Urgent Response Needed

[DaFreak71]

My husband is a RN, I am nursing school. My husband I routinely discuss our patients, without breaching confidentiality (no names, no identifying information whatsoever). We discuss the various conditions we deal with and how they are treated, the nursing profession in general, etc.

I have looked at our states board of nursing site and it does not help with my question, so that is why I am posting here.

My husband has a patient who presented with necrotizing fasciitis and kidney failure which she receives dialysis for three days per week. When the patient was first admitted, the NF was limited to her leg, but was very severe. She has been surgically debrided 10 times now. She has been at this hospital for over two months now. Last week, despite no improvement, she was transfered to the floor (she had been in the ICU). Due to her renal failure, she cannot take vanc or any other strong antibiotic. She is putting out about 10cc of urine q 4 hrs. She is 36 years old with young children. Her NF has spread to her abdomen. Originally, her wounds were being packed with a diluted bleach solution, now they are packed with saline. She is scared and is beginning to ask questions about whether or not she is going to be ok. The doctors won't answer her questions.

This particular hospital where my husband is a travel nurse has documented on her condition and brought it to the attention of her doctor, who claimed it was surgery's problem. He has also brought this to the attention of his charge nurse and the other nurses on his rotation and the incoming rotation. This hospital does not have a wound care nurse, nor do they have an infection control nurse.

My question is this:

Can nurses independently go to the hospital's social worker to get someone else on board to advocate for the patient? He is worried that what he charted will "disappear" from her chart. He has advised the patient and the the patients family demand answers from the surgeon and her doctor.

What else is he allowed to do to advocate for this patient? According to my husband, he thinks she should be transfered to a hospital that has a wound care nurse or maybe even a hyperbaric chamber (which can help with the healing process depending on whether the organism is aerobic or anaerobic). It is obvious to him and the other nurses that she is getting worse, not better and it seems as though the doctors aren't providing her with answers or aggressive care.

There are two hospitals located within three blocks of the hospital where is working. Both have hyperbaric chambers and wound care nurses, one has a burn unit.

What else can he do to advocate for her? It is a sad situation. She is of a certain culture that does not tend to ask questions about their condition. But this patient has opened up to my husband and has expressed her fear, asked directly about her wound, and has expressed frustration about her doctor's refusal to answer questions.

He said he wrote several pages documenting this. He even attached a sticky note (taped down to the page) about the patients fears, questions, etc.

Please, someone, anyone, tell me what YOU would do and what is generally in the scope of a nurses practice. Can he call in social work? Who else can he go to? Report to JHACO? The hospital is a very terrible place (not just because of this, but other issues too) so he isn't sure if going up the chain of command would do anything, but he knows he has to try despite the possible futility.

ANY advice or suggestions are much appreciated. Thank you very much for reading this.

Adri

P.S. the NF is so bad that it takes all the nurses on the rotation to assist with wound packing. It is extremely deep in their opinion, could break through the abdominal wall at any time. So this is an emergency situation.

[TrudyRN]

Well, you run a risk of making the docs mad and your boss when you inform patients of stuff their docs don't know about or want them to know about.

Calling in Social Work - also risky, unless this is normally done at your place.

Not informing patient - risks your self-respect.

Tough call, no easy answers. The first thing I thought of was hyperbaric chamber. Why don't her a'head docs inform her of this? It sounds like your husband has already done so, right? Aside from informing the patient and family that this treatment exists, what more do you think he should do? There might be other treatments, too - alternative med type things.

[Nazarite]

Well as a brand new RN who has yet to work on the floor as a nurse, I don't know if what I'm about to say is correct, within the bon, etc...so I'm just qualifying that this is my opinion...

Can your husband help the patient or her family advocate for herself so to speak? Like tell her that she has the right to a second opinion, and therefore can she request another Dr. and to be transferred to this other facility? It certainly sounds like the other hospital has more availability of options as far as her treatment is concerned......I don't know where that will put your husband though, as far as his job is concerned with telling her this...

Additionally, I had a situation as a SN with a patient that was about to go ama and the nurse could have cared less....well I realized this man was in desperate need of social work, so I asked my instructor if i could request a social work consult and she said sure...so I did....the pt didn't go ama, he got the help he needed and i was complimented by my teacher for advocating for him....so in that case it was acceptable to request social work.....but was at a hospital in my state.....

