Nursing Ethics
A decompensated psychotic patient who happened to be a large muscular angry man presented for evaluation in the ER. He was demonstrating auditory hallucinations, multiple paranoid delusions, and expressions of homicidal ideation towards various individuals who he perceived to have mistreated him (including the staff at one of the local psychiatric facilities).
The bottom line was that he was a scary tightly-strung dude who was potentially a danger to himself and others, and we happened to be not only understaffed but also without any security that night. So he needed to be sedated.
He was coherent enough to discuss his medication history, however, and he completely refused any antipsychotic medications. Over the years he had been given numerous antipsychotics, he said, and he didn't like the way they made him feel. He insisted he wasn't psychotic and got even angrier at the implication. He was willing to take a shot of Ativan though, so I asked the nurse to give him a shot of Ativan with some Haldol mixed in, but not to tell him.
The nurse refused to administer the medication without telling the patient what was in the syringe. Because we were able to verbally calm the guy down a bit and he didn't make any attempts to escape, I guess she didn't feel justified in medicating the patient against his will. And yet, if he had tried to escape, an ugly and dangerous situation might have occurred.
I don't think that a psychotic patient who is hallucinating and threatening harm against others has the right to know what medication I am going to administer to him. Heck, I'm going to be incarcerating him against his will as soon as I can get a court order, what's the big deal with medicating him against his will? But I've never seen a nurse not tell a patient what medication (and what quantity) they were giving when asked.
I ended up giving the shot myself. I skipped the B-52 and gave him a Big 10-4.
Nighty night.
UPDATE: Interesting blog reactions by GuitarGirlRN, Shadowfax, Girlvet, and ER Nursey
The bottom line was that he was a scary tightly-strung dude who was potentially a danger to himself and others, and we happened to be not only understaffed but also without any security that night. So he needed to be sedated.
He was coherent enough to discuss his medication history, however, and he completely refused any antipsychotic medications. Over the years he had been given numerous antipsychotics, he said, and he didn't like the way they made him feel. He insisted he wasn't psychotic and got even angrier at the implication. He was willing to take a shot of Ativan though, so I asked the nurse to give him a shot of Ativan with some Haldol mixed in, but not to tell him.
The nurse refused to administer the medication without telling the patient what was in the syringe. Because we were able to verbally calm the guy down a bit and he didn't make any attempts to escape, I guess she didn't feel justified in medicating the patient against his will. And yet, if he had tried to escape, an ugly and dangerous situation might have occurred.
I don't think that a psychotic patient who is hallucinating and threatening harm against others has the right to know what medication I am going to administer to him. Heck, I'm going to be incarcerating him against his will as soon as I can get a court order, what's the big deal with medicating him against his will? But I've never seen a nurse not tell a patient what medication (and what quantity) they were giving when asked.
I ended up giving the shot myself. I skipped the B-52 and gave him a Big 10-4.
Nighty night.
UPDATE: Interesting blog reactions by GuitarGirlRN, Shadowfax, Girlvet, and ER Nursey
Labels: ER, nighty night, nurses, patients, psychos
posted by scalpel at 1:12 PM
42 Comments:
I think it's unethical to NOT medicate acutely psychotic patients whether they want to be or not. They're PSYCHOTIC.
It would have been nice, however, for you to put the patient on an official 72-hour hold which stated that the patient was psychotic/unable to make rational decisions prior to the nurse giving the drugs if she was uncomfortable giving the shot to the patient.
Until you had bim declared incompetent he had a rght to know.
"He was coherent enough to discuss his medication history,"
"Coherent to discsuss his medical history" is not equivalent to "not a danger to himself or others". He definitely WAS a danger to himself or others therefore 1. he needed a 72 hour hold and 2. you as a physician would have been liable had you not sedated/restrained him.
Either you should give the meds yourself or you should obtain nurses who will take orders from physicians.
should obtain nurses
Heh. Obtain nurses. We're not like warrants, insurance policies, or restraining orders.
