I am a nursing student and work PRN at a hospital as a Nurse Extern. Last Friday I was with a patient who had just had major abdominal surgery. He was on IV fluids and oxygen, as his O2 stats on room air were in the upper 70's. He suddenly decided he wanted to leave the hospital. He put his jeans on over his incision, which still had staples in and asked me to remove the IV.
I called the nurse and she can in and told the patient he wasn't well enough to leave the hospital. He said he didn't care and was going to leave right now. The nurse called the charge nurse, who also told him he couldn't leave the hospital yet. His doctor then came in and told the patient he would probably die if he went home now. He still insisted on leaving, so the doctor said to let him go but he had to sign out AMA.
The patient refused to sign any papers, so they told him he couldn't leave. The charge nurse called a code rush and the patient was put into restraints, wrist and ankle. He was also given Haldol, though he was never violent and never threatened anyone.
The situation made me very uncomfortable. It was the first time I've seen restraints used on a patient. Is it alright to use restraints to keep a patient from leaving the hospital without signing a paper saying he is leaving AMA? I thought restraints were only for violent patients. We haven't learned much about using restraints in school yet, so maybe this is a common practice. I just don't know.
I feel like I've been involved with something slightly unethical, but that could just be because of my inexperience. What are your thoughts on the use of restraints in this situation?
yea, I had to restrain one of my pts on monday. She was a confused L_O_L... She pulled out her IV's, climbed over the bed rails and walking around with her foley bag in her hand saying, "I need to put my purse in the closet!".
So I explained the situation to the resident, Got an order for a vest and wrist restraint. She didn't like it one bit. I also documented every 15-30mins and switched the wrist res from left to right ever two hrs. Kept her hydrated with fruit smoothies...
The patients that I have had leave AMA were typically those that were brought in, less than competent, and not usually of their choosing. They found out we were going to keep them and once the need to find a source of ETOH became an issue for them, they chose to leave. Even after supervision, MD and significant others all explained til we were blue in the face. If they are stupid, but competent, they can leave. And they do. They will most likely end up coming back again........
Sometimes, you have to choose the lesser of two evils. If the pt had been allowed to just walk out, and then was injured or died, there would then surely be a big lawsuit. The plaintif's lawyer would say. "This man's O2 sats were low, and he was not capable of making sound decisions for himself. As professional health care providers, you all should have known that and taken steps to prevent my client's actions from causing him harm. You did not and you are libel for my client's subsequent injury."
Even if found responsible for unlawful imprisonment for not letting the pt leave, the $ettlement for that case would no doubt be a lot less than if the pt had died or been further injured by being allowed to leave. The hospital would probably be able to prove "danger to self and others" on this pt.
I have an LNC friend whom has consulted with me on several cases. This is my .02
This is one of those cases where you are darned if you do, and darned if you don't. If you let him leave, and he bleeds to death, the family and a jury would surely lean towards the hypoxic pt that was not protected from himself by the hospital staff. If you tackle him, and tie him down, he could claim battery, or whatever, and sue you, too. I would rather take the risk of tying him down, and calling family, if any, to stay with him if at all possible.
I also had a pt that required restraints after surgery due to confusion, pulling lines, climbing over rails, etc., that cussed us up and down to anyone that came in her room. Even after she was discharged and back to her right mind, she told people we treated her awfully. Then some months later, she apologized. She finally believed her husband who had told her many times just how awful she was while she was confused.
Sometimes, you have to choose the lesser of two evils. If the pt had been allowed to just walk out, and then was injured or died, there would then surely be a big lawsuit. The plaintif's lawyer would say. "This man's O2 sats were low, and he was not capable of making sound decisions for himself. As professional health care providers, you all should have known that and taken steps to prevent my client's actions from causing him harm. You did not and you are libel for my client's subsequent injury."
Even if found responsible for unlawful imprisonment for not letting the pt leave, the $ettlement for that case would no doubt be a lot less than if the pt had died or been further injured by being allowed to leave. The hospital would probably be able to prove "danger to self and others" on this pt.
I have an LNC friend whom has consulted with me on several cases. This is my .02
That's interesting because every "against medical advice" could fit this category as it is against medical advice, there's potential bad outcome from refusal of treatment. When they sign AMA they are releasing the hospital from liability, so I don't think it's as easy as you presume to get compensation. But since you have experience with your LNC friend, I appreciate your two cents, and believe there are cases such as you describe. But I also believe it's difficult to win an AMA case, if there's proper documentation.
Where people go wrong is they don't treat it like they would another discharge. They don't give discharge instructions, they just let the person go. I treat AMA cases, as I do any other discharge and document the instructions and teaching.
Definately, 100% of the time if we let an unstable alert and orient free American citazen out on the street because he insists and there's a bad outcome someone is going to sue. That's a given. :rotfl:
Unless there's an MD willing to committ the patient against his/her will because they are making a poor decision, I'm not going to restrain an alert and orient person. No way. Last time I checked "incompentency" is not a nursing diagnosis or protocol. The right to refuse is an inherent health care right. (Although, I've seen several cases where patients have humbly returned to the ER for treatment after leaving either the ER AMA or the floor.)
Again, let me say it's an entirely different situation if the patient is confused.
Okay, his O2 sats were int he 70s on RA. He was a fresh post op. Obviously, he was in no condition to go home. He was also in no condition to make a fully informed decision about going home. I think this is a pretty cut and dry case. The staff was right to do whatever they could to get him to stay.
Patient autonomy is a very important principle, but my guess is this patient would probably thank the staff later when he is thinking more clearly. After all, he chose to have this surgery rather than refuse treatment. Doesn't that say something?
happystudent, RN
552 Posts
yea, I had to restrain one of my pts on monday. She was a confused L_O_L... She pulled out her IV's, climbed over the bed rails and walking around with her foley bag in her hand saying, "I need to put my purse in the closet!".
So I explained the situation to the resident, Got an order for a vest and wrist restraint. She didn't like it one bit. I also documented every 15-30mins and switched the wrist res from left to right ever two hrs. Kept her hydrated with fruit smoothies...
Sometimes you gotta do that...