Many people that become hospitalized and become a patient feel like they have lost control of their life. Everyone is doing everything for them including making decisions without consenting the patient. New medications, lab draws, starting an IV, placing a urinary catheter, lifting your gown up exposing your body etc. It's just wrong.
I always empower my patients to speak up! Especially to doctors. Patients all of a sudden become mute when the doctor walks in. Especially in teaching hospitals with it's a whole pack of doctors that come in and are all talking to each other while poking and prodding at the patient not even acknowledging them as a human being lying in that bed. I always tell my patients, "bring that up to your doctor when they come in", "tell them you are still in pain", "tell them that you want that tube out today not tomorrow".
What happens is the doctors especially forget that what is medically the right thing to do doesn't always coincide with what the patient wants. In this situation as healthcare providers our job is to EDUCATE the patient on the benefits/risks of doing or not doing what is medically advised in a given situation. It is then the patients choice whether they want to do what is advised or not. Patients have a bill of rights. On that bill of rights one of them is PATIENTS HAVE THE RIGHT TO REFUSE. Let me say that one more time, patients-have-the-right-to-refuse. As a healthcare provider whether you agree or not you need to respect the patients wishes. You did your best. You did your job by educating and advising the patient that their decision is not what you recommend based on your expertise and knowledge and leave it at that. Sometimes it really is just a power game and it's sad and infuriating to me as a nurse.
I was observing a situation today where there was a young patient in her mid twenties who just had a kidney transplant. It is standard for a kidney transplant patients to come out of the operating room (OR) with a urinary catheter (foley). This is a usually a silicone tube that is placed through the urethra into the bladder and secured by inflating a 6-10 ml ballon at the tip of the catheter inside the bladder so it does not slip out. The purpose is to drain urine into a bag so that we as healthcare providers can have a precise count of urine output for this patient as it is an indicator for how well the new kidney is doing after being transplanted.
Sounds very important right? It is. However, this patient since she arrived on the floor at about noon was in hysterics over this catheter. It was causing her to have bladder spasms that were sending her flying through the ceiling. She was not even my patient but she caught my attention because I had the 2 patients in the rooms on either side of her room. Inherently I went in out of concern thinking no one had attended to her pain. I find out what is going on and speak with the nurse taking care of her. She told me the MD was already aware. I looked at her puzzled and asked her what the MD was doing about it and she told me they tried to manipulate the catheter but the patient freaked out and would not let them touch it because it hurt so bad. Sometimes depending on where the catheter is sitting in the bladder it can cause spasms, so simply manipulating it can fix the problem. In this case the patient could not tolerate even the slightest of movement of the catheter. I stepped out of the situation because she was not my patient and did not want to get involved. About 2 hours later I hear her screaming. I couldn't help but think to myself, "what the fuck is going on?!?!?!" I walked out of my patient's room next door to the patient's room that is screaming bloody murder and I see the nurse caring for her again and ask, "what is going on?!" At this point I am seriously concerned. The nurse tells me that the doctor ordered for a muscle spasm relaxer called ditropan and she already had a dilaudid PCA and was also going to be given Vicodin. So I am thinking ok that should do that trick hopefully. Wrong. Another 2 hours pass and it is now almost 5 in the evening and I am just returning from my break; as I am walking passed this patient's room I see her standing at the edge of the bed doubled down holding on to her belly just crying and pleading to please take out the catheter. At this point I am seriously boiling because I just do not understand why the doctors have not pulled the damn catheter out!!! The patient is not even asking she is demanding that the catheter be taken out and they just keep "educating" her on why they need to leave it in completely disregarding that she is in extreme discomfort. All the education in the world will not solve the pain issue!
This is crazy!! Is what I was thinking to myself. She has the right to refuse care! If she does not want the catheter and she is COMPLETELY oriented and knows what the hell is going on she has every right to get it taken out. It doesn't matter if you want precise urine outputs. There are different methods to get precise urine output. The patient can walk she can use the bathroom and pee into a hat. The urine can still be measured. The doctors already maxed out all alternatives by trying different drugs and asking her to relax and take deep breaths. If a lawyer got involved in this case the doctors & nurses and everyone directly involved in this patient's care would horribly lose. All it would take is the patients bill of rights and the argument that the urine could still be precisely measured without a foley. To say the least, I was livid. If that was my family member I would have gone up the chain of command. If that was my patient I would have advised them to do that as well.
The argument the doctors and the clinical nurse specialist all had was "she is exaggerating". IT DOESN'T MATTER. You have to take everything for face value in terms of pain in the hospital. How do we know 100% she is exaggerating! WHAT IF there truly is a serious problem?! What happens if there becomes a complication and for the passed 7 hours everyone did nothing about it because they felt that she was over reacting. My question was WHY can't we pull the foley catheter out and give her 6 hours to pee on her own like we do with everyone else and follow what the RESEARCH suggests and if she doesn't we bladder scan her. If she is over 300 mls of urine in her bladder the foley has to go back in?! What is the problem? I don't get it?!
This situation boiled down to a power struggle where doctors and specialists were completely tunnel visioned. Only thinking about how they need to get a precise urine output and not thinking about the human being involved. Essentially what they were saying to this patient with their actions was we doing care if you sit here writhing in pain with this catheter in because we care more out the urine output that your comfort.
If I were a lawyer on this case I would hang these people with their words because ethically this situation was wrong on SO many levels. I left work frustrated, upset, and sickened by this situation. I just can not believe it.
As a nurse it is MY job to advocate for my patients. I feel MANY nurses are too scared to speak up and push back at the MDs when they are simply being irrational. Just think about it if that was you or your loved one in that situation. Would you just go with the flow? Agree to everything the MD wants to do? As a COMPETENT nurse it is your JOB to suggest better ways to handle the situation if the MDs way of doing it isn't working. YOU are the one with the patient for 12+ hours. YOU know the patient better than anyone. YOU have to deal with all the bs. Speak up!! Often as nurses we get a gut instinct that something is wrong. In this situation even though the patient was not my patient I just felt like something was horribly wrong here and everyone was just blowing it off.
The most important thing to remember as a patient and a healthcare provider is the patient has the right to refuse! We cannot force or impose a treatment on a fully alert and oriented patient. Even in the "confused" patients situation it can be a sticky situation to force treatment on them if they are refusing. Have good judgement. Think to yourself, "if I was put up on the podium in a court of law to explain my actions in this situation would they be valid?", "what does the research say?", "what are the patient's rights in this situation?", "could I possibly lose my license over this situation?". Remember, the court is going to judge you on the five areas of ethical standards as defined by the nurse practice act: nonmaleficence (do no harm), beneficence (keeping the PATIENT'S welfare as the primary goal of care. Promoting good and preventing/removing harm ), autonomy (the law of oneself/self determination/having moral responsibility for your actions and understanding patients right to autonomy/respecting it), justice (what is morally/legally right), and privacy/confidentiality which are self explanatory.
Don't forget the reason why you chose to be in healthcare. If the reason was for money, prestige, or because your family told so...you are probably the person not speaking up and not realizing what the patient perceives is best for them may not meet eye to eye with what YOU perceive is right for them and that is where the problem lies.
If learn how to balance that and understand it you are golden.
Until next time.
-Norah
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