Transplant or Hospice

Last spring,  Banner Health took action against an Arizona nurse who counseled, even encouraged, a prospective transplant patient about hospice care.  With 6 years of nursing under her belt, the nurse (whom I’ve declined to name),  identifies herself as a nurse specializing in cardiology, geriatrics, and end of life/palliative care. In the wake of her dismissal from the hospital, and loss of her nursing license [edit: as of 2/3/2012 the Arizona State Nursing Board has listed the nurse's license as active; under investigation], thanks to blogs and online communities throwing her support, she’s now been dubbed a patient advocate.  As of January 2012, at the request of the Arizona State Board of Nursing, she’s scheduled to undergo a psychiatric evaluation.

In the nurse’s own words: “I had discovered (patient) had no clue about what they were about to participate in when they agreed to get a major invasive surgery. When I properly educated the patient using the allowed materials by my employer they became upset that the physician never explained details of the surgery or what had to be done after the surgery (complex lifetime daily self care).

In a typical medical practice, or hospital – it would be the doctor or surgeon, the one with the medical degree, who would be responsible for educating the patient about surgery.  Nurses are trained, and hopefully well trained.  They are not, however doctors, or surgeons. While nurses, good ones anyway, forge relationships with patients, it is not the place of a nurse, with 6 years of experience, or 60 years of experience, to counsel a patient into hospice care, especially when the patient is scared or is lacking information about surgery. The surgeon is qualified to, and prepared to, explain thoroughly, as many times as necessary, any medical procedure a patient is undergoing. A surgeon will typically explain the surgery, and after care needs to the patient as well as the patient’s family.

Also worth noting is that there is procedure in place for initiating Hospice care. I am not affiliated with Banner Health, however, as is standard in most hospitals across the country, hospice care is not initiated by a nurse, and certainly not without the knowledge of the attending physician. I’ve been disillusioned by the huge outpouring of support the nurse has received. Not only do I have personal experience (that I share below) that’s shaped my opinion on this matter, I take offense to the supporters who have adopted the attitude that this nurse was fired because she upset the attending physician, and threatened the dollars attached to a transplant procedure.

Starzl did the first liver transplant years ago- saving many lives

Several years ago a friend of mine, Rod, was dying.  His liver was failing him. I remember seeing him the day before his transplant. At first I didn’t recognize him – he was stooped over, wearing baggy clothes, and only when he looked up and spoke to me did I recognize him.

In the years I knew Rod, he had gone from being a patient, to the handyman who worked on my house, to a friend. But now I looked at this man, and my clinical instinct told me he didn’t have but days left to live.

Rod’s words to his wife that day were, “I think I’m done.”  In his early 40’s, the man with a smile who would do anything for you, couldn’t face life anymore.  His jaundice skin was so itchy that he would jump in the swimming pool in the middle of the night (winter, no heater) – just to get some relief.  His ankles were four times their normal size from the edema.  His abdomen, normally flat, was puffed out because of all the ascites (water from a failing liver) in his belly.  He had no energy, and could only work a few hours a week.

The next day Rod’s pager went off. Mayo Clinic had a liver.

Four years later, Rod is working full time.  No jaundice, no swelling, no itching, legs and belly are back to normal.  He has some issues with the medicines he takes for rejection – but he has now seen one son finish high school, and the other one is as tall as he is.

When I think of people who have end-stage liver disease, I always think about Rod. I asked him what would have happened if someone had pushed him to hospice the day before the pager went off, or even a few months before that—he said he would have had it not been for the excellent education he received from Mayo, although at his low times he would have taken hospice.

HOSPICE OVER TRANSPLANT HOW A NURSE CAN STEER YOU

This brings us to the case of a registered nurse, who on her shift  this last year “educated” a patient about end of life care when they were waiting for a transplant. Some hail the nurse as one who stands up and informs people about end of life care. She said “I was caring for a dying patient whom I had discovered had no clue about what they were about to participate in when they agreed to get a major invasive surgery.”

Pre-transplant liver patients are some of the most ill patients you can see.  They tend to go from one crisis to the next, be it from bleeding, or infection, or jaundice, or liver failure.  Because of the scarce supply of livers, these patients are literally brought from the precipice of death.  Often prior to the transplant operation they need other operations, or procedures, just to bridge the gap. Imagine your worst illness, where you first thought you were going to die, then wished you would—imagine living like that for months. It takes grit, determination, and a supportive family, and a transplant team to help rally you.

So when this transplant patient would come into the hospital, in a crisis, but not yet ready for a transplant – and feeling horrible here comes this nurse – telling her that this was just the start, and giving pamphlets while telling her there is another way—death with dignity in a hospice.

The nurse isn’t a transplant educator, because she would know that you don’t take a patient who is critically ill and educate them about transplant. You wait until they are healthy, and have better mentation.  This was a “temp” nurse, filling in on this floor- self described as “specializing in cardiology, geriatrics, and end of live/palliative care.”

The next day when the surgeon came to see the patient, the surgeon became upset, and asked that the nurse be relieved.

 

Here is what this nurse did wrong:

(a) She isn’t a transplant educator, and therefore does not know about this procedure

(b) The materials she used which she describes as “When I properly educated the patient using the allowed materials by my employer they became upset that the physician never explained details of the surgery or what had to be done after surgery (complex lifetime daily self care).”un  The educational materials she referred to are summary materials, an adjunct. A small piece of what the patient will learn in the process of receiving a transplant.

(c)  She says “I was doing my job and protecting the patient’s rights to full disclosure about the surgery and their right to choose their course of care.” This was not the motive of this nurse, in my opinion.  There is a right time to educate a patient, and a wrong time to.  When the patient is very ill, but there is a procedure that will bridge them until they can obtain a transplant, is not the time. There is a whole group of classes transplant patients are REQUIRED to take, in the evaluation process for the new liver.  It is not up to this nurse, at this time to do this.  Her job was to watch over the patient that shift, not to steer this patient to hospice.

(d) This nurse also says nothing about going up the chain of command in the nursing structure.  She didn’t talk to her charge nurse, she didn’t talk to the supervising nurse on duty, nor did she talk to the nurse administrator on duty. This nurse took it upon herself to do this task. This is rogue behavior.  Had she gone up the chain of command she might have been educated – if she were to allow to be educated – about the educational process with transplant patients.

(e) There is always a role for end-of-life teaching and counseling. The best time to have those discussions is with a person who is feeling as well as they can, given a bad situation. The worst time to have those discussions is when the patient is feeling so ill that the thought of death is a fine release. She justifies her actions by her anecdotes of patients who “lying in hospital beds for weeks on end, suffering debilitating pain, air hunger, bed sores, muscle wasting, and their dignity is not respected – as their family members stood by horrified.”

(f)  This nurse then brought this to the public view – for sympathy, for political support, and does not admit to any wrong. She will get sympathy, and she frames the argument in that manner – but this points out that she believes she has nothing to learn, and the sole reason she was dismissed was because of greed, not because she can learn something from this.

(g) What this is NOT: this is not the case of a surgeon planning to do a transplant on a patient who is completely unaware of the circumstances.  As much as this nurse publicly attempts to frame the discussion in that manner, that simply does not happen with transplant patients.  Nor is this the case of a nurse providing a patient with informed consent about a procedure.  I’m a surgeon- while I nurse may obtain “consent” a piece of paper we ask patients to sign – if the patient has any questions, in over 20 years of surgery, the nurse always calls the surgeon to answer them.  A nurse cannot give informed consent – the surgeon can.  It is not uncommon for patients, the day of or before to have more questions – we, as surgeons are obligated and willing to answer them.

In surgery, we have four pillars of ethics: Autonomy, Nonmaleficience, beneficence, and justice.

 Autonomy 

Autonomy is that as a physician we have ethical obligations, and expectations to our patients. People are truly free to choose their treatment but must have the information that is required to make that choice. Because of innovation and research, it is the surgeon’s obligation.  In the case of transplants there are protocols, classes, a whole range of education that has been proven, over many years, to work well for education. The educational process has been tested, to the point where some public school systems have adopted the methods of this education. One cannot get educated from a busy nurse on a floor who has a self-described bias to hospice, and provides some cursory reading material.

Autonomy is not a nurse, without a background in the field, steering a patient to hospice.

