 

Education is typically a driving force in getting outdated policies/ procedures/ processes updated. Supervisors sometimes are just trying to keep everything running smoothly and may not have the time to delve deeply into something at that moment.