C'mon. Not even hard. Presuming the patient either:
1. Was unable due to his psychosis to make an informed refusal, or
2. Presented an imminent threat to the safety of others,
You would be justified in medicating him without his knowledge or against his will. Sounds like this was pretty clear-cut. It would have been clearer if the patient were, say, in 4-point restraints. Presumably the nurse would have had no problem giving him an unidentified shot in that case?
Have you tried Geodon yet? I've heard it works well, but for reasons I'll detail later, we rarely do the Haldol thing and I've not tried Geodon...
Annals of EM had a discussion on this in Jan 2006 entitled, "An Unusual Case of Subterfuge in the Emergency Department: Covert Administration of Antipsychotic and Anxiolytic Medications to Control an Agitated Patient."
Maybe William could obtain a fairy from his ass while he's at it.
Good that you gave the shot, Scalpel, mission accomplished.
- Shari Ann
I can be obtained for all kinds of things.
It'll cost you, though.
If he was antipsychotic naive, would Zyprexa IM be a better choice given the lower risk of NMS?
Eric, Always Worried That A Med Error Will Mix Up The Toradol With The Haldol and Ruin His Carefully Constructed Personal Reality
There are certainly newer choices and perhaps better choices than the old standby. But when push comes to shove, we tend to use 1) what we are familiar with and 2) what's in our pyxis.
Geodon and Zyprexa aren't in either category in my world.
A 72 hour hold for dangerousness and/or grave disability, and a physician declaration of incapacity to make medical decisions are 2 separate issues. Your management of this case sounds appropriate.
Perhaps not a fairy from my ass, but an incident report to document the reason why the person's not getting a raise this year.
MT's can get fired, why are nurses magically protected?
I find the whole notion of nurse "insubordination" interesting, as well. We think of the ER as a semi-military hierarchy, because, well, that's more or less the way it operates. And from the doc's perspective, if I give an order, I damn well expect it to be carried out.
But of course, there are doctors who make mistakes, who are incompetent or unethical, and I have seen cases where nurse averted harm by saying "no" to an egregious order. (and sadly, I have seen more cases where a nurse could have averted harm by saying no, but did not.)
In a case like this, I can see why the nurse would have felt uncomfortable, and I would not hold it against them for refusing to perform what he or she saw an an unethical order. I would do what you did, and educate her more fully after the fact.
We have a few nurses who are chronic obstructors of care in this manner. They are more problematic to deal with.
I'm all about making nurses comfortable. If they have any doubts, I want them to speak up. If they want an explanation of something, I'm happy to give it to them. Good nurses have saved my butt more than once.
There is usually more than one way to get things done, and I like to think that I'm approachable and open to suggestions. We are a team, after all, but the buck ultimately stops with the physician.
military hierachy? OK.....when the nurse doesn't do what you want do you tell them to drop and do twenty?
I don't think I would have had a big ethical problem giving a psychotic patient haldol but obviously, this nurse did, which indicates to me that perhaps your patient was more rational than presented. It is also possible that Ativan alone would have worked. On the other hand, if it didn't, you'd all be screwed. Interesting dilemma.
I think nurses and doctors need to tell patients what meds they are getting. Cops arrest people. Courts can make people do things.
Doctors don't have the right to decide for patients without the patient's permission.
stormy, courts and juries have repeatedly shown that doctors do, in fact, have an obligation to make decisions for patients on occasion. It's not about "rights." Your comment is so inane I can barely respond. Can't you think of many situations in which doctors MUST act without consent?
"No sir, you can't have 40mg of morphine and then drive home."
"You seem to be unconscious--would you like that shot of glucose to save your life? What? I didn't hear you."
"So you have a gun at home and plan to blow your brains out. Well, I guess you just have to make up your own mind about things."
Or, as above, "You seem to be threatening, violent and under the influence of methamphetamines. You also seem to want to kill my nurses. Well, if you agree, I'd like to give you a medication which might ensure the safety of all these hard-working people. But only if you say so. Otherwise, feel free to start hucking things violently--that otoscope, for example."
If this were a "black and white" kind of world, the nurse would have been right. Giving meds without consent is quite unethical.
However, this ain't a "black and white" world. Ethics, especially, operate in lovely shades of grey.