Nonmaleficience

Nonmaleficience is that we do not use our skill and knowledge to harm a patient. There is risk associated with every surgical procedure, but that risk isn’t “doing harm” unless that procedure has NO HOPE of benefit. Transplants have a well-proven track record – over 85% at one year versus certain death without it. Hospice has 0% one-year survival.

 Beneficence

Beneficence is our duty to act in the best interests of the patient. We must always intervene for the comfort and well being of the patient.  Here is the hitch – it is not up to the surgeon to determine this. It is judged by the patient.  It is our goal to ease pain and suffering, it is not our goal to cause it. While this nurse publicly frames it so she can lay claim to beneficence – she cannot.

 Justice

Justice is the final pillar of ethics. This is how we decide how organs are dispensed. This is how we go to fight for the rights of our patients and not our self-interests. This is why I’m blogging about this act of  what I consider a rogue nurse.

The Arizona State Nursing board has asked that this nurse undergo a psychiatric evaluation.   The state has an obligation  to know if this is the act of an illiterate nurse, or someone who will tend to rogue behavior beyond the bounds of the profession. The board is rightfully concerned that she brought this into public, and instead of this nurse learning  how transplant education works, this nurse vows to change the system so any nurse can steer a patient from transplant to hospice. Where is the line between steering a patient to hospice and taking it into your own hands  – there is one, and does this nurse know that line?

Florence Nightengale - a hero, worked for her patients, not to send them to hospice

There is some misplaced sympathy for this nurse.  She states her license was revoked – it wasn’t she was simply referred to the board of nursing- an appropriate reaction. She thinks it is that referral that doesn’t get her a position – it isn’t, it was her action that proves it.  She thinks she was in the right- when she was so wrong.

Some sympathy comes from those who think it was the surgeon and the hospital who maintained the goal of  more dollars from procedures.  Funny thing about Banner Hospitals, they are considered, by many of my peer physicians, the most doctor-unfriendly and nurse-friendly hospital systems. For the record, I am not on staff at any Banner Hospital. And to be more clear, many of my friends are surgeons, and I know of no surgeon who wants to operate on someone who is terminally ill and without hope.

The perception that we surgeons are simply in it to “cut” and for “greed” is a sad perception that we need to correct. Until then, of my many colleagues, never have I met one who would do such a thing.

On a Happier Note: 

Today I am happy that my friend Rod is four years out with his new liver. I am happy that Rod didn’t have that nurse talking him into hospice care. Rod was as sick as any of them, had been hospitalized a dozen or more times before his transplant, and had many surgeries prior to the transplant.  Rod didn’t have an easy transplant, but he survived.  I am happy that Rod saw me become a father, and that he has become the uncle of my son. I know that Rod’s wife, his parents, his sons, and other friend are happy that Rod got his liver I’m glad Rod is here and is not someone we say “boy, Rod would have loved to see my son,” – as we put flowers on his grave.  Because you know what- if Rod had met that nurse, at the right time- he would have probably gone for hospice.  It would not have been death with dignity that would have been an unnecessary execution.

"There is no dignity in death." Dr. Gregory House - I agree

Comments for this post have been closed. Thank you everyone for participating in this discussion.

Dr. Terry Simpson About Dr. Terry Simpson
Dr. Terry Simpson received his undergraduate and graduate degrees from the University of Chicago where he spent several years in the Kovler Viral Oncology laboratories doing genetic engineering. He found he liked people more than petri dishes, and received his MD. Dr. Simpson, a renowned weight loss surgeon, is a leading advocate of culinary medicine. A frequent contributor to media outlets discussing health related topics and advances in medicine, he is also a proud dad, husband, author, cook, and surgeon “in that order.” For media inquiries, please visit www.terrysimpson.com.

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  • http://Www.danielparamd.com Daniel J Para, MD

    Very nice, Terry. And so true.

    We must continue to advocate for the patient and beware “educated” allied practitioners, with their very dangerous limited knowledge, but positions of political strength in hospitals, and ready access to our patients.

    • The Doc

      This nurse is now making political ploys — trying to be a martyr instead of the rogue nurse she is. She is trying to put pressure so any nurse can get hospice involved– which is a dangerous place to be.
      I greatly appreciated some comments on Twitter from liver transplant patients who understand what is involved.

  • Edward

    With respect, talk about jumping in without knowing all the facts…

    I happen to know the nurse in question. I worked closely with her for two years. She does have considerable transplant experience (most of her career has involved transplant care, both pre- and post-op).

    The actual situation was that the patient in question was not going for transplant surgery, but was about to be worked up for a surgery she didn’t understand and the lifelong effects of which she did not comprehend. She had not yet gone through the extensive classes to which you refer.

    The nurse, who was working the night shift before the work up, responded to the patient’s high anxiety level by talking to her about the procedures to be performed the next day, and then discussing the transplant itself, at which point she became aware that the patient did not understand what was about to occur.

    Are you not aware that patient education is an integral part of nurse training and practice?

    When the patient stated that she was uncomfortable with the idea of transplant and sought other options, the nurse took it upon herself not to initiate hospice care (which would be outside of her scope), but to place a “nurse ordered” hospice consult in the hospital’s computerized order entry system to request that someone bring the patient more information about their program, NOT to enroll her as your article would suggest.

    Ultimately, it is the patient’s right to make these choices. And it is absolutely the nurse’s duty to help educate the patient within their experience.

    • The Doc

      Lets go through the fallacies of your points:

      (1) Transplant experience – really- she didn’t list that in her reply to the board or in her blog. Had she indeed had transplant experience in education, and she used the hospital materials, she would know how inadequate that is for patient education. So- if she did indeed have experience as a team of the transplant education – and she felt she educated this patient properly, she clearly didn’t learn anything. Thinking that she provided adequate education regarding transplant is flawed.

      (2) Regarding information for surgery– I am a surgeon. That is what I do. NEVER does a nurse provide informed consent for surgery in any hospital in the United States. It is the surgeon, and the surgeon only that (a) Knows the operation and what it will entail (b) knows the patient and what it will likely do with that patient (c) can explain how it is a bridge. Unless that nurse is performing the operating, has a knowledge of the patient and that physiology, then it is not giving informed consent. It is the surgeon who does this.(d) The State of Arizona requires that a physician, not a nurse, provide informed consent (check the state nursing board) -

      (3) Patient education and nursing- there are policy and procedures in every hospital that outline the patient education and a nursing care plan. Providing education that was inadequate, and uninformed is not in the manual.

      (4) We have this nurses side that the patient wanted other options. The “nurse ordered” hospice consult is to be done WITH a physician – per the hospital policy. This is not something that this nurse could have ordered without a physician’s input.

      (5) The patient has the right to make choices that are informed – the patient was not informed by this nurse.

  • http://www.nursefriendly.com/amanda/ Andrew Lopez, RN

    Thank you for weighing in on this issue. Suggest you check your facts and her attorneys response to the state board complaints available at

    Amanda did notify the charge nurse and her superiors of the situation. She detailed the situation in nurses notes for the physician to follow her actions.

    It is absolutely in the scope of practice and a nurses responsibility to “fill in the gaps” left by doctors in explaining procedures to their patients. We do this every day.

    Having said that, respect your right to voice your opinions on this issue, will agree to disagree.

    Andrew Lopez, RN

    • The Doc

      Read the atty response – thank you.
      Nursing notes are not adequate communication to the physician. We all carry cell phones and can be found.
      It is not in the scope of practice to do informed consent. Nor is that in the State of Arizona nursing board for nurses to educate patients regarding a procedure beyond their role in the procedure. I don’t know of one surgeon (and since I am one and have many friends who are one) that want a nurse to “educate” a patient the manner in which this patient was “educated.”
      I appreciate that you are advocating for this nurse- however, I believe we disagree

      • Alpine, RN

        there is a significant difference between my SCOPE OF PRACTICE as an RN and what a doctor “wants” me to do on occasion…As my chain of command does not INCLUDE doctors, what a doctor WANTS me to do, while it often has an effect on my day, in no way OBLIGES me to obey his or her WANTS. I obey a doctors ORDERS. Not their WANTS.

        Patient education is integral to my practice, to my education. Educating a patient “beyond the nurse’s role in the procedure” is something we do ALL THE TIME. we aren’t in their rooms to explain “i will hold the scalpel and hand it over”, we are supposed to explain “this is likely to be what you will need to do with this wound vac for the next four weeks. This is why you need to be worried. This is what it would look like if something went wrong”. THAT is ALL within my scope of practice.

