forced catheterization

[Aidey]

So the patient was violent enough he was placed in 4 point restraints, and his clothes were cut off, rather than removed with security assistance. Why do you think he would have been anything other than combative when the foley was placed?

Why do you feel it was punitive? Because he as combative? Do you believe he would have been any less combative if you attempted to have him urinate in a cup or urinal? Do you believe it would have been any less "humiliating" for him to urinate on himself? How did the catheter violate the patient's rights? Do you understand that being a patient advocate does not always mean doing what is warm and fuzzy for the patient?

Edit: If it patient was brought in because of intoxication, why do you think adding to his intoxication is beneficial? A foley takes a couple of minutes, sedating him could mean he spends another couple of hours in the ED.

 

[usalsfyre]

Vene's rule of EMS #1.

"Never wrestle with a man holding a lightsaber."

May the Schwartz be with you....

 

[Medic Tim]

I see your Schwartz is as big as mine

 

[VFlutter]

1: Catheterization is relatively harmless and painless to the patient.... UNLESS it is forced upon the patient blatantly and flagrantly against his will as he screams and writhes.

2. Yes, in fact, I did feel it was somewhat punitive.

3. I do not yet know what my refusal will entail. But I will stand by my decision.

4. I am an advocate for patients' rights.

5. "Guess I'm just a wondering idiot!" I couldn't have said it better.

Was this a straight cath or foley? It is not punitive if it is a standard of medical care for that situation. A catheter is an appropriate procedure for this situation.

Not to sounds arrogant but do you really know what it means to be a patient advocate? What patient rights are you trying to protect? I hear this thrown around a lot by people and it typically comes down to "The patient should be able to do whatever they want". If that is the case then you should have left him to die drowning on his own vomit on the side of the road.

So if this patient was intoxicated and driving and killed a school bus full of children then got brought into the ER, would he have the right to refuse an IV blood draw because it was painful and humiliating?

Or another situation: A patient came into the ER with a shattered pelvis after an MVA in a wheelchair van. He was writhing in pain and kept saying "Dont touch me, let me die, kill me now, it hurts too much" Should we have just stopped and let him die? should we have not taken any images because we would have caused pain by manipulating his body? Should we have just loaded him up on narcotics even if he was peri-arrest and unstable? Or better yet should we have gotten a Psych consult for his suicidal comments?


You opened up Pandora's box....

 

[bigbaldguy]

I happen to like warm and fuzzy folks.

Now lets turn it down a notch, my warm and fuzzy goes only so far.

A question was asked, either answer it politely or move on.

I'm now watching this thread when I have much better things to do so be nice.

 

[VFlutter]

I happen to like warm and fuzzy folks.

We will have to agree to disagree with that one :blink:

 

[Veneficus]

What patient rights are you trying to protect?

I think when people are new, the only thing they can base patient advocacy on is what they would want done to themselves or a close relation.

That is slightly out ofcontext though.

They see the "brutality" of the the action without understanding the intent.

Let's take a look at it from a different perspective.

This patient was intoxicated. But the mechanism that alters the mental staus is inconsequential. It could just as easily have been an accidental poisoning, hypoglycemia, etc.

If you were having chest pain, you would likely want to go to the hospital, be evaluated with EKGs, labs, maybe even an angio CT. You want and need to know what it going on. (The reason that physicians focus so heavily on diagnosis is that one you decide on something, because of understanding on why that causes pathology, the treatment is intuitive.) But in order to get these diagnostics, it is not without a marginal amount of suffering. You may even require diagnostic vascular surgery. (I can assure you as a coping mechanism when it comes to dignity, when you are on that table, you are a slab of meat. Even your head is obscured removing your humanity.)

But the average patient thinks nothing of the associated loss of dignity with bypass surgery.

But take this in the context of your brain. When your brain is messed up, it has its own set of symptoms. If you want help with your heart or liver when it was messed up, why would you not want help with your brain when it is messed up?

In order to do that a set of diagnostics has to determine if there are "forces" outside of the brain (like toxins, renal failure, etc.) or "forces" inside the brain, (vascualture, neurons, neoplasms, etc.) which are causing this alteration in personality.

So in the event you or a close relation winds up in the hospital and the organ involved is the brain, wouldyou really want less diagnostics? No diagnostics? Would you want at least the sandard of care if not the all that could be done in order to discover and relieve (I didn't use the word "heal" on purpose) your sickness?

To not only retain the vegatative aspects of the brain, but also the parts responsible for who "you" are?

Making sure the patient gets the best diagnostics and treatment when they cannot communicate or even control themselves is patient advocacy.

The only thing that makes it different from an unconscious person is they still have muscle activation. (which does complicate the matter slightly.)

Not wanting to be in the patient's position yourself is not advocacy. It is your desire for you.

 

[luke_31]

It wasn't a forced catherization at all. It is a standard treatment for an altered patient to get a urine toxic screen if the cause is unclear. Granted the patient might not have known that if he got blitzed that he was going to get a foley. But look at it this way, what if he has gotten this intoxicated before and has been through the same situation and knew what happens to him when he shows up in the hospital like this. In this case you can assume that he gave his consent as he knew exactly what his consequences were going to be getting this intoxicated.

