Question about when or if to go over pt's desires

[ohioln, RN]

I have a pt that refuses to have his md called, go to the hospital (I do home care through an agency) or have the agency called when something needs attention. He AAOx3, and makes his own decisions. I have called my agency and told the previous DON when I feel that something needs attn. but then the agency calls the pt, and he then gets upset with me bec. he asked me not to call them. Whenever I think someone should be called and he refuses, I document it. I (before docomenting) always tell him the rammifications of not getting medical attn. and have adviseed him not to take his hypertension med if his BP is low and to have family recheck it before taking med (he has an automatic digital BP cuff that family can use which I use too). He went to the hosp. last wk and they said he has a bowel obstruction. I'm sure I heard bowel sounds when he came home fm the hospital about 1 1/2 wks before. If he was obstructed, why didn't the hosp. find out on his last visit? I'm not giving pts name or location bec. of HIPPA rules. I don't want anyone to know who he is.. Could I loose my license from this? His condition is "fair". They have good, fair, poor and serious, so he is ok. I was taken off of this assignment bec. they said he's gone to the hosp frequently and has freq. UTIs. When someone gets a streight cath 2/da fm nse and 1 fm family, he is being exposed to bacteria bec. at home this isn't a sterile procedure. I wash his cath in warm water and antibacterial soap, urinal too everytime I do his tx. People who have foleys for many mos or yrs or who get str cath often can have UTI that is only txed when symptoms (pain, fever, burning etc) arise. I have said many, many times that his insurance should provide a sterile cath for ea tx and a few extra in case one is contaminated. He can't afford to buy these & his ins. doesn't supply them for home care. Please let me know if you feel that my license or job are in jeopardy bec. he has now been dx'ed w a bowel obstruction.He was placed on a small amt of Lactolose daily for constipation, and I don't know ea time he had a BM, but I do know that he has had them since he came home fm the hospital. I do not always ask him abt this bec. his daughter gives him his meds, except for 1 new med. I started giving him. She is a HHA and has had training and I'd think she'd have told the agency (she works for them too) or me if he hadn't had a BM for a long time and the med was not helping. He had a temp of 101 a day or so before my last day with him and he said he took some Tylanol and was waiting for it to go down. I offered calling someone but he refused. The last day I cared for him he had a temp of 99.3 said he didn't feel well and ref'd to have someone called! I alqways document anything out of the ordinary and if he refuses tx frm medical staff (his MD, hosp, agency, etc). Please excause the long post! Thanks for your help!

[Anagray, BSN]

this is a really tough situation. It think i would be very uncomfortanle doing this, because if this patient dies from whatever is wrong with him, the person that had knowlege of his illness can be blamed.

For legal reasons, I would talk to him,his daughter and his doctors and make a legal document stating that this patient wants palliative care or somehting of that sort. I would want (for my own sanity) the doctors to know that the patient is refusing care. While someone can be alret and oriented, they can also be in clinical depression secretly wishing to die.

Good luck, and please let us know what happens.

[Jolie, BSN]

The patient has the right to refuse treatment, but he does not have the right to prevent you from communicating with his designated healthcare providers (his physician and your agency).

When you observe something that you believe needs to be communicated to your agency or his physician, I believe that you are legally and professionally obligated to do so. The patient can then refuse any treatment orders that you receive as a result of that communication.

If you fail to communicate pertinent information to your agency and his physician, I believe you could be putting yourself at risk legally.

[ohioln, RN]

To anagray and jolie,

Whenever I tell the agency's DON in the past, have a new one now, they always contact him and let him know that I told them whatever he wanted me to keep in confidence, and he doesn't like it. Then he is upset with me and less likely to tell me if something is wrong (which would not be observable to me), which might make it dangerous to his care. I always document when I offer/advise him to contact his doctor so that the clinical supervisor at the agency can see this in writing when she reads my notes and if she didn't feel comfortable, could have contacted me. I am not longer on that case. The last I heard, he was ok. Thank God, I'd be awfully upset if something had happened to him and also if I'd gotten in trouble with my license. In the future, I will tell the client's doctor, my agency and/or anyone else if there is someone else to be told. I think, after reading what both of you said, that this would be the best thing. Then he can refuse meds, treatments or whatever is offered if he wants to do this. Thanks for the help.

[ohioln, RN]

I was trying to say in the above reply that I documented his refusal of anything and teld him the rammifications of not doing what I suggested/advised, & the clinical nurse in my agency can also see that in my notes. Also the next time I have a client and they refuse anything, not "he" this client, but any other client, I will tell my agency, their MD, etc as I feel necessary and then if client refuses anything, that's up to them. I try ti have a good nurse client relationship with my clients, so they'll feel comfortable telling me things. I may have to tell them that I am required to tell my agency and their doctor if they tell me something that in my judgement, needs attention. Then if they do refuse, it's up to the doctor and family to work with them about it. Re: above post to anagray and jolie @7:32pm Sat 5.3.08.

[Jolie, BSN]

I agree with your most recent post.

The reason that I believe it is wrong to "with-hold" information from your agency and the physician is that you are part of a team. The others depend upon your assessment and report of the patient's condition and care in order to make their own decisions regarding his care. If you do not relay important information, then they are not able to do their jobs properly and professionally. To illustrate my point, imagine that you are relying on a CNA to provide you with accurate vs and blood sugar readings to manage the care of a diabetic patient, but the CNA withholds that information at the patient's request. You provide care assuming that vs and BS are stable, when in fact, they are not. The patient experiences a crisis that you could have averted had you been given the pertinent information. You are now responsible for a mess that you had no prior knowledge of or control over. That may be a bit of an oversimplification, but you can see the position that another provider is put in when they are managing care based on false and/or incomplete information.

I uderstand the fine line that you walk trying to maintain a relationship with your patient, and trying to encourage the patient to be open and honest with you. But to do that at the expense of another provider is legally treacherous.

I wholeheartedly agree with your statement that you may have to tell your client that you have no choice but to relay information to the other members of his healthcare team, and allow him the option of keeping such information to himself if he does not want it shared with his physician. He may choose to dismiss you from his care, which is his choice, or his physician may choose to dismiss him from the practice if s/he can't provide adequate care based on the patient's compliance and willingness to share pertinent information.

[ohioln, RN]

Thank you Jolie, this is true, next time I will do this. What you said sounds like what I should have done, it makes it very clear.

[caliotter3]

From your posts can't see where you've done anything wrong. You informed your agency and documented everything. At some point though, I would have encouraged you to make a decision about your comfort level on this case. It sounds as if you had misgivings serious enough to justify asking to be removed from the case, a long time prior to the situation you described. When you let things go on so long that the agency takes action by removing you from the case, then you haven't helped yourself. This always is treated in a negative manner by the agency when it comes time to evaluate you. From now on, think about being more proactive about when you decide the case is becoming too risky for yourself. You said you informed your agency and then they went around behind your back and spoke to the patient. Red flag. Your judgement is being questioned and the agency supervisors are setting you up for failure with your patients. They know that one reason they are being called is that the agency does not trust your rendition of matters. The patient, or patient family, then has an idea that in order to make it "hard" for you to resist their requests, all they have to do is call the agency behind your back. When you talk to your agency, document this phone conversation also, to include any actions by the agency personnel. And continue to make it clear to your patients that you must communicate with the MD and agency. If they continue to circumvent your efforts at doing your job, then you need to look for a new case. You don't go to work in order to spend all of your offtime worrying about what is going on because your patient is not being honest or cooperative with you. They can refuse care without being uncooperative. Withholding vital info is being uncooperative and is detrimental to their own well being. You don't want to be a party to that game. Better to find another patient.