        • The Doc

          We appreciate education. To frame this as a discussion about education is incorrect. This is not about the nurse educating a patient. The hospital nursing staff didn’t think so, and the board is investigating it. We appreciate the scope of practice- but this isn’t about educating a patient. The concern here is did this nurse go beyond with a patient, and should that nurse have communicated the patient’s concerns with the physician.

  • Sallie

    Dr. Peter Pronovost : “Health care is a team sport not an ego sport”.

    • The Doc

      True indeed. Nurses cannot fly solo – they must be a part of the team. When nurses are a part of a team they do the most wonderful work. They are indispensable for what we surgeons do. When my wife had our son, it was the nurses who helped us through that first few days – my patients love the nurses at the hospital where I do surgery. Surgery and nursing is a great symbiotic relationship – and from what I have heard about Banner Del Webb – and I have spoken with people there- it sounds like a great place.

      • sallie

        Physicians cannot fly solo – they must be part of the team, as well. To me , the situation sounds like an opportunity for learning on both sides, surgeon and nurse.

  • zoe

    “There is no dignity in death”, really? That says it all, your true feelings.

    • The Doc

      Nor is there dignity in keeping alive someone who has no hope – and will receive no hope of benefit. Apparently you didn’t read the post re:
      Nonmaleficience

      Nonmaleficience is that we do not use our skill and knowledge to harm a patient. There is risk associated with every surgical procedure, but that risk isn’t “doing harm” unless that procedure has NO HOPE of benefit. Transplants have a well-proven track record – over 85% at one year versus certain death without it. Hospice has 0% one-year survival.

      Glad you think you can capture the essence of the post with a few words- but you didn’t.

  • Marsha

    Well it sounds like your friend Ron was appropriately informed,thank God. He made a CHOICE, having had the appropriate information to know the long term pros/cons of transplant surgery. Again he was informed enough and made his own choice as THIS NURSE’S patient did after s/he was informed. They were two different people. Not everyone wants to add years of pain and a strict drug regime to their life in the hopes of surviving a liver transplant. You have the usual “death is the enemy” mindset of most surgeons. Death is a part of life and no,informing someone about palliative care does not make them an “Angel of death”. How dare you.
    You make quite a leap comparing your recovered friend to this patient when you have no such knowledge of his/her condition.
    I have been a nurse for 30 years and fortunately haven’t had this situation crop up. If it had I wouldn’t have hesitated to teach the patient and the surgeons that I worked with(without fail) would have been grateful for my intervention. They too would additionally inform the patient until the patient made a decision that s/he was comfortable with. There is no need for such condescension and thinly veiled hostility. You are part of the problem.

    • The Doc

      This nurse wants to frame the argument as a matter of education and educating the patient. However, this nurse does not have the qualifications to educate that patient. It is the surgeon’s job to educate the patient and provide INFORMED consent.

      This is a matter of communication: the nurse had the surgeons telephone – she could have called. She chose not to. She went beyond her scope. Nurses call surgeons when they are uncertain about the care of the patient, uncertain about orders – even more important to call the surgeon when the patient wants more information. It is the surgeons duty to provide that informed consent- that is a foundation of our ethics.

      We are a team. When a member does not communicate with the other part of the team – then the health of the patient is in jeopardy.

      Taking a patient who is ill, who has a condition that is terminal without intervention – and circumventing the system to provide a limited view of education – is not information. It is outside the bounds of communication with the team. This floor nurse didn’t have the time, the background, the expertise to give this patient the education they needed to make an informed choice- this nurse did clearly have a bias – and that came through.

      • http://www.codeblog.com gina

        I admit I have not read all 60 comments, so maybe this is addressed later on down the page, but you seem to be repeatedly repeating INFORMED CONSENT. It is my understanding that INFORMED CONSENT is what you do to prepare a patient before surgery, before you have them sign the consent.

        It is my understanding that this patient hadn’t even had a work-up for the transplant yet? It seems as though the nurse was providing general education, not “informed consent.” It’s not like she was going to hand over the consent form after providing some printed out materials.

        I wasn’t there (and neither were you, or anyone else weighing in on this discussion) so I don’t know exactly what transpired. I don’t think anyone is saying that she provided enough education for the patient to make a decision right that minute. It doesn’t sound as if that was her intention. There is nothing wrong with providing a patient some general education about what their options are, especially if the information helps relieve their anxiety.

        • The Doc

          We have a simple rule in the field of medicine: when the patient is on the floor, and there is a change in their condition – the physician is to be notified. In this case the change in condition was the patient. That is the bottom line – communication stopped.

  • http://rehabrn.blogspot.com RehabRN

    Doc:

    I beg to differ. Health teaching (aka education) is within the domain of the ANA’s Transplant Nursing Scope of Practice, developed with the International Transplant Nurses Association. (see more info here: http://www.nursesbooks.org/Table-of-Contents/Standards/Transplant-Nursing-Scope-and-Standards-of-Practice.aspx)

    I would hope any physician who doubted my decision for transplant would consult the hospital’s ethics committee (or similar group) to help me determine the final decision, before jumping to conclusions that I don’t know anything.

    Respect, is indeed, a two-way street.

    • The Doc

      Health education is not the issue- the issue was about informed consent for a surgical procedure. This nurse took that in her hands. Yes- there are transplant teams, education systems worked out – and if someone goes through and decides against it- that is not a need for a hospital ethics consultation. There is a simple protocol. There are well worked out programs for nurses to be a part of, and they are an integral part of those teams. This nurse was not a part of these teams. She was a floor nurse- in a hospital where people say they want more nurses on the floor- so how much attention and detail did the nurse give? She went outside a protocol. This hospital doesn’t even do transplants.

      Respect is a two way street — it means if the surgeon has a patient on the floor who needs more information about the procedure- then the nurse notifies the physician. It is the physician who gives informed consent.

      • http://crasspollination.blogspot.com Nurse K

        I think it’s hilarious that a surgeon thinks that a nurse should call his/her cell phone every time a patient has a question about an upcoming surgery. That would mean that nurses would be calling your cell phone constantly. Maybe you weren’t aware of this, but nurses are with patients 24/7 and, oddly enough, have oftentimes figured out (despite out lack of an MD degree and our borderline intelligence) the routine following specific types of surgeries and feel comfortable providing basic information on these topics. I know it’s strange to think that a patient would bother opening their mouth to speak when a physician wasn’t in the room, but patients are anxious and ask questions to nurses constantly.

        Generally, nurses answer questions that they feel comfortable answering and refer questions outside of their scope to the physician who will be doing the surgery. Yes, you will need anti-rejection drugs for the rest of your life, yes, you will be at a higher risk of infection for the rest of your life, yes, you might get infections other people won’t get for the rest of your life, yes, your liver could be rejected by your body. I’m just an ER nurse, and I know all these things.

        This nurse was not attempting to provide “informed consent”. That’s just silly.

        I want to see how long it would last if nurses were required to remain silent on all issues of patient education and refer all questions to the physician via cell phone. My guess? Five, maybe six hours. If you want to keep nurses from educating patients, please order Ativan drips on all of them.

  • Angel of Death RN

    Dr. Simpson
    Im touched at the the time and thought you put into sharing your experiences and position on this issue. I am always grateful for the candor from my medical colleagues as it serves to help me grow and learn and become a better healthcare provider. Your views, suggestions, and the passion you have for the mutual respect between members of the healthcare team within a patient centered framework for care are well received. Thank You.

    • Caryl J. Carver, RN, BSN

      You seriously do not want to start a war between nurses and doctors. A huge part of a nurses job is most certainly education. You obviously did not educate yourself to obtain the facts of this case. SHAME ON YOU!!! Surgery is NEVER the only option. Just because a nurse advises a patient that they have options does not in any manner indicate that they are steering a patient in any particular direction. I am appalled at your ignorance. Coerced consent by a surgeon does not equate to informed consent in any way shape or form. I so hope for the sake of the health care community at large that you are only a blogger and not a practicing physician.

      • The Doc

        Education is a patient’s job- and if you read the pillars of medical ethics in the blog the last thing I, or any surgeon I know, want is to coerce a patient into surgery. However, we do not want a patient coerced into hospice either.

  • T

    This doctor is so belligerently arrogant, it’s disgusting.

    Always terrified that a “mere nurse” might show you up, and expose what you’re really after: that you won’t make any money.

    By all accounts, said nurse was well within her scope.

    I hope they fry that doctor’s ass, who got her fired.