You have to know when to bend the rules for the safety of everyone...including the patient in this case.
I'm not a medical professional, but to me it sounds like giving the medicine without consent was the right thing to do in this situation. Still, it scares me to think about doctors doing this. I'd say that 99% of doctors are good, ethical people who can be trusted. Then there's that 1%. I'm always scared of getting them. Being given medication against my will when it's not necessary is a frightening thought.
Jamie-
Many psychotic patients don't like anti-psychotic meds. They don't feel good. They make them dopey. In some instances, with long-term use, there are side effects, like tardive diskinesia. They have to be monitored carefully, for malignant hyperthermia.
But, bottom line is, they need them. And there's a difference between civilian life and the military. In the military, you can't fire people. A nurse refusing to carry out a doctor's order? three words "Fired For Cause." No unemployment, no 'nuthin, out the door. Can't do that in the service.
Interesting post and comments. I think you did the right thing Scalpel. If I were an employee in the ED I would hope the ED doc took precautionary measures for patient and staff's protection. We all know the ED is at a higher risk for violence over the other departments. At our hospital we had to take the mandatory tests every year regarding hospital procedures, etc. and part of that includes being able to recognize a potentially violent situation and subsequent protocol once identified.
If a person is making threats they should be taken seriously. Always. If you have a suicidal pt you are obligated to admit them into or get them transferred to mental health. Why would it be any different for a psychotic pt who was making HOMICIDAL threats? If you didn't follow your instincts/training and he harmed someone...maybe even you...the next thing you know we'd be hearing about the ED Doc from Texas who didn't follow protocol which resulted in a needless death. I'm just sayin.
Also...if he's not taking his meds well then just how lucid is he in his thought processes. He may present one way but you don't know what dialog is really going on in his head.
Also my girlfriend's father had a significant senile dementia and yet you could carry on normal conversations with him for long periods of time. He was an educated man and quite gregarious. Everyone liked him. If you didn't know all the facts you wouldn't know that he no longer knew how to take care of himself, use the remote or how to get back home. He even fooled the PCP and my girlfriend was shocked. I know this doc and he is good but her father presented normally. On the surface he could answer all the questions but he couldn't do basic things. I know...apples and oranges but you can't always know what is going on under the surface but when someone blatantly makes threats...you have to pay attention to that.
If there is a doubt and there is risk for potential violence well to me it is a no brainer. I'll tell you what...if some serious harm came to me or someone I cared about because the doctor in charge didn't do everything he could have...well suffice it to know I would be real unhappy with him. As a pt...I do not ever want my rights violated but if I am a danger to myself or others then I would hope that the Doc would have the cojones (spelling?) to do what needed to be done.
Sometimes you just have to choose the lesser evil for the greater good. That's my non medical expertise opinion anyway. :)
Virchow,
hahahaha. "Fired for cause"? Good luck with that! Ever heard of the nurse's union? Especially if he or she can reasonably assert an ethical defense. And don't lightly piss off a nurse, because they can refer you to the medical staff quality board and next thing you know, you'll be defending your own self!
Seriously, as Scalpel said, it's a team sport and you're best off talking it through. If you get in a pissing match you'll both just wind up wet, and you'll still have to work with each other.
Fired for cause! LOL!
I have suffered with and been treated for Major Depression for many years. I once spent 2 months in the state mental hospital in Wichita Falls, Texas. I am also familiar with a couple of other private hospitals, halfway houses and outpatient facilities.
All this to say, I've met your patient and I know what he can do. He needed your help and it was an emergency. You did what had to be done because you saw the danger ahead. I have to wonder what kind of experience and/or understanding this particular nurse has with mental illnesses.
In general, I agree that the patient should know and understand what medications are being given. That wasn't going to happen in this case. He was OUT OF HIS MIND and needed IMMEDIATE intervention before he hurt himself or someone else.
I can't help but wonder if she just didn't recognize or truly understand the danger of the situation. Cause really, do you announce to the crazed gunman in the clock tower that you're about to ambush him and take away his rifle?
