What should have been said? Did i do the right thing?

[Jay2daq]

We all have stories of "funny things" and not so funny things patients say....

i had one about a week ago, that my heart goes out to....i had NO idea how to handle this situation. The general med/surg floor was full so we got this young woman (36 years old) who came to our unit from a lady partsl hysterectomy. We are a med/surg specializing in cardaic and pulmonary, but she was young/healthy and was doing fine. We knew how to do the monitoring for bleeding etc. SUPER nice woman, husband was super sweet/supportive. You could tell they were not of higher education, lower income etc. Keep in mind she is HYSTERECTOMY (Fibroids i believe). Left her ovaries.

Anyway...she asks me the question "How long does this usually take to heal before i can be come sexually active again?" Ok, I feel comfortable discussing this with patients. No big deal, common question we get.

i went over her patient education on sex with her, addressed her sexual concerns etc.

then she says to me "Good. I think we want to start trying for children soon."

I said to her...."Do you mean your own children or adoption?" (i wanted to make sure i was hearing her right) she went on to say "We would like our own." At this point she knew something was wrong as i had NO IDEA what to say. She said "Is there something wrong with that?" i asked her what education she had prior to the removal of her uterus, she told me they went over everything with her. I said "Were you made aware that without the uterus you will be unable to have children?"

Okay i thought it was like hospital policy to over something like that with a woman!!! i mean i know she is 36, so they cant just assume she doesnt want children....just because she is 36? I dont know call me crazy. I know this was TOTALLY wrong and i reported it to my manager because i felt this was kind of a big issue that i wasnt sure how to handle. She looked into it further, i don't really know what came if it yet but i do know that their ARE hospital policies regarding this discussion no matter patients age. Either noone did it or she didnt understand it.....

my heart goes out to this patient,they were the sweetest couple and i can't help but get it off my mind. Did i say the right thing?? Could i have said it better? What should i have done?

How would you have handled the situation?

[merlee]

You did the right thing. Sometimes 'informed consent' doesn't mean they truly understand. Many years ago, I had a patient ask me 'after they take my bladder out, how will I pee?' She was having GALL bladder surgery, and had no idea that there were 2 bladders. She signed for the surgery without asking the doctor this incredibly crucial question.

Many people are still intimidated by docs, and do not even know they can ask questions, or don't know what to ask.

Apparently there were assumptions made here, and possibly the doc simply assumed that most people know what a hysterectomy ultimately means.

[Tait, MSN, RN]

I would have been shocked as well, and probably would have just stood there dumbfounded, and I am rarely caught off guard by patients.

Tait

[ebear, BSN, RN]

Guess we "brainiacs" just don't understand Miss Mab. She bowed out before I could reply. Oh, well...she would have continued to be head-strong anyway. :cheers: A real peach she is....

[nurse2033, MSN, RN]

Sounds like you did as good as any of us could have. One thing I have learned is that you can never be ready for every situation. You were right to alert your manager. There is a huge potential for that patient to get very upset. Holy cow! Good example that you can never make assumptions. Good job.

[rn/writer, RN]

Hey guys, Miss Mab apologized for her abrupt presentation. Can we let it go now? Please?

*********

"In vitro" is a term with more than one implication. It can mean fertilization using the couple's eggs and sperm with incubation inside a surrogate. It could also mean (and this is a more common usage) external fertilization and implantation into the egg source's uterus.

In this case, the first possibility is still an option, but the second is most definitely ruled out.

I work postpartum and when we take care of babies conceived through in vitro fertilization, it's almost always the case that the fertile eggs were returned to the mom they came from.

So to say that in vitro is not possible is largely true. In vitro via a surrogate would still be a choice, but not a likely one for a couple of limited means.

[elkpark]

It's also possible that the physician did go over everything with the client prior to the surgery, but she heard what she wanted to hear (or didn't hear what she didn't want to hear) -- I've been in a number of situations over my career where I was present in the room and heard what the physician told the client, and, later, the client seemed to believe s/he had been told something entirely different from what I heard the physician say. People who are anxious often hear only a fraction of what we think we're telling them, or misunderstand but are too intimidated by the Great Almighty Physician to ask the questions necessary to get things straight (like the bladder/gall bladder example earlier), or they just tune out the stuff that they don't like. I don't meant that as a criticism of anyone -- it's just a coping mechanism, and human nature to some extent.