    • The Doc

      This is not about money – or making money. The doctor cannot fire a nurse. The nurse is employed by the hospital, and they have their own human resource process for hiring and terminating people. Nurses should communicate patient’s issues with physicians and not take it on their own to go down a road without a team input.

  • http://Grchealthcareblog.com Greg Mercer

    I find a few assumptions in this well-written article curious:
    1) The surgeon in question MUST have provided adequate informed consent: surgeons apparently never EVER rush or cut corners – they all take whatever time it takes to ensure every pt is fully informed. Common perceptions that some surgeons may prefer their own opinion to that of anyone else (especially patients and nurses) are completely without merit, this article assumes.
    2) Having a code of ethics proves categorically that every surgeon follows it perfectly in every case – otherwise there would be no logical basis to assume so with an unfamiliar case and surgeon. Nonsense, of course: there has never been an entirely ethical professional group (I.e. every member in every case) in human history. Some physicians seem to conveniently and arrogantly overlook this obvious point, only as regards themselves. Nurses, of course, can be assumed in the wrong in any conflict like this one, as they are mere humans.
    3) Surgeons, unlike every other group in human history, can all be assumed immune to the conflicts of interest others know all humans are subject to regardless of intent. Further, they are immune to unusually powerful conflicts like large sums of money. Otherwise, such an assumption could not be made in an unfamiliar case.
    4) Surgeons, contrary to common sense, actually never allow ego or their temper to affect their behavior or interactions, especially towards Nurses.
    5) When a surgeon misbehaves or fails to fully inform a patient, the only reasonable course of action is to depend on another surgeon to set them straight – agaIn contrary to much experience of surgeons entirely failing to do so and instead actually defending their guild and all it’s members. Remember, all surgeons are perfectly ethical.
    6) Fine rules of procedure and protocol outweigh, obviously, any patient needs – proper channels are always pursued by Surgeons, unlike human beings like Nurses.
    7) While we can safely assume with little investigation that a Nurse’s claims are both false and self-serving, such issues can safely be ignored in the case of surgeons.
    8) Nurse bloggers are easily manipulated and can’t be trusted, whereas Surgeon bloggers must be right – they’re surgeons, of course.
    I could go on, but I’m a mere human and aware of it – I wouldn’t want to irritate those of us with delusions of grandeur, and a rather poor grasp of human nature and reality in so many respects.

    • The Doc

      We have a code of ethics – and we need to be reminded of it all the time. We need to practice it- we need to get better at it, and we need to refine it from time to time.

      Years ago it was the standard that surgeons would not talk to patients. They would simply tell the patient they were going to be operated on. This was common practice in the 1960′s. As time has gone on that standard has – thankfully – changed. We have refined it, and that generation of surgeons has gone.

  • http://Grchealthcareblog.com Greg Mercer

    One more minor point – who polls among Americans as the most honest/trustworthy professional group in America? Is it surgeons? Actually not – all those poor saps, mere human Americans, picked a different group – Nurses, actually. Please, tell us how they must be wrong, because they’re not purely ethical, perfectly self-controlled, perfectly rational Surgeons.
    How, one wonders, could people ever got the notion that Surgeons have rather more Ego than might be considered healthy, rational, or trustworthy? Perhaps they read your blog, or perhaps they’ve interacted with some Surgeons.

    • The Doc

      Surgeons have healthy egos – and we need to keep them in check.
      In terms of the logical fallacy of appeal to popularity- no comment

  • http://Grchealthcareblog.com Greg Mercer

    I apology for any typos – using a phone, I repeatedly stumbled onto shameless ads for…. Surgery!

  • Lori

    I fully appreciate your passion for patient advocacy and education. It’s a huge part of what we all do. After all, we are here ultimately for the patients.

    You are very correct about the fact that Nurses may not gain consent for procedures that they will not be carrying out, of course only the transplant surgeon may do that. What a nurse can do though, it use the teaching aids provided to a client and their own experience and knowledge to provide collateral information to a client.

    I have a few questions for you though. Are you well-acquainted with the RN scope of practice? Do you have in-depth knowledge of this hospitals’ protocols?

    In my experience, most hospital computer order systems have built-in guidelines about who is enabled to enter certain types of orders. For example, I am enabled to enter a referral for service that my hospital protocols say that it’s appropriate for me to. Ones that require a physician to refer, I am not able to enter that order. I also don’t work for Banner health, nor do I know this RN. From what I’ve read, however, it sounds as if the hospital protocols enable RNs to make and enter referrals for a case manager from Hospice to see a patient. And since referring other health care professionals is well within the usual scope of practice for RNs, I don’t think that you are correct in saying that she went outside of her scope. My areas Scope of Practice document says that it is “unrestricted” for RNs to undertake “Counselling clients”, “Teaching”, “Coordinating care services for clients”, and “Assigning care to other members of the health care team”. Of course, scope of practice is superseded by facility policy or protocol. If Banner health thought that it wasn’t appropriate for RNs to independently initiate the action of a consult, then it should have put a system in place to block that action on their computer system.

    I agree with you that when a patient is encephalopathic and hypotensive is no appropriate time to discuss ANY care decisions with them, be it consent for transplant or end of life care. But from what the RN has said about this situation, the client was in hospital for pre-transplant workup, which as we both know is ideally done when a client is relatively stable. The client sounds as if they were vocalizing feelings that they wanted to spend as much time as possible with their family, were able to read and understand printed materials, and to carry on a lucid discussion. This to me does not seem that the patient was on the “precipice of death”.

    And just a caution for you, as easily identified on the Arizona Board of Nursing online verification, this RNs licence is still active, but listed as “under investigation” because there is an ongoing inquiry. So you saying that she suffered the “loss of her nursing license” and claiming that she said her “license was revoked” is factually untrue. And could be libelous.

    • thedoc

      Thank you for your comments Lori. To speak to the state of the license, “…and insisted I be fired and my license taken. He was successful on all counts.” This quote is taken directly from an email that was identified as being sent from the nurse in question.

      You are correct regarding the current status of her nursing license. As of 2/3/2012, according to the Arizona State Board of Nursing website, the license is classified as “under investigation.” (The
      blog post has been updated to correct the status to reflect the current state of her license).

      The definition of libel, according to Black’s Law Dictionary is: “An untruthful statement about a person, published in writing or through broadcast media, that injures the person’s reputation or standing in the community.” I would suggest that the reputation of the nurse in question is not in fact damaged by using a blog to express an opinion of her actions, which were reported in the news media. The source for stating she
      lost her license actually came from an email sent by the nurse herself, who erroneously states her license was taken. Of course, it will be up to the Arizona State Board of Nursing to determine the status of her nursing license.

    • The Doc

      RN scope at that hospital is clear- and their policy, as told to me was clear. How their computer system works, I do not know. The hospital policy is that the hospice order is to be done in conjunction with the attending physician. As a physician who admits patients to hospitals – if one of my patients wanted to have such discussions, such are always welcome, but communication to me would be important. Far more important than many other calls that we physicians receive.

      There is a lot we do not know about the case- and a lot of outside information filtering in that is rumor. The story changes a lot as time goes on. In terms of what the patient was vocalizing- that story changes. The duty, however, is for that nurse to communicate with the physician, especially if the issue is concerning the operation and what is to come. This nurse’s job that day was NOT to discuss transplants – that hospital doesn’t have a transplant program. If the patient wanted that discussion, such should have been referred to the transplant team- who are more than ready and willing to have those ongoing discussions. Not everyone gets a liver transplant, and there are those who choose not to go through that process – but it is those teams that are charged with that process.

  • kris

    Recognizing lack of knowledge and addressing it is part of the nursing mandate. The issue here is how it was done.She offerred hospital approved literature concerning the procedure. Hospice was not discussed till the patient made an inquiry. Her immediate supervisor was aware of her actions and sanctioned them.
    None of this seems to be rogue behavior or a nurse with an agenda. As to whether she overstepped her bounds wil be determined by the Arizona BON.
    You seem to imply that since these patients are so ill that their judgment is impaired. If so how can they consent to anything?Being so frail and labile, it can’t be that uncommon that they might be hesistant till zero hour. Or even choose to refuse the procedure.
    If the transplant surgeon is the one to best understand these patients’ vulnerabilities, could he not have just walked down the hall and said “You seem to be having second thoughts and now seem interested in hospice. Let’s talk.”
    Afterwards, he then could have requested a private meeting where all concerns could be raised by all parties.
    Perhaps she erred in putting in the case management order although she did add the addendum “per patient request”. Maybe policies aren’t clear. Again her immediate supervisor was aware.
    In the real world it is just not that out of the box for the surgeon to think the patient is on board only for the nurse
    to realize the patient doesn’t have a clue.
    The reasonable and prudent thing to do is to offer some additional information and advise the physician.
    Unfortunately this incident happened at night. It doesn’t seem unreasonable not to call at that point since no one
    is probably going to come rushing over to talk to the patient. The nurse in fact advised the day nurse of the serious nature of the situation and the need to talk to the surgeon. She might have assumed the surgeon would round early.
    You are absolutely right that informed consent is the domain of the physician. I just don’t see this a rogue nurse with an agenda sabotaging a surgeon.