I commend the nurse for her refusal, only because if the guy turned out allergic or later some shit was thrown, she'd be liable, letting the patient know is part of the 5 rights, yadda yadda. Lawyers love to make a stink when a mental patient is involved. That's all there is to it. She was trying to protect the patient.I hope that I have the sense to be careful in situations like those.
However he needed medicated, and I'm glad he got the med needed even though you had to give it it at least got given. Perhaps the nurse mistrusts you or was having a bad day? I know the feeling Scalpel, I have worked with aides who wouldn refuse to do what I told them, whether it was for the patient's good or not. I unfortunately had to step in and do whatever it was that they refused to do. Which wasn't fun, (usually it was assisting the verbally abusive patient so he could yell at me instead of hurting the poor aide's feelers but there were several more emergent things that would have gone easier if they'd just done it).
A few times it was easy to go back later and the staff understood why at that time it would have been better for all to do what I said, and never had another problem. Those I never worried about writing up, they thought they were benefiting the patient. But the repeat offenders, you can be sure I had a fit over them.
I respectfully disagree with William the Coroner’s point of view. Nurses are not obligated to follow a physician’s orders. Nurses have the RIGHT and the DUTY not to carry out orders that are unsafe, unlawful, or unethical. The patient in this case was clearly a danger to himself or others, but
unfortunately, he had more rights than the staff did unless he acted out. Medicating someone against his or her will when there is a perceived threat of violence is dicey, and cases like this one can easily end up in court. Hospitals usually support a physician during a lawsuit, but they will sellout a nurse in a New York minute if they can save a few bucks. Ultimately, I think Scalpel did the right thing, but I would not have given the injection myself due to the strict laws in my state.
MJ
i wasn't going to comment, but i will not medicate a patient without telling him or her what i am giving them. i feel that my patients should be able to trust me and my word. i also have never had a reason like the one we are all discussing.
if someone was currently acting out, unsafe, out of control then do what you have to, if a person is calmly sitting and answering questions i don't know that i would give them a med they said they didn't want. but i wasn't there.
There seem to be two issues here: The RN's see an ethical/clinical issue, while a number of doctors are wound up with the idea of disobedience.
With regard to "obtaining" a new nurse: possibly the individual with that comment needs to employ and pay an tech who would answer exclusively to him. Most ER nurses that I know work for the hospital, and their job is to follow the hospital's guidelines for administration of meds. Sending this incident to the hospital's ethics committee might provide a precedent for future situations.
This is a complex case. First of all, psychosis in and of itself does not mean that a patient is a danger to himself or others, or even gravely disabled. Lots of schizophrenic/schizoaffective folks live with chronic auditory hallucinations and fixed/discrete delusions. Of interest to me in this case is, Scalpel stated he "presented" to the ER. Well, how did he present - ie., was he coaxed/threatened into the ER by others/family, was he brought to the ER by police, or did he just walk into the ER and ask for help - and what kind of help, for WHAT?
The fact that he is basically described as tightly wound is an important one. In the world of psych treatment, very ill patients are often unable to convey symptoms of great importance for treatment. The gut response of perceptive providers of all kinds is very important. Furthermore, chronically ill persons who suffer from psychosis frequently suffer from ANOSOGNOSIA. To learn more about it check out: http://www.psychlaws.org/BriefingPapers/BP14.pdf
I evaluate folks all the time who want to kill people. That doesn't mean they want to kill ME or are a danger to ME or my staff. But again, in this situation, we have fairly slim info and the discription of the intensity and edginess, which I give heavy weight to.
Bottom line here, in my opinion, would be documenting to fully support your actions - ie., in your opinion, this patient wasn't just a potential danger to others, with (insert careful description of affect, mood, any physical signs of "edginess" and verbal statements, as well, of course, as content of psychotic communication)he was a reasonably imminent threat to staff attempting to care for him in the ER, as well as other pts and visitors who might be in the ER and those he might encounter in the community if he were to leave the ER.
I have practiced in 5 states. Alaska, like your state of WA puts ER Docs and others in a terrible bind when they are trying to do what is RIGHT for the very ill psychiatric patient.It is no little thing to take away someone's rights by writing a hold, but, it is a necessary and THERAPEUTIC action when the person is a danger to himself, others, or is suffering psychotic symptoms to the point of making him unable to care for himself and thus, gravely disabled.