[GHGoonette, BSN, RN]

While it's not the task of the nurse to explain the surgery to the patient, this thread does illustrate the need for further education by the nursing staff to take place pre-operatively, in order to reinforce what she has already heard from the doctor and to ensure that she is properly informed before she signs consent.

Informed consent, as we all know, includes not only the nature of the operation and its expected outcomes, but the consequences to the patient's life- possible, probable and inevitable. If she did not understand these consequences, can the consent be regarded as "informed"?

I am reminded of a case when I was a student; an elderly lady was admitted for a hysterectomy, and when I explained to her (prior to obtaining consent) what the operation entailed she was horrified. Apparently the doctor had not even told her what she was being admitted for! She discharged herself....

Question for the legal eagles out there: do you think this patient has grounds for a lawsuit?

[roser13, ASN, RN]

OP, I feel for you. What really strikes me is the fact that both husband and wife were in the dark. The odds of a youngish, fertile female not understanding the consequences of a hysterectomy are one thing, but the odds that both of them are clueless?

I do want to ask how the wife reacted to your anatomy discussion?

[Esme12, ASN, BSN, RN]

You did the right thing. Sometimes 'informed consent' doesn't mean they truly understand. Many years ago, I had a patient ask me 'after they take my bladder out, how will I pee?' She was having GALL bladder surgery, and had no idea that there were 2 bladders. She signed for the surgery without asking the doctor this incredibly crucial question.

Many people are still intimidated by docs, and do not even know they can ask questions, or don't know what to ask.

Apparently there were assumptions made here, and possibly the doc simply assumed that most people know what a hysterectomy ultimately means.

Another example that we should never assume.......

[Jay2daq]

Braniacs--

She still has her ovaries----therefore ---they can still have ' their own'.

Granted, via in vitro though...w/blessed surragate.

Maybe you mistook her sex question for more than she meant. She wanted to know when she could get going again. Maybe her mind just clicked over to the baby issue. Maybe SHE was testing YOUR higher education?

I pray for a troll

sorry---i should have said caring braniacs at least. My bad.

You asked what could you have said or done better? Just not phrase an answer like this---

"""Even if the patient is aware you need a uterus to concieve, they need to made aware without it they cannot have children"""

You could talk about it being tougher and offer education and referral info options but maybe not so much the false stuff...

No, I am aware of that. I didnt want to post my whole conversation with her but she wasnt really wanting to in-vitro. she meant literally carrying her OWN child. I made sure this is what she meant.

[Jay2daq]

Someone mentioned my answer to her sounded a little "harsh". I dont know...maybe it did reading it. But it was more the way i said it than anything. i am NOT a snobby/mean person. I'm very quiet, soft spoken so it was said in a nicer and caring way. I think alot of the times we have good intentions to say something, but it can come out wrong. I'm young, im new, i had NO clue how to handle that situation. Could i have said or done something better? Probably....

we are taught in nursing school our "utopia patient" who knows what a uterus is and what it does. But not all patients are the "utopia patient" and i'm in the real world, not practicing nursing education on my classmates anymore.

My guess is that the patient was made aware, i can't imagine that she wouldnt be. I know which surgeon did the surgery and he has a strong german accent. (Off topic: He one time asked me where my boss was, i thought he asked me where my balls were.)

As for grounds for a law-suit?? i have NO idea. I havent been further contacted or anything or asked anymore questions about it.

OP, I feel for you. What really strikes me is the fact that both husband and wife were in the dark. The odds of a youngish, fertile female not understanding the consequences of a hysterectomy are one thing, but the odds that both of them are clueless?

I do want to ask how the wife reacted to your anatomy discussion?

Without postingour entire discussion, i did assess her understanding of pregnancy. Trying hard to make it sound like im talking to an adult and not a child. Much to my surprise she knew more than i thought she did, just information was slightly "discombobulated." She told me she thought pregnancy occured in the ovaries because thats where the eggs are.

She was pretty teary eyed and said "How could i have been so stupid?" Handled it much better than i would have.

[PetiteOpRN]

When I am assessing a patient pre-op, there are some questions I defer to the surgeon. Sometimes, the patient has had this conversation with the surgeon umpteen times and thinks that if they ask me they can change the outcome. Other times the patient is simply uninformed.

Legally, it is the doctor's responsibility, not the nurse's to explain the procedure and implications.

Even though this conversation took place post-op, I would have paged the doctor to come up and have this conversation with the patient. I tell the patient, "that is a question that your doctor can answer much better than I can, let me go get him/her for you."