    • The Doc

      We don’t know how it was handled, or what happened. At this point we know the view as presented by one who was there, and the facts that the nurse was (a) terminated by her hospital and (b) told to have a psychiatric examination.

      You present an alternative – and it is a very reasonable one.

      • kris

        What alternative are you referring to? How the situation was handled by the hospital and surgeonor the nurse’s choices?

  • kris

    I also wanted to know how having a witnessed temper tantrum at the nurses station was in the patient’s best interest? This could be construed as disruptive behavior which is also reportable and subject to review and possible sanctions.

    • The Doc

      Physicians who are disruptive have no place in modern medicine. However, we have one side to this. But Banner Hospitals has a policy regarding disruptive physicians. Throwing a tantrum – if that happened – is counter productive.

      • kris

        You might be naive on this one. I was subject to this once and was asked by my manager what I did to provoke the outburst. Sort of like what did you do to make your husband hit you. I was never told that the incident would be reported and quite honestly I was afraid of retaliation so I let it go. This is the culture of hospital nursing.

        • The Doc

          There is no excuse for physician disruptive behavior. Such a culture is not welcome either. I would be upset if this happened to my patient, and would express my frustration in a measured, controlled, and quiet manner to the supervising nurse.
          Being upset, expressing concern, and asking for matters to be handled is appropriate – throwing a tantrum is not — if that happened. Banner Hospitals have a very active physician disruptive policy, and they have brought physicians before the Medical Board for that, and have suspended physicians for that. Hence, when the person who is fired says the physician threw a tantrum, given the nature of Banner- one has to wonder.

  • Caryl J. Carver, RN, BSN

    So why are your making statements and waging a war against nurses when you clearly admit, “We don’t know how it was handled, or what happened.”. Opinions are like assholes, we all got one. You have a forum where you can spout off about whatever you please; however, when you make comments such as, “This was not the motive of this nurse, in my opinion”, you are essentially attacking the character of this nurse. There is no way your or I or anyone who is familiar with this case can know what the nurse’s motive was. As a nurse I can tell you I don’t wake up in the morning thinking, “what can I do today, in between running my butt off to care for my patients, to mess up some poor schlep doctor’s plans?”. I have more important things to do. Clearly you stepped outside the bounds of informed reporting on this one.

    • The Doc

      Not waging war against nurses

  • Another RN

    If, as you delineate, it is the physician’s job to educate the patient about the surgery, they clearly did not do it well — the patient was anxious, which is why they turned to their nurse for education and support. And no physician I have worked with would be happy to receive a phone call at night from a nurse, saying their patient is in need of more education and could they please stop in and clear things up.

    • The Doc

      When you say ” the patient was anxious, which is why they turned to their nurse for education and support,” you assume the story the nurse tells is true. We don’t need to be called in the middle of the night for many things- but if it is a major change in the patient- then yes, we want to be called. In this case, the patient was being cared for during the day. There is an entire resource of transplant people who would have been better able to answer the questions, as well as the surgeon.
      We do not know what happened in this particular case- but surgeons are called to talk to their patients about the operations all the time. It is our job- whether we “clearly” do it well, or not- we have to do it to inform the patient- and a nurse cannot provide informed consent.

  • Angel of Death RN

    For the last time— getting informed consent for a procedure is out of my scope WHICH is why I DID NOT DO THAT
    It was a night shift! And the education provided was from the hospitals approved patient education library. Furthermore when I was hired I printed out ALL banners policies and studied them do that I could work within them. Finally—-THERE WAS NO POLICY specifying a case management consult was not allowable by nurses.

    • The Doc

      First – I have no idea who you are. Here are some general comments:
      – (a) Informed consent is talking to the patient about risks and benefits of the procedure and whether they should get it, and if they get it what the expected results would be. The nurse not only admitted to talking to the patient about the procedure and what it would ultimately entail and the road to transplant. That is informed consent. As much as people attempt to frame this as “educational” which informed consent is- there is a clear line crossed here. If a nurse does not understand that line, that when a patient begins to have questions it is time to call the physician- and not attempt to “inform” the patient- then there is an issue here. For the nurse involved, she needs to go to the board with the understanding that Yes- this was over the line and to have learned from this
      – (b) Glad you printed out all policies and procedures- probably the only one who does that, and yet, it was the common sense of not communicating with the physician that this nurse ran in trouble with. While all the policies and procedures are there- it is was the basic tenant of communication and being a part of a team that this nurse would have violated.
      – (c) If my patient is starting to have questions and wanting to talk about hospice, using the night shift as an excuse is not adequate. This is also a decision where the patient needs to be informed- and the best person to discuss informing the patient with that disease process is the physician. They do, after all, have a fair bit more education and experience with disease, not to mention have a more intimate knowledge of the patient. Del Webb does have that as a policy – according to their nursing office.

      This was a difficult situation for all involved. For the patient whom we serve, for the physician of the patient, and for the nurse involved. It is a question of boundaries and ethics. Not accusing any of unethical behavior here- simply stating that this provides a means to restate the ethics which we, as surgeons, have as the pillars of our profession. As much as this blog has brought a lot of comments that show a rift that needs be mended – behavior of surgeons that needs changing – this involves real people. Rod is real, the patient, the physician, and that nurse are all real people. For the nurse involved – if you read this blog, I am so sorry you are going through this, and wish you well.

  • ivy

    Was this nurse have special TRAINING and education about transplant? Is she certified to give education to patient? Was she educated enough and trained enough to be able to give an accurate transplant education to patient. SHE CANNOT PROPERLY EDUCATE THE PATIENT USING THE ALLOWED MATERIALS BY HER EMPLOYER. I am under the impression that this nurse think she can educate the transplant patient better than the surgeon. Scenerio: we are nurses (I’m BSN,RN 22 years), our patient have wounds, who did we go to and ask their recommendations? WOUND NURSE why because they have extra education and training and they are certified (and yet they still need the DOCTOR’s order). For me “LITTLE KNOWLEDGE IS DANGEROUS”, she should just let the SURGEON do their job. Surgeon can educate the patient better, all this nurse need to do is contact the surgeon and let the surgeon know that the patient have questions about transplant. This nurse will be a good advocate for the patient by directing them in the right direction TO HER SURGEON then the patient can make a decision if TRANSPLANT OR HOSPICE.

  • Chris, RN

    I’ve been in this business for about 13 years now as an ICU RN. I have worked at a handful of good sized, urban hospitals, taken care of many types of surgical patients. I have often wondered why it is me, as the nurse, that so often is the one to actually get the patient’s signature on the consent form when surgeons are the ones that do the procedure…

    • The Doc

      Getting the patient to sign a piece of paper is “obtaining consent” and it is fine– it isn to the same as providing informed consent

      • Canadian

        interesting. Where I work the Physician must get the signature on the consent form.Also maybe you should look up the term vicarious liability, unless that only applies in Canada.

        • The Doc

          Informed consent is the surgeon responsibility to give– the signature is considered paperwork to prevent lawsuits for battery.

  • Chris, RN

    For me, this whole case highlights issues that our healthcare system desperately needs to examine: In this modern day and age, what truly is “informed consent”? What is the current state of professional relations among various elements of our healthcare system and how can it be made better? How does fee for service methodology in healthcare impact patients? Does it so? Why do so many nurses feel so much disrespect from administrators and MDs, yet so much respect and admiration from their patients? Where’s the disconnect? Why is burnout and turnover so high with more and more younger people not choosing nursing as a career?
    We have 77 million baby boomers coming down the pike–the first of which are just now beginning to enter retirement. As professionals, and as a society, we best get this stuff figured out….