I think everyone who has to your blog is clear that the pt needed treatment.I think the ball was in your court, though as a nurse, I also see it as having been in nursing's court, to establish the dangerous of the pt and to document accordingly to support giving appropriate though unwanted treatment.(And everyone's documentation better be conveying the same picture!)
Another route, I believe brought up by another responder, is that of holding the haldol and giving the 4mg of AtivanIM (and I'd throw in about 100mg of Benadryl) and wait a bit. I'll pretty much guarantee you, having been there and done that a few hundred times, that your man would be quite calm and quite amenable to whatever treatment you suggested in about 30 min - and a danger to no one.
I also agree with you or whomever wrote it, having split my 24 year career between ERs and psych emergency services, that letting very sick psych patients suffer in the ER, waiting for whatever contracted entity to come in and evaluate them is, well, barbaric. Again, the key is documentation - by nursing as well as ER Doc. And document to the criteria. Then put it right under the nose of the person who comes in to evaluate.
And consider going and practicing in CA. ER MDs are the ONLY ones in a regular hospital setting who can write legal holds. In psych settings, a variety of psych providers, including trained RNs, therapists and psych techs (these are licensed folks in CA) can also write them. And cops frequently write them and do a pretty bang-up job of it, as well as sticking around untill "all is well" when they bring in potentially violent patients.
As for what I would have done...that would depend on my assessment of the pt and most importantly, your actual or intended documentation of the pt as an IMMINENT threat to others, due to the degree of paranoia, delusion, anger, physical signs described,verbal content etc. If it wasn't happening,(your exacting documentation that would legally give us the green light to over-ride pt consent) I'd suggest we could do the cocktail I described and give it 30 min. And if the patient wanted to leave, I'd NEVER try and detain him. That is what phones and cops are for in states like yours where you can't even initiate a legal hold!!!!
What is right/therapeutic/medically appropriate can conflict with what can be legally defended. It's a pain and sometimes we have to be creative to figure out how to help the patient!
Very interesting post and clearly there are strong feelings regarding this issue.
I just want to point out that a psychotic person is not ABLE to legally give consent. Informed consent requires that the patient is of sound mind. So regardless of whether the patient is told about the Haldol, it would still be given in the absence of legal consent.
I think Mem made a great point about an Ativan Benadryl cocktail. After all, your concern was for getting the patient calmed down. If you can accomplish that goal with a fairly benign combination of meds, why risk a dystonic reaction? If the patient needs to be on an antipsychotic, the treating psychiatrist should order that.
The bottom line is that you had a responsibility to keep everyone in the ER safe and sometimes there are no right answers. Just the lesser of two evils.
Psychotic , like beauty, is in the eye of the beholder. To prevent a crime( assault/violence) , you chose to drug him. Why was he being violent? He didn't want to be there, and take your antipsychotic drugs. Circular logic.
If you examine the science of antipsychotics, you will find no antipsychotic molecule, since psychosis is unmeasurable. They are tranquilizers renamed to antipsychotic.
To drug everyone ( potentially dangerous ) into a stupor, before they can commit a crime is the way of the future.LINK
Your compassion and respect for your patients is breathtaking. Truly. It shines forth in every word.
And I'll just raise my little voice and say: good for that nurse, for sticking with her professional and personal ethics in a situation that wasn't exactly peaches & cream for HER, either.
This was an interesting case, but more interesting to me is the attitude of some of the MD comments.
Damn well carry out an MDs orders? Oh, they will get carried out, but if I am uncomfortable doing ANY order, I will not do it.
The doctor can do it, thereby carrying out the order themselves.
I may join the bloggers who responded, this is not a good trend - I did not realize this attitude towards nurses was still so prevalent.
Obtain more nurses? We aren't exactly disposable toilet paper....
Where's the insubordination? Nobody refused to give a medicine. She only refused to lie to the patient. I would have told him he's getting Haldol whether he likes it or not.