Well, I hope my thoughts on this are helpful, and like I said, I'm not sure if what I'm saying is the right path, but it is just another possible option.....I hope this lady gets the help she needs, and thank you and your husband for being such great advocates....That is the type of nurse I hope to be....:nurse:nazarite

[puggymae]

The hospital should have a patient care representative (or patient ombudsman). The family could contact him/her and voice their concern and what they want done. The patient rep can set up a meeting between social services, the doctors, the nurses, the family, and patient to discuss this situation.

Your husband is doing a good thing being an advocate for this patient. Even if there is nothing else that can be done for her she deserves to be told that up front.

[DaFreak71]

Well as a brand new RN who has yet to work on the floor as a nurse, I don't know if what I'm about to say is correct, within the bon, etc...so I'm just qualifying that this is my opinion...

Can your husband help the patient or her family advocate for herself so to speak? Like tell her that she has the right to a second opinion, and therefore can she request another Dr. and to be transferred to this other facility? It certainly sounds like the other hospital has more availability of options as far as her treatment is concerned......I don't know where that will put your husband though, as far as his job is concerned with telling her this...

Additionally, I had a situation as a SN with a patient that was about to go ama and the nurse could have cared less....well I realized this man was in desperate need of social work, so I asked my instructor if i could request a social work consult and she said sure...so I did....the pt didn't go ama, he got the help he needed and i was complimented by my teacher for advocating for him....so in that case it was acceptable to request social work.....but was at a hospital in my state.....

Well, I hope my thoughts on this are helpful, and like I said, I'm not sure if what I'm saying is the right path, but it is just another possible option.....I hope this lady gets the help she needs, and thank you and your husband for being such great advocates....That is the type of nurse I hope to be....:nurse:nazarite

Thank you so much for your kind words and for your advice! Yes, he has told the patient that she has the right to demand answers and the right to request a second opinion. I do not know if he told her that she had a right to request to be transferred to a different hospital. I will ask him when he wakes up. Can a different hospital refuse to take her if she is uninsured? He is a great nurse and doesn't play the politics game. Patients come first and if it comes back to bite him in the butt, at least he can look at himself in the mirror and know that he did everything he could to take care of someone else without considering any potential backlash. I am proud of him too. Plus, he sleeps well at night knowing he does the right thing, all the time, even if it pisses people off. God I love him!

[DaFreak71]

The hospital should have a patient care representative (or patient ombudsman). The family could contact him/her and voice their concern and what they want done. The patient rep can set up a meeting between social services, the doctors, the nurses, the family, and patient to discuss this situation.

Your husband is doing a good thing being an advocate for this patient. Even if there is nothing else that can be done for her she deserves to be told that up front.

Hi Puggymae!

Can my husband do that on his own, contact the patient care rep or the patients omsbudman, or does this have to come from the family?

[GregRN]

Your hospital almost certainly has an ethics committee. They can help apply ethical perspectives to sorting through issues like a different doctor, second opinions, transferring to another hospital to provide care, etc. If your husband is worried about certain parts of the patient's chart up and disappearing then the more eyes you have looking at the patient, the better off she will be. Requesting ethics consults are absolutely within the scope of practice for RN's and can be done by any RN at any time.

One more thing to add: one of the nice things about being a traveler is that you don't have to tread as lightly when it comes to political stuff like this. As a full time RN one has to maneuver some political waters carefully when calling for an ethics consult. Sometimes the docs feel like an ethics consult was called because they were doing something unethical, were doing something wrong, or weren't doing enough, etc. The ongoing relationship can be hurt after this. However, some ethics consult requests are done confidentially, as is the case here. At the same time, a traveler has the ability to rattle some cages without as much worry of relationship strain or retribution from others on the health care team since their assignment is much shorter and ongoing relationships are not a concern.

lostdruid, am I correct that your husband works in a non-teaching hospital?

[DaFreak71]

Your hospital almost certainly has an ethics committee. They can help apply ethical perspectives to sorting through issues like a different doctor, second opinions, transferring to another hospital to provide care, etc. If your husband is worried about certain parts of the patient's chart up and disappearing then the more eyes you have looking at the patient, the better off she will be. Requesting ethics consults are absolutely within the scope of practice for RN's and can be done by any RN at any time.