    • The Doc

      There is a robust discussion about consent and information and how we can improve it. Yes- burnout is common in this profession. I think the reason burnout is common is not because of the patients we take care of- but the overlying burdensome administrative issues. I’m sorry nurses do feel disrespect from physicians – we cannot do our job without you. Were it up to me- instead of the difficulty this young nurse is going through- we would have a broad based discussion among all of us so we could all understand. I suspect we could all learn something, and then move on without the rancor.

  • ivy

    It is a shame that the patient had a high level of anxiety (EDWARD) and it was night shift (ANGEL OF DEATH) and this nurse intervention was to educate the patient about the transplant procedure and the patient opted for HOSPICE…tsk tsk tsk I hope it HELPED THE PATIENT’s ANXIETY’…NURSES, NURSES, NURSES i know that if you were the patient you wouldn’t want a nurse with only 6 years floor nurse experience educate you about transplant, using written material provided by employer, you demand to talk to your doctor so why is this patient any different?

  • kris

    I am not a lawyer but unless the patient is interviewed some of this can’t be resolved. Was it just a simple here’s some information and I’ll make sure the doctor sees you immediately in the morning or did she lead the patient to a choice. Of course this won’t happen but some of the controversy does seem centered on whether she had an agenda or remained neutral.
    Also when nurses take in a consent form their only legall responsibility is to witness the signature. We have an ethical responsibility to be our patient’s advocate and that’s where things get dicey. The ethics of something is always subjective.
    The crux of this is nurses understand their scope of practice one way and the docs another way. Maybe ,a collabborative effort to hash this all out is in order since people find this so polarizing.
    Just trying to be a reasonable voice and not throw more gasoline on this fire.
    I might add….a psych eval??? Really? How humiliating. I know nurses with substance abuse problems who weren’t subject to this. That is a little chilling.

    • The Doc

      True informed consent is not what a registered nurse can give. The physician also has the ethical obligation to be a patient advocate. The right thing to do was to let the physician know that the patient was having questions about the operation – and to not proceed down a conversation that led where it did. Well meaning nurses, with many years of experience, have given wrong information to surgical patients – and trying to undo wrong information, when the patient trusts that a nurse has a level of knowledge to provide the information they did, is difficult. Even a bit of misinformation from a nurse to a patient regarding an operation can place the patient-physician relationship in jeopardy (e.g.- nurse tells patient one thing, that is wrong- doctor tells another – patient confused and then loses faith in the surgeon).

      The Board decided to obtain a psych evaluation. Here are the concerns that a board might have – and I am not privy to their reasons: (a) does this nurse have the ability to recognize that the actions taken were outside the scope (b) does this nurse have an agenda that would continue to lead to actions outside of the boundaries of what the Board wants (c) does this nurse have the ability to learn from a mistake or will this continue to be an issue (d) was the nurse suffering from burnout (e) does the nurse have any underlying psychiatric issues such as depression, borderline personality disorder, etc – that need to be addressed. It is not punitive to request such an evaluation, but it provides a neutral party a chance to help resolve a situation that, sadly, has become public.

      The polarization is sadly evident between some nurses and some surgeons. As can be viewed by some of the comments made, fast judgments about stereotypical surgeon behavior abound. The prejudice against surgeons is more evident and tends to hide the underlying issues that you see. For example: the surgeon threw a tantrum — how many people would believe that – as it turns out quite a few. Let me provide a story I witnessed: a surgeon discovered a nurse who called in the middle of the night to order a sleeping pill, had not called later when the patient’s blood pressure was in the 80′s and heart rate over 120. The surgeon, in a low voice, calmly explained that this was more important, that the patient was very sick, and needed to go to the operating room immediately, and he would appreciate calls about vitals as was the protocol. The surgeon didn’t swear, his voice was lower than when he normally talked- and while he was tight in his face, he was visibly upset. I was chief of surgery at that time, and when I received the complaint from the nurses that this surgeon had used profanity and yelled, it was easy to dismiss. Had I not witnessed it myself, we would have investigated it. Did the nurse feel she was being yelled at? Did she feel there was a tantrum? In this case- whether the surgeon threw a tantrum or not is polarizing information that deflects from the issue. It is a separate issue, but it is not the issue of what happened that night when this patient was “being educated” and the surgeon should have been notified.

      • kris

        Where there’s smoke there’s fire. People believe the surgeon threw a hissy because quite simply everybody has seen one if not more of these events.
        So please educate me. As a surgeon, how do you discuss with a patient that their options are transplant or death?
        Do you say you can choose not to have the transplant and we can explore hospice?
        Or do you just suggest the transplant evaluation route and after that is completed have the discussion of all the options.

        • The Doc

          First- it doesn’t matter if the surgeon had a “tantrum” or not. That was an inflammatory statement made to get sympathy- and does not detract. True consent gives risks and benefits of the surgery, and risks and benefits of not having the surgery.

      • http://crasspollination.blogspot.com Nurse K

        If a patient wanted to use the hospital’s wifi to research her own upcoming surgery on her own computer, would you be opposed to that too because she would be giving herself “informed consent”? If no, why is it any different handing her some printoffs from the hospital’s intranet and providing basic information?

        I like to think that patients would want at least to have some basic information so they can ask more intelligent questions. It’s like going to a car dealership with and without having researched cars at home first, only more serious. If you don’t even know that you need antirejection drugs, for instance, you wouldn’t think to ask about which drugs you’ll likely be started on and the possible side effects of these.

        • The Doc

          A nurse is not an extension of Google- a nurse is a person who has access to the surgeon when a patient has an issue with surgery. Misinformation given by a nurse is one of the most difficult issues surgeons deal with, as patients can lose trust in their surgeon. Even the most experienced nurse can give this. But a patient who is in the hospital for a procedure is not the time or place for a nurse to come and start a discussion- especially on a night shift.

  • Angel of Death RN

    1. I DID NOT GET CONSENT FOR ANYTHING, I DID NOT EXPLAIN RISKS OR BENEFITS OF ANYTHING
    (I GAVE HOSPITAL APPROVED PATIENT EDUCATION MATERIALS)
    2. I DONT LEAD PATIENTS TO HOSPICE THATS UNETHICAL, THEY ASK ME I GIVE THE INFO
    3. THE PATIENT WAS INTERVIEWED AND CORROBORATED THE EVENTS

    why does this consent thing keep coming up? My job was not to get consent it was to fill in the gaps lacking in the area of knowledge.

    • The Doc

      When you start to “fill in the gaps” about a surgical procedure- that is getting consent. When you talk to patients about hospice, instead of a surgical procedure or set of them – that is obtaining consent. When you “use hospital approved materials” it is not in a vacuum. The issue is you didn’t contact the surgeon – he found out on morning rounds.

  • ivy

    IT IS ALARMING THAT MANY NURSES DO NOT GET IT…this issue is as simple as “YOUR/THE NURSE PATIENT C/O PAIN AND YOUR CNA TOLD YOUR PATIENT TO PUT WARM COMPRESS TO RELAX THE MUSCLE AND DID NOT INFORM YOU/THE NURSE”. The CNA might be right , it helped the pain but the CNA might be wrong, the patient may get burnt. THE POINT IS THE CNA DID NOT TELL YOU/THE NURSE THAT YOUR PATIENT C/O PAIN, THE PATIENT DID NOT GET THE RIGHT INTERVENTION AND TREATMENT. because you/the nurse was educated about pain management more than the CNA. Then you/the nurse discipline the CNA to correct them to AVOID FURTHER MISTAKE and provide better care for the patient. CNA to NURSES, NURSES to MD, follow the chain of command and let the experts on their field educate the patient/family .THE DOC DOES NOT WANT TO WAGE WAR AGAINST NURSES BUT INFORMED THOSE NURSES…so this will be avoided in the future and the patient get a right intervention and treatment.

  • Angel of Death RN

    Well, then, surgeon, lets just make this easy so its nice and black and what for you—the surgeon is right and the nurse is wrong. In this case there wasnt even a surgeon involved YET. It was a gastroenterologist! But, I digress, Im just a nurse with a biase who wants to push everyone toward death, which, according to you–there is no dignity in. You need to review the definition of informed consent. But that is neither here nor there—again, the surgeon is right and the nurse is by all means, ALWAYS WRONG. So nice to know that when I go test for my nurse practitioner credentials Ill have to interact with providers such as yourself. Im thrilled. And oh so honored.

