Refusing "Hospital Protocal"

NurseNora, BSN, RN · Oct 1, 2007

Just the other night I had a patient who refused an IV and to have labs drawn on admission. She had some concern that her doctor would refuse to care for her because of her refusal. Since she agreed to whatever might be necessary in the case of an emergency, there was no problem. I had her sign a form stating what procedures she was refusing and why she was refusing them. She didn't like needles, had had routine prenatal labs done, and had had her first baby with no IV and no problems. In our hospital it is not routine to get admission blood work (CBC, T&S, RPR) on patients who have had prenatal care and have no special risk factors. I discussed with her that not having an IV or a saline lock in place could delay emergency treatment and result in injury or death for her and/or the baby. She was OK with taking that risk and everything worked out fine for her, as it usually does.

We in the hospital have to prepare for the worst of possible outcomes, and as a result, often forget that birth is a healthy normal experience. If a significient number of women really needed all the "stuff" we do, there would be a whole lot less people in the world today than there are. An adult has the right and the responsibility to evaluate the risks for herself and make an informed decision as to just how many risks she wishes to take.

If there had been a bad outcome in this case due to the lack of an IV already in place, there probably would have been a lawsuit. But if there is a bad outcome in any obstetric case, there will probably be a lawsuit anyway. Whenever you show a dead or damaged baby to a jury, they want to throw money at the situation. We live in a litigeous society that believes that every pregnancy should result in a healthy mother and a superior baby and that if this expectation is not met, someone must have done something wrong. This is the down side to working in OB. As an adult, it is a risk that I am willing to live with in order to keep working in the very best field of nursing there is.

CEG · Oct 1, 2007

Okay, one problem here, EFM and amniotomy have never been proven to worsen outcomes. The c/s rate has gone up, but outcomes worse, lets be reasonable. No way. Infant mortality rate in labor is next to ZERO percent, now studies do show that continuous EFM has not significantly decreased CP rates, but I don't want anyone to ever think it has worsened anything. Having a c/s is not the worst thing in the world, but having your baby die during a shoulder dystocia or asphyxia event can be. Next, I have to ask why insurance would prevent delivering at home? Seems to me that there'd be no charge. As an OB nurse, yes, it is frustrating to take care of these patients who "refuse" care, but show up, I agree...but refusal of care and refusal of active management of labor are two different things. Amniotomy and pit are not necessary, but ask yourself the question, why do you come to a hospital? For safety and the "what ifs", so if you also refuse ANY monitoring and at least a hep lock, then yes, stay home, because these are the ones who are going to sue in the end when things go wrong. IMO Can you tell that this is one of my pet peeves??

They have been shown time and again to result in worse outcomes. It is widely acknowledged that FM increases the c-section rate wthout improving outcomes. C/S is a complication and a morbidity- not to mention all that goes with the c-section (increased pain, healing time, breastfeeding difficulties, infant admission to NICU, increased risk of infections maternal and infant, increased RDS, and on and on). As for amniotomy, the only thing in its favor is that it MAY decrease labor time by an average of 45 minutes (per Cochrane). This is stacked against the risks associated with it (infection, prolapse, malposition to name a few). To say that these interventions do not worsen outcomes is to ignore all evidence.

As for not understanding why insurance doesn't cover homebirth, many women would agree with you, but unfortunately it is not covered. by most policies despite the potential savings to all of us by reducing unnecessary costs. Much to do with the ACOG statement against homebirth that many other groups (ACNM, MANA, RCOG, to name a few) have discredited.

OzMW · Oct 2, 2007

:monkeydance:

If there had been a bad outcome in this case due to the lack of an IV already in place, there probably would have been a lawsuit. But if there is a bad outcome in any obstetric case, there will probably be a lawsuit anyway. .

I think you're spot on with that one Nora. No matter what we do there will always be bad outcomes in any environment. And then people will sue. In my mind practising defensively only opens you up to more complaints? Don't women pick up on the attitude that a nurse has when she is orifice-covering.

You WILL have the IV because I'm looking out for myself! Doesn't matter that the risk I am concerned about is so minuscule that you probably won't get it anyway, but I've gotta look after myself (because even though you are the one having the baby this is all about me and my nursing license). And to just add a bit more protection for you and your baby (but REALLY for my protection) we will monitor you continuously just in case you are part of the less than one percent part of the population who will drop a cord or abrupt. And god forbid if you are informed and choose not to have the EFM:devil:.

May as well give her the name of the patient complaints coordinator there and then I reckon..Hee hee. :uhoh3:

Elvish, BSN, DNP, RN, NP · Oct 2, 2007

What seems to cover orifices more than all that crap is building a good rapport with your patient. That has been my experience. If she feels like you are on her side rather than your own, she will feel taken care of no matter what.

There are always going to be those who would be unhappy and sue even if God Himself came down from heaven to be their RN. They compose like, what, 0.1% (if that) of the gen pop? I can't live my life worrying about them.

Dayray, RN · Oct 2, 2007

My pat response is, "I cant and wont do anythign to you that you tell me not to, all I ask is that you let my explain the reasons behind it before you make a desiction". I tell them the reasons and explain the downsides to the procedure and tell them my opinion then wait for them to tell me what to do.

Most ppl calm down after that and listen, all but the most unreasonable of ppl want to be safe and are willing to accept small discomfort for lage amount of safety. When they are havign a hard time makeing up their mind I remind them that the 2 reasons ppl come to the hospital to have a baby are 1 safty and 2 pain medicine and then explain why the intervention is related to one of those.

