Staff Members who refuse treatment ???

safarirn · Dec 15, 2009

They are adults. They have the right to refuse treatment. I don't think you can send them to the hospital or force them to have any medical treatments against their will if they are oriented & coherent.

I would take this opportunity to EDUCATE, EDUCATE, EDUCATE!!!

Why does she even tell you she is having CP & ask you to take her B/P if she is not going to do anything about it? That would be frustrating!!

bergren · Dec 16, 2009

What kind of chest pain? It sounds like you were comfortable with her driving home, so you did not think she was having angina or an MI?

Many who have symptoms of a heart attack refuse to go to the ER. Offer to assist her while calling her physician, and if she refuses, call 911. You have done what you can as the health care provider. She will then have to refuse treatment to the paramedics.

rn/writer, RN · Dec 16, 2009

I wouldn't encourage someone with the symptoms you mentioned to just go home. She really ought to be evaluated.

You can't force her to go to the ER, but that isn't the only issue here. How can she give safe and attentive care to her patients/duties if she is under physical stress? What happens to patients and staff alike if she just keels over one day and lapses into unconsciousness or even death? That would be horrible for everyone involved.

Maybe you can let her know you care about her (if you do) and dread having to watch her collapse at some point. Take her aside and ask what stops her from getting help. Is she afraid of losing her job? Does she have family that knows about her symptoms.

I suppose there's a chance that she enjoys the attention, but the more serious (and grimmer) possibility is that she is bouncing back and forth between denial and paralyzing fear and doesn't know how to get unstuck. Either way, she needs help.

If she absolutely refuses to do anything about her symptoms, your nurse manager may have to ask HR or look up P&P to decide what should happen next. It's a shame that it might come to that, but maybe a personal "intervention" of her co-workers would break through the haze and let her know that you guys are afraid for her and want her to take care of herself.

Let us know what happens.

safarirn · Dec 17, 2009

So if you call 911 for a teacher/ staff member against their will & they refuse to go or be treated, who pays for that rescue call dispatch out?

If the teacher refuses to pay for any of the incurred fees because she told you she did not want treatment/ services... is the school stuck with the bill?

How does this work?

rn/writer, RN · Dec 17, 2009

When I posted earlier, I didn't realize that this was the forum for school nursing. Sorry.

With the school context in mind, I would still ask her to consider those around her if she can't take care of herself for her own sake. Can she understand that, while you respect her autonomy, you still worry about her? And about the kids and the colleagues who might witness a collapse?

So if you call 911 for a teacher/ staff member against their will & they refuse to go or be treated, who pays for that rescue call dispatch out?
If the teacher refuses to pay for any of the incurred fees because she told you she did not want treatment/ services... is the school stuck with the bill?
How does this work?

I worked on two different fire departments and have worked with many others. In the municipalities I am aware of, folks were only billed in the case of a transport. A "treat and release" or a refusal of treatment incurred no charges.

Could it just be that she doesn't want to pay for an ambulance? I doubt that it's that simple, but sometimes people go cheap about the craziest things.

bergren · Dec 17, 2009

In the communities I have lived in there is no charge for 911 if there is no transport. If the teacher refuses transport, you fulfilled your obligation as a professional registered nurse by calling 911 if warranted. If the teacher does not refuse treatment or transport, she consented, and any charges would be incurred by her.

I am a bit nervous about basing whether to call 911 or not on who will be charged? Shouldn't the decision tree of whether to initiate the Emergency Medical System for a teacher, a student, whoever, be based on your clinical judgment independent of who pays? What are the negative consequences of not calling if in your judgment as a professional registered nurse it is an emergency? Both you and the district will be held liable. Many districts have policies in place that no individual can overrule the health professional's decision to call 911.

safarirn · Dec 17, 2009

I understand what you are saying. I see both sides. Thankfully, I have never had to deal with this. The fact that the original poster felt comfortable with the staff member DRIVING themselves home, makes me believe that her vital signs were okay (b/p on the high side, but not off the charts). From the original post it sounds like she wants the staff member to make a F/U appt with a doctor for preventative care/ diagnosis/ treatment.