  • Angel of Death RN

    Oh and let me take this “up” to your level—my stethoscope is better than yours!

  • Linda

    I remember standing by the elevator when two physicians were discussing how nurses did not follow their orders when their orders were clearly written. I was wishing I had my students with me to hear the discussion when the nurse standing next to me said “And that’s exactly how it should be.’ We have a scope of practice that overlaps yours. But that in no way means I have to clear what I do in my scope of practice with any one as long as it is reasonable and prudent.

    Also, even if policy had been violated (which is not clear), there are appropriate measures to deal with this. Anyone can see that the entire incident has been overblown way out of proportion. No one was injured, no adverse event happened.

    The only reason this is happening in this manner is because of one physician. Please do not try to blame shift.

    • The Doc

      Somehow Banner seemed to believe this was enough of a violation of their policy that this nurse was fired. Physicians cannot fire nurses. Human Resource Departments from hospitals cannot arbitrarily fire people- there is a process. In fact, the larger the organization, the more involved and uniform the process is. Banner is a large organization. So, Banner did their measure with this- the nurse was fired. This was then sent to the Nursing board – which has placed this under investigation. We do not know if the patient was harmed by delaying a procedure, nor do we know if this would lead to an issue between the patient and the physician which harms a relationship. This is not happening because of one physician – this is happening because a nurse didn’t pick up a phone and talk to a doctor.

  • Kelly

    Clearly nurses do not obtain informed consent, I’ve been nurse for over 20 years and in peri-operative nursing for the last 13 and I’m always very quick to hand the consent over to the surgeon unsigned when the patient has a question. On the other hand, nurses do provide patient education constantly and questions of concern often arise. No way does anyone page a surgeon in the middle of the night for a non-emergent issue like patient education…not unless they want to be hung up on and reported to their manager–really, seriously. I probably would have called surgery around 6am and asked if he/she had been spotted around the hospital yet but not in the middle of the night.

    The thing is it is so easy for things like this to happen–just last week–I’m preparing to witness a patient signing consent for placement of a suprapubic catheter and I said my usual spiel about ‘tell me who your doctor is’ ‘what’s he gonna do?’ So far grandma’s getting all the answers right….Then I say ‘did your doctor explain the procedure to you? she said “what do you mean procedure?” so I said “your surgery, did your doctor explain the surgery to you fully?” and SHE SAYS “I had no idea this involved a surgery, I thought I was just going to have a better urine tube put in” Uh YEAH…So of course I didn’t witness her signature but then she’s going on about how she doesn’t want to have a surgery yada, yada, and I’m thinking oh great…can of worms right here, opened….that’s seriously how even a simple question can start a situation like this.

    I was the target of a hostile outburst by a surgeon who was upset with both me and anesthesia–his patient was refusing surgery due to a positive pregnancy test (it was likely a false pos due to her dx which we all knew and which anesthesia fully explained to the patient) Surgeon arranged new anesthesia and told me to wheel her to the OR…Honestly I could not in good conscious or under MY practice act wheel her to the OR under the circumstances and let’s just say the ‘F’ word was flying in front of multiple patients. I was fully supported by the many great docs, nurses and patients in pre-op who backed me up and the surgeon was sent to anger management. This doesn’t always happen.

    The truth is many hospitals do look the other way when physicians exhibit bad behavior, even if they have a great anti-nasty policy in place. It’s the fatal flaw in our health system that facilities rely on procedures to bring in revenue, MDs perform procedures and are also reliant on procedure revenue to pay their own bills. This has caused a massive conflict of interest that has to affect even the most caring and ethical MDs (and facilities). This is the reason nurses immediately assume the nurse is being thrown under the bus…so many times that is what happens, really, it’s less costly to fire the nurse than to lose the MD. That’s just a fact–I wish it wasn’t.

    We’re all stressed, nurses, doctors,patients. Our system is a mess. There are good and bad docs, good and bad nurses. It serves no purpose to berate each other, that will just make the whole situation worse. Most want to work as a team, I know I do.

    • The Doc

      Teamwork is what we have. No one is helped when there is a rogue physician, or any rogue member.
      I’ve sent surgeons to anger management – although apparently this is a gastroenterologist- never sent one of those- they seem to be more meek and mild than we surgeons who roar load and clear.
      Patient refuses surgery- sometimes we just have to accept that no matter what.
      And, yes, if you don’t call me at 2 am with a patient in crisis that is fine- but if you instead intervene with that patient in such a way that the patient, when I arrive, is now refusing to be operated on– well, that puts a whole new light on it. It isn’t the money- it really isn’t

    • ivy

      KELLY,you mentioned the patient is a grandma, did you check her diagnosis? she might have DEMENTIA and forgot that she, her family and her power of attorney for health care was informed about the procedure. The grandma patient was informed about the procedure that’s why she was there at the hospital and the family drove her there. The surgeon have problem how to control his anger but it doesn’t mean that you and the anesthesiologist were saint, you are a team the surgeon is your leader , if there is a mistake you are all held accountable for it. the physicians bad behavior is irrelevant to the current issue of discussion. Why do you think poorly of nurses. Physician perform procedures but it is the nurses who takes care of the patient after procedure, both are important to the hospital’s “procedure revenue” and both are replaceable too.

  • Linda

    Like I said, if it is reasonable and prudent, I don’t have to notify. I really don’t understand what you don’t understand about that. The patient was interviewed and substantiated the circumstances.

    The whole idea that i would call a surgeon during the night shift to notify him I gave his patient some hospital education information is just absurd. Stop being ridiculous. i have more respect for surgeons than that.

    I’ve been in the business long enough to know how it really works so please do not feed me the whole physicians cannot fire nurses line. Most administrations will do anything to shut a ranting physician up. Heck, so will I.

    It is happening because of one physician.

    • The Doc

      Apparently this was a gastroenterologist- how the story shifts over time.
      If my patient has issues- the job is not to in the middle of the night have a discourse about transplant, end of life care, and whether they need a procedure or not.
      I’m on the governing board of one hospital, on the executive committee of another hospital,- No, a physician cannot fire a nurse

  • Linda

    Well, as the person who is at the bedside in the middle of the night, I can tell you that is when those conversations happen. That is the job.

    Yes patients get cold feet. Yes they have epiphanies in the middle of the night and change their entire course of treatment. And I am not going to wake a physician up unless it will have emergent results in the patient. That stuff can wait until he/she rounds.

    In your prestigious capacity on the board and committees, you probably do not have any direct dealings with HR decisions so you may not know. Physicians cannot fire nurses directly. What typically happens is they threaten to take their business to a different/competitive hospital along with all the income the procedures and research their practice brings to the hospital. They can easily do this because they will typically have privileges at all area hospitals dealing with their specialty. It is fiscally irresponsible for a facility not to comply with a physician request for the removal of a nurse. So every time I have seen this happen, the physician does not fire the nurse but the nurse is fired because of the physician.

    • The Doc

      I’ve seen the opposite happen – a physician being disruptive, with a large volume of business being placed on leave- knowing that they will take their business elsewhere. Also have reported physicians.
      In this case- the behavior of the nurse was such that as a physician I would not wish her to take care of any of my patients, and I suspect most would not- unless that nurse learned to use a telephone. She will think she was fired because of greed- as do some others– but in my mind, she was fired because she couldn’t communicate to the physician.
      Having a nurse that doesn’t work well on a team, that disrupts the team, and causes patients to have unnecessary anxiety and steer them without interaction of the team – -what do you do with that nurse? If you have a nurse that isn’t working with the other nurses, doesn’t function as a team member – what do you do?
      We do have direct dealings with HR decisions when they effect the hospital in any way- we are informed, and get a list of actions from HR and compliance reports. This nurse would have fallen out of compliance, and I am certain that the board of the hospital as well as the medical executive committee will have discussed this among themselves — however, I don’t know for certain

      • Linda

        Hey you are projection your own issues here. I just went over how what she did was reasonable an prudent and you will find it to be a standard in nursing practice. If you think calling a physician in the middle of the night to tell him I gave a patient some hospital information is playing on the team you are grossly mistaken.
        Of course you don’t know if she was in compliance or not. You are making stuff up and probably thinking of some nurse you know.
        Interesting you have seen that because i have NEVER seen a facility dismiss a physician that was generating income. Compliant or not. But I have seen facilities fire nurses at the request of a physician. Not because of nursing at all in some cases. Sometimes it was who she was sleeping with. And yes the HR report is created to reflect that she is not in compliance. But I have had this type of paperwork cross my desk and I refuse to participate. Then HR has to go to my report to because I will not sign that type of paperwork. So what the board sees is appropriate documentation that was contrived.