Ive only had 1 pateint refuse an IV after a calm explaination. She told me she had done this 8 times and how could I possibly know anything sense i had never given birth myself (she was G8 P0 ) She later chose to get one when she had been in "labor" for hours, refused all vag exams and monitoring but was requesting an AROM and the midwife refused to do it until she had an IV in place.

OzMW · Oct 2, 2007

. When they are havign a hard time makeing up their mind I remind them that the 2 reasons ppl come to the hospital to have a baby are 1 safty and 2 pain medicine and then explain why the intervention is related to one of those.
.

Isn't that a form of bullying.....women have very few options to go anywhere else to have there babies because they have been led to believe that technology is safest! IV in labour on all women is complete overkill and orifice covering at the least. :monkeydance:

OzMW · Oct 2, 2007

What seems to cover orifices more than all that crap is building a good rapport with your patient. That has been my experience. If she feels like you are on her side rather than your own, she will feel taken care of no matter what.
.

SPOT ON Arwen......:D:D:D:bow: :bow: :bow:

Elvish, BSN, DNP, RN, NP · Oct 2, 2007

Hey Oz, were we separated at birth or something? We think alike so often, I was just wondering...

OzMW · Oct 2, 2007

Hee hee!!!:blushkiss

AlabamaLegalRN · Oct 3, 2007

Do what you will, with what you have. Those of you with less than 10 yrs experience, talk to the hand...Oz I respect your opinions, but must remind you that they are just that. Its amazing how many of you truly believe that medicine is a cospiracy, yet you entered the field, I guess to change the world. Fewer and fewer states in the US are recognizing midwifery, why? Because it is a proven fact that risks are higher AT HOME, no matter how "low risk" you start out. But I bet this group preaching natural birth is the same no deodorant wearing, tree hugging, imagery using "nurses" that never should have gotten a license to begin with, since medical professionals are all evil anyway. I will continue to cover my orifice, and help patients seek restitution when you don't. Protocols (with ALL "o"s) are developed BASED ON SCIENTIFIC EVIDENCE...and if you don't know this, then you have never been an administrator. You can't just "write" a protocol because you want to. You sound like a bunch of ADNs that were LPNs and wanted higher pay, and never learned the theory. FYI Cochrane has been discredited by AWHONN time and time again, try using more than one source all of the time. But there are always people out there everywhere who find someone that believes what they believe and then quote them all day. Yes labor * there is NO "u" in the word * is a natural process, and people have been doing it forever unaided, but remember if everyone believed that, then you wouldn't have a job...so why did you choose nursing if intervention is actually interfering? You can stand and hold someones hand for free, and without a degree. It has always amazed me how nurses always think they know better than the doctors. Go back to the herb farm, rub some oil on peoples feet, hand out magnetic bracelets, and do the profession a favor and let your license lapse.

OBGYN Legal RN · Oct 3, 2007

The lady does have spunk! I agree in sorts with the southerner, and applaud her kahunas. There is too much kissy, touchy, feely crap around these days. Yes, mama had me at home, dirty towels on the floor, doc "in town" ready to come if something happened, but that is what we move forward for. We make advances in medicine for the better, do you know how many people thought pennicillin was a crock, it was evil and "we never needed no medicines to get over a sore throat"...well guess what, its still here, but some out there would still argue we interfere too much. I think nurses forget their places in medicine though, we are the patients advocates, not the doctor, not the decider, we carry out orders, yes...we do!!! We are NOT doctors, and if you want to be, go back to school, otherwise you are there to bridge the gap between doctors and patients, you are the interpreter of sorts, don't judge them for their own ideas, but also don't look down on them because they have faith in the docs. That said, I too have read many articles and journals discrediting the "Cochrane" ideas as ideals, I am not the biggest fan, I have truly been in this long enough to have seen, that EFM has bloody by GOD made a huge difference! You have your little studies, but live it, watch it, and practice it for this many years and you will agree. The reason CP rates have not changed (even slightly risen) has NOTHING to do with EFM, it has to do with the fact that we are resuscitating 21 and 22 weekers nowadays and they are living (not judging, just stating facts). These children are going to have problems, and they count in the CP numbers, but the one's that EFM did not save. I have probably been present on hundreds if not close to a thousand stat sections in my time, and if you deny that continuous EFM does not save lives, you are either too new, or in denial. I think the southerner has some valid points as well on the ADN vs. BSN thing, could have been put another way, but valid none the less. Now THIS will stir some snotty remarks from the peanut gallery.

joyflnoyz, LPN · Oct 3, 2007

>Yes labor * there is NO "u" in the word * is a >natural process,

Uh, 'scuse me for barging in, but laBOUR, colOUR etc ARE legitimate spellings of those words in Great Britian, Australia and Canada.(I'm sure there are more countries that don't use "americanized" spellings of the English language.)

As far as the rest of your post, it's getting pretty close to crossing the line as a personal attack on those who do not agree with you.

joyflnoyz (a LPN for 26 years working on ADN, 2 hospital births, 2 homebirths, homeschooler for 25 years, have NEVER

been a tree hugger, worn a magnetic bracelet, lived or worked on or near a herb farm, always shower AND wear deodorant/antiperspirant, and will fight for the rights of everyone for self determination for his or her life.)