 

[abckidsmom]

Beyond all this, when the standard of care dictates that you need a clean urine sample, you catheterize the patient, come what may. I am still a little scarred for life by the straight cath episode of my 2.5 yo daughter who spiked a temp up to 106.7 on a Wednesday afternoon.

We needed to know, immediately, what her big deal was, and getting a urine sample from a 2 year old happens with 4 big grown ups holding her screaming, writhing self down, and slipping in the straight cath. Later, the LP.

It sucks. And yet...we just do it, because it's the right thing to do.

I will venture that perhaps the issue you have with the situation is this perceived injustice on top of disrespectful behavior from the staff. THAT is the part where you can be an advocate, and do what you can to make them stop teasing the caged bear, but good luck with that as the new nurse, who is also a medic.

Those are NOT the kind that have an easy first year. Ask me how I know.

 

[bigbaldguy]

It sucks. And yet...we just do it, because it's the right thing to do.

I will venture that perhaps the issue you have with the situation is this perceived injustice on top of disrespectful behavior from the staff.

Well said.

 

[mycrofft]

stray shots

Suprapubic needle urine collection? Need a screen or a blindfold. Or a couple hits of nitrous.(Kidding about the nitrous).

If an IV is an inevitability, get a serum sample? Might reveal an organic reason as well.

"Don't medicate them they'll be stuck in the ER longer"....very ethical.

Remember the urine results will be inadmissible for LE if the pt is resistive even if he/she is ALOC (altered level of consciousness). So test results will need to be released to LE only in a sealed envelope for their medical people to read.

Sometimes if you don't have the training and experience you have to fall back on the closest info you have. OP, I support your actions as being the best you had, and wish you luck integrating this into your learning curve.

 

[DrParasite]

I said I would not cath him unless he was sedated, to spare him any pain or humiliation.

I believe the "forced" part is the fact that the combative patient didn't to be cathed, and the "patient advocate" part was because he wasn't medicated or sedated for a potentially painful procedure. at least that's how i'm interpreting the OP's post.

Either way, there are sometimes procedures that get done that aren't the most pleasant, but are medically necessary, and need to be done despite the altered person not wanting it.

 

[Aidey]

"Don't medicate them they'll be stuck in the ER longer"....very ethical.

Sedating a patient for a procedure that normally does not require sedation for the comfort of the RN treating the patient isn't ethical either.

 

[Survivor2222]

I know this is an old thread but I found it pretty interesting.

I was a pre med student who became an EMT briefly and decided to become a trauma therapist instead.

My question:

Why are patients allowed to have DNRs and able to refuse life saving care in some circumstances, but not forced medical procedures like a forced cath?

You may know what is best for the patient, but when does patient consent matter? When do patients have choice? Is it when you deem themableto make those decisions?

I have worked with more than one client who has ptsd symptoms from forced medical care they didn’t want, and others who had pre-existing PTSD thy was significantly worsened. The numbers are not huge, but they are significant. Some are so traumatized or retraumatized they refuse routine medical care and treatment.

So how is traumatizing the patient with your good intentions good for health if ignoring consent means they later endanger their lives with suicide attempts and refusal to get even the most routine care?

I get that there are timwspatients can’t think for themselves. Right now there are a number of lawsuits against law enforcement for forced catherizations on resistant patients, even times it was done in the name of health and not legal proceedings.

Consent needs to matter more in healthcare.

 

[VFlutter]

Why are patients allowed to have DNRs and able to refuse life saving care in some circumstances, but not forced medical procedures like a forced cath?

Patients, whom are deemed competent to make decisions, are able to refuse any medical procedure or treatment. Do not think that was ever being argued.

You may know what is best for the patient, but when does patient consent matter? When do patients have choice? Is it when you deem themableto make those decisions?

See above. Consent matters when the patient is medically/legally competent to make decisions and give informed consent. If they are not, then treatment is provided under implied consent that is considered to be in the patient's best interest and what most reasonable people would expect.

Are there situations where a patient may be deemed incompetent due to their mental state but still be very aware and traumatized by the experience? Absolutely, and that is unfortunate.

I get that there are timwspatients can’t think for themselves. Right now there are a number of lawsuits against law enforcement for forced catherizations on resistant patients, even times it was done in the name of health and not legal proceedings.

Consent needs to matter more in healthcare.

Not sure how many law enforcement officers are catheterizing patients...unless you mean blood draws. Usually those are being performed under a warrant.

And unfortunately we live in a litigious society that can sue you for everything you did or did not do. In many situations are you damned either way.

 

[Tigger]

Consent needs to matter more in healthcare.

Informed consent needs to matter more. There was no way for this to happen with this patient.

What do you suggest for a better alternative?

 

[Survivor2222]

Google. You can find many cases in many states where courts have rules that forced catherization of drunk patients is a violation of patient rights.

There are hundreds and of cases like this all over the country. Nah, it doesn’t work to try to wash away the harm that savior complexes do by saying it’s a litigious society.

People get drunk.

You don’t always have to save them against their will.

Let them be drunk. Let them say no. So what?

What, you think that forcing your good on them will cure them of alcoholism? Nah. All you do is spin the cycle more. You see them one moment, one night, one day. You don’t have to deal with the aftermath of what the patient