  • Kelly

    IVY, I know you identified yourself as an RN in your previous posting but I have difficulty believing that from some of your questions and comments. As a registered nurse you should already be well aware that you are not accountable to the surgeon or any physician but rather to the board of nursing in your state. Provision two of the code of ethics for professional registered nurses states “the nurse’s primary commitment is to the patient, whether an individual, family, group or community’ As such, when a patient is verbalizing refusal of a procedure, as a professional registered nurse (NOT an angel or saint) I cannot wheel an oriented patient to the operating room who is verbally refusing a procedure no matter how much the surgeon wants me to do so.

    And you are confusing my ‘grandma’ patient with the possibly pregnant patient. The possibly pregnant patient was obviously not of grandma age. I have wheeled many patients with dementia back to the operating room in spite of loud refusals but only when the properly documented legal guardian has completed consent. And YES, believe it or not Ivy I do check to see patient diagnosis and I’ve occasionally been known to read an H&P and test results, LOL. Ivy what do you really do? You do not sound like a professional nurse and that’s okay, it’s good to hear from everyone.

  • Kelly

    IVY, I actually want to offer an apology for the above comment about you maybe not being an RN, I reread all of your posts and you DO sound like an RN. I’m thinking perhaps there is a cultural variance of some kind occurring because I notice in your posts that you seem to think physicians are in the nursing chain of command and while that is not true in the United States I’m sure it is true in some other countries. I know many of my co-workers who received their basic RN preparation in the Phillipines have told me that physicians are in the chain of command in that country. How does this work where you are from?
    Again, I apologize for the above comment, you do sound like a nurse and I’m very interested in hearing how other countries frame their health care services, there has to be a better way than the way the U.S. is currently framing care.

  • Caryl J. Carver, RN, BSN

    This nurse requested a CONSULT. A consult is exactly that a consult. She did not steer the patient in any direction. She gave requested information from the approved literature of the hospital. She worked within her chain of command by advising her supervisor and advising the oncoming nurse as well as documenting her actions. How do you interpret this as a rogue nurse? I am seriously perplexed in your interpretation.

  • ivy

    KELLY, I ACCEPTED YOUR APOLOGY. WE DO NOT HAVE BASIC NURSING IN THE PHILIPPINES, WE HAVE BSN WHICH IS FULLY ACCREDITED HERE IN THE US. THEY ACCEPTED our CREDENTIALS FOR MASTER’S. I WORKED IN THIS COUNTRY FOR 15 YEARS, SO I KNOW THE PROCEDURE HERE MORE THAN MY OWN COUNTRY AND TO TELL YOU THEY ARE BASICALLY THE SAME, “CENTERED TOWARDS PATIENT CARE”. the scenario i was explaining on my previous post was from this country. i did not confuse your grandma patient for a pregnant patient. you want the signature for the consent from grandma, for supra pubic catheter insertion, grandma said i do not know there is surgery involve, then why was she there? you proceeded to explain, after your explanation grandma patient did not want the supra pubic catheter procedure. you were not able to explain it to grandma that it is important, for her own health because no one would like to do supra pubic cath just because. grandma don’t want supra pubic catheter…then what will happen to grandma, suffer urinary retention? .2ND PATIENT your pregnant patient does not want to go to OR, what is your intervention? fight with your surgeon, F words flying around… you’re a team, even with an ill tempered surgeon, it just makes the patient scared more and lose faith in your team. NOT JUST NURSES ARE FOR THE PATIENT, BELIEVE IT OR NOT, PHYSICIANS TOO , (CNA’S, PATIENT FINANCIAL COUNCILOR, SOCIAL WORKER, and more). all i am saying is that we should work as a team and where ever you go, NO MATTER what country you belong too, there is always CHAIN OF COMMAND to follow, otherwise it will be chaos. ..and it would be for the patient because that patient could be you or your family . and MAJOR SURGERY LIKE TRANSPLANT I WOULD LIKE MY SURGEON TO EXPLAIN IT TO ME, NOT NURSES EVEN WITH 60 YEARS EXPERIENCE.

  • Z.J.

    I lost my brother last summer to cancer. He spent his last 6 painful weeks of life in hospice. (He was not treated in Arizona, so we had no experience with the hospital or staff at Banner Health). What I can say is that the team (doctors + nurses) that treated my brother, put his treatment first, with the ultimate goal being his recovery. When it was clear that the cancer could no longer be treated, or perhaps – further treatments would offer no relief, and my brother was going to lose his fight against the disease, my family was counseled and told our different options. Hospice was our choice, after all medical treatments had been exhausted.

    In my opinion, hospice is a dignified choice, when death is the next stage of the patient’s life. I don’t believe that educating patients (and their family) about hospice as a choice, is wrong. Not being personally familiar with Banner Health’s policies, I cannot speak to the exact point at which the nurse in question crossed the boundary. But clearly, her employer felt she did act erroneously, and they took action, as an employer. How did this turn into a “surgeons only care about the $$$ bottom line” discussion? The nurse was dismissed for her actions, by her employer, not by the physician.

    I also do not see, reading Dr. Simpson’s post, at which point he points fingers at nursing as a profession and questions the value nurses have. I don’t believe that Dr. Simpson is for one minute, devaluing nurses or the profession. There is absolutely no question that nurses are a most valuable part of the treatment team, and patients develop strong bonds with them. I know the nurses who helped to treat my brother are still dear to my widowed sister-in-law.

    Is the health care system in this country flawed? Without question. Should physicians and nurses be held to high standards of conduct ? Without question. However, when a nurse who stepped outside of her bounds (as perceived by her employer) is held to answer to the State Board of Nursing for her actions, why do the claws come out? Do I believe the nurse in question believes she was acting in the best interest of the patient? Yes, I believe the nurse thought she was doing the right thing. Her employer believed she did not do the right thing. Therefore, they took action. And now, the State Board of Nursing will determine if the nurse retains her license.

    For all we know, this is not the first time the nurse in question had her actions on-the-job called into question. With six years of nursing experience, perhaps this is the first time, perhaps not. We also aren’t privy to other personnel issues regarding the nurse. She may have shown a pattern of behavior that factored into their decision to dismiss her.

    The comments I’ve read here make it clear to me, and I find it sad, that there is a high level of hostility or resentment in the nursing/medical professional between nurses and doctors. As someone who’s family benefited from the kind and conscious actions of both doctors and nurses, this is especially troubling to me. The patients, and their families, need nurses and doctors to come together, and find a way to continue to advocate in our best interests.

    • ivy

      calm down. i will not blame the surgeon bashing the nurses calling them at 2am because the patient is not aware of hospice. it will be for the nurse to reassure the patient that the hospice team will be contacted first thing tomorrow , to discuss hospice with the patient and the family if that is their choice. if the patient had a high level of anxiety like mentioned from previous post, it is not the best way to discuss her procedure and hospice. it will just make the patient more anxious and not able to make a good choices. the nurse should have called MD for anti anxiety or sleeping pill and reassure patient that her MD will be notified of her question regarding transplant and the hospice team will be contacted. this is nursing, “patient care”.

  • The Doc

    Thank you for all of your comments . Our task is to work to mend rifts, because if we mend them we provide the best care we can for our patients. If we find more details we will post them in a new blog.
    The surgeon isn’t always right – that would be me- nor perhaps the gastroenterologist as apparently it was in this case.
    I’m not a conspiracy type, so I don’t believe that Banner would remove a nurse based on a physician’s request, but I suspect we won’t hear the end of that . I am not associated with Banner, and probably will never be – .
    Our perceptions of what happened are clearly different, perhaps it would be helpful to have a blog about medical ethics and not use a case, but place instead scenarios and see how we would solve those issues. We will have a new section about medical ethics and include those in them, and perhaps we could agree in specifics how we would handle them, and what would be the prudent thing.
    Thank you again.
    TS

  • Linda

    I would like to thank you Dr. Simpson for opening up this discussion. Thank you for listening to opposing views and for giving a forum for the discussion. It is appreciated. I believe you give outstanding care to your patients just as I do. We take great pride in our care and it is apparent in the discussions.

    This forum allows a glimpse into the practice of others and can only improve our practice. On behalf of patients and nurses, thank you.