Thank you Greg. I will let him know that he can request an ethics consult. I know he will follow up on it. In addition, I will call the hospital and find out if they have an ethics committee. He works the night shift and it's hard for him to handle things during "business hours", lol. Thanks again!

Follow Up--The hospital didn't know what an omsbudman was, lol, but they do have an ethics committee that is available 24/7. Got the contact information, even gave me her cell phone number, so I'll pass this on to my husband and he will run it up the flagpole. She said that all reports will be confidential, although with my husband, he wouldn't care, LOL. That's just how he rolls. But I do like that they do keep it confidential because it encourages concerned patients and nurses to report their concerns. Again, I thank you for your advice!

[CarVsTree]

Hi Puggymae!

Can my husband do that on his own, contact the patient care rep or the patients omsbudman, or does this have to come from the family?

Yes, absolutely.

NF is very bad especially for a pt who is already compromised (ESRD). There is a very good chance that with limited atb therapy choices that she will succomb to the NF. This is very unfortunate and a very realistic scenario no matter what facility she is in.

My problem is not with the therapy choices or even that it appears that they may be withdrawing care, but with the lack of frankness with the patient and her family. In addition, Infectious Disease should be consulted and I find it hard to believe that they don't have an ID specialist. They must have one. I'm not sure what they could do or not do, but that is their area of diagnostic/therapeutic expertise.

Unfortunately, your husband is stuck in the middle and must tread lightly. Has your husband asked the docs for a prognosis? I would suggest that he ask the docs directly what her prognosis is. Then I would he suggest he ask, "have you shared the prognosis with the patient and her family?" He needs to stress the importance of their communication and let the docs know that she is frustrated in their lack of answers. Also, has he witnessed them not answering her questions or is he just telling you what the patient told him. I ask this because it is possible that they've told the patient and her family a poor prognosis and they don't want to hear that awful reality. Not saying this is the case, but it is possible. I suggest he be direct with the care team and then take it from there.

[DaFreak71]

Yes, absolutely.

NF is very bad especially for a pt who is already compromised (ESRD). There is a very good chance that with limited atb therapy choices that she will succomb to the NF. This is very unfortunate and a very realistic scenario no matter what facility she is in.

Very sad, but true. she deserves aggressive treatment regardless of the outcome. Husband said that if they had treated her aggressively, she might have been able to contain the NF via leg amputation before it spread to her abdomen. That is only opinion though, he certainly isn't a surgeon.

My problem is not with the therapy choices or even that it appears that they may be withdrawing care, but with the lack of frankness with the patient and her family. In addition, Infectious Disease should be consulted and I find it hard to believe that they don't have an ID specialist. They must have one. I'm not sure what they could do or not do, but that is their area of diagnostic/therapeutic expertise.

It is amazing isn't it? No wound care, no infectious disease personnel. We found it hard to believe as well. :angryfire

Unfortunately, your husband is stuck in the middle and must tread lightly. Has your husband asked the docs for a prognosis? I would suggest that he ask the docs directly what her prognosis is. Then I would he suggest he ask, "have you shared the prognosis with the patient and her family?" He needs to stress the importance of their communication and let the docs know that she is frustrated in their lack of answers. Also, has he witnessed them not answering her questions or is he just telling you what the patient told him. I ask this because it is possible that they've told the patient and her family a poor prognosis and they don't want to hear that awful reality. Not saying this is the case, but it is possible. I suggest he be direct with the care team and then take it from there.

Yes, he has asked for a prognosis but neither the doctor nor the surgeon will give one to him, so it's unlikely that they would tell the patient something they won't even tell the nurses. He is being as assertive as he can be, but not getting anywhere so far. Since he works the night shift, he gets to see the doctor, but he won't answer him, as for the surgeon, he has left several messages for him to update the chart about her condition, but this hasn't happened either. He has NOT witnessed any communication between patient/doctor. The family is very concerned and has expressed that they would rather have bad information rather than no information at all. I did get the name and phone numbers (a cell even!) to the woman who is in charge of the ethics committee. She said that she also works the works the night shifts during the week and that any nurse can report anything they want to report confidentially. So this is very good news!

Even if the outcome is bad, which it does look like it is, she does deserve to have more aggressive treatment since that is what she desires. She has two small children who deserve to have their mommy treated as aggressively as she can be.

Thank you for responding to my post!