She is dealing with a competant adult. I would *never* make a MEDICAL decision based on who pays for what. But this competant adult is stating she does not want to go home/ go to the hospital... in the rural farm town I live in, I can't imagine using my emergency resources this way & pulling them from another REAL emergency where seconds may matter to come & get turned away by this competant adult.

'There are specific rules under which you CANNOT refuse a transport to the hospital. They include-but are not limited to-head injuries or other injuries that affect your mental status (you are not considered to be mentally coherent and not able to make medical decisions), any threat or attempt of suicide (you lose the right to refuse medical care), if you are under the age of legal consent (under the age of 18 unless you are married, emancipated or a parent yourself), or if you are taken into police custody and the police deem that you need medical treatment (such as a car accident involving a DUI).'

This is NOT one of those situations, so I still wonder what I would do. I would hope I would make the right decision based on how the person presented & I would know what to do. But with what I have read so far, I am not reading about life-threatening distress/ immenent danger. I might be reading it differently than you though.

Trauma Columnist · Dec 17, 2009

Okay - so this adult staff member comes to you (school nurse) and complains of these symptoms but doesn't want help?

I would refuse to further examine this pt and I'm gathering there is no charting or accountability done for this? Uh....this is a lawsuit ready to happen.

Are you charged with seeing these adult pts? If not, then I would refuse to discuss their complaints except to say "you need to call 911, I'll be glad to do so."

If...on the other hand, you do keep charts on these pts, then I would document well and also report this to the mid-level provider or your medical director.

safarirn · Dec 17, 2009

GREAT ADVICE, traumaRUs!

THANK YOU for putting in to words, exactly what I was thinking!

Flare, ASN, BSN · Dec 17, 2009

i'd call for EMS - she can refuse from them too then document the heck out of everything

bergren · Dec 18, 2009

Great information! Good advice re: checking your job descrition re employee health. However, in an emergency, it would not matter. And once you agree to take the B/P, you have engaged as a healthcare provider.

I have always been a pediatric nurse. Very very little adult experience. I did work a stint in a VERY rural hospital, and when they were short in MICU or SICU, I was pulled because, with my NICU experience, I knew how to work the EQUIPMENT! I was always a wreck, (what does jaw pain mean again???, I remember something about that from Med Surg class????). I would always get assigned to the R/O MIs. In report they would always say, "The enzymes were not back yet, but we are SURE he/she did not have an MI". And then of course, at 10 am the morning labs would come back, and sure enough, they did have an MI!! So, I would be biased toward assuming the worst and not trusting my adult cardiac assessment skills enough to be certain nothing significant was happening.

So what are our choices? Let's assume sky high BP and chest pain, anxiety enough that they come to see us. And with women, the physical signs can be muted. If we cannot get them to call their MD, we can let them walk out and do nothing, let them drive home and then they do nothing, or call 911. I think choices 1 & 2 carry some liability for the nurse and the district. We cannot share anything with the principal due to privacy laws UNLESS we think it is an emergency, and if we think it is an emergency, why didn't we call 911? (I am picturing myself on the witness stand defending my decisions.) I assume we would all know which choice is best using other assessment skills if we were in that situation, but the teacher has really backed an RN into a corner by not agreeing to contact MD. I would not allow them to drive themselves with high BP and chest pain. Even if the doctor said "come in to the office", I'd have someone drive her (another

can of worms). If I stated to the teacher that as an RN, in order to protect my license, if she refuses to contact her MD, I had no choice except to call 911, my guess is she would call. She is a ticking time bomb. Why is she coming to get nursing advice, worried about her health? I am going to go with the possibility she wants US to do something because she does not have the confidence or courage to do it.

It is a tough call. That is why we get the big bucks!!! :