Your lack of security staff is not a nursing issue and if that results in a threatening environment I'd be taking it up with administration and not be threatening a nurse's job or license.
Even when I'm psychotic, I still remember everything that happens when I get pulled in for treatment afterwards. Even when crazy, I expect the hospital staff to tell me what they're giving me. I don't have to approve their decision of what they give me, but I have to know. If I found out that the doctors were getting sneaky with my meds, I would take it personal and get sneaky in revenge in the future. Don't hide stuff from psychos - it makes them less trusting later on.
Large, muscular, angry man? Decompensated psychotic? Halucinations and delusions? Homicidal ideations?
I could get over any ethical concerns I might have and give the medication. I am not a good liar, so if asked, I'd probably simply have stated that it was the sedative Dr Scalpel had ordered and that he could discuss the contents with Dr. Scalpel, but please hold out your arm, because he's going to be busy a few minutes.
Getting away from whether this patient was competent or not, the bottom line issue here is the need for a nurse to protect his or her own license.
If a nurse feels an order is unethical, whether the doc agrees or not, the nurse is obligated to adhere to the standards of their licensing board. Period.
Very interesting discussion, but I want to add just a side light to seaspray and their discussion of their girlfriend's father.
First of all, the use of "senile dementia" is kind of out of fashion, as it implies that mental deterioration is a natural product of aging. It isn't. The brain naturally slows down its processing, and can't multi-task, but capacity is not inevitably lost.
Secndly, with dementia of the Alzheimer's type (vs. vascular) social skills are among the last things to go. That is why so many PWD are able to "pass" for so long. And while dementia is a mental illness, it is not the same as a paranoid psychosis. Apples and broccoli indeed.
First of all, to the nurse in question, good for her. She thought that you were asking her to do something that was unethical, illegal, and/or against hospital rules and she stood up for her patient. I would have someone like that as my nurse any time.
Second, there seems to be at least two versions of what went on: Scalpel's and the nurses. Scalpel thought that he was entitled by the circumstances to use deceit to drug this person against his will. The nurse disagreed.
It seems to me, that given the disagreement, we don't really know how appropriate Scalpel's actions were or were not. We need an outside agent to investigate what happened . That way appropriate disciplinary action can be taken by the hospital if needed.
Of course, a copy of that investigation should be made available to patient so that he can decide if it is appropriate to pursue civil or criminal actions.
Actually, this should take place any time a person is drugged against their will by force or deceit. It is called accountability, but that is not a very popular concept these days.
Ha ha, good one.
Good Job! :)
Interesting conversation. I have been a psychiatric social worker for over 25 years and am currently working on a second masters degree to become an advanced practice psychiatric nurse. I have to say, I have worked most of my career as a social worker in ERs and crisis centers. It is common practice to inform the patient what medication they are receiving, why they are receiving it and expected outcomes and risks even when given involuntarily. The patient may have had an allergy to the medication in the past, so the EN would have been liable.
The question about involuntarily medicating patients has to do with ethical issues of capacity to make decisions and the practitioner's legal duty to protect (either the patient or the public.)
Informed consent only comes into play if someone has capacity. If the patient lacks capacity then an agent needs to be determined for the patient-in crisis situations this is often the health care provider if no guardian or HCPOA has been identified and present. The health care provider is then held to the standard of 'reasonable person'- what a reasonable person would consent to as a means to attempt to determine if the patient was not acutely ill they would want to have done on their behalf. You can have degrees of capacity-as you stated he was able to provide history acurately but was acutely psychotic. But even if the patient lacks capacity, only way to form long term therapeutic alliance is to involve the person as much as possible into the decision making process.
For example if you restrain someone (which you were doing chemically) you are mandated by law (and ethics) to let the patient know what conditinos they must meet in order to be released from restraint. I realize in an ER setting some of these issues are not as pressing as with inpatient psychiatric treatment or community commitment, but they still warrant consideration.
Patients who are involuntarily committed also have the right to refuse parts of their treatment even if they are not able to be released. This is protected by Supreme Court ruling on first amendment rights to privacy.
So even though the heat of the moment the situation may seem cut and dry-the ethics and legalities are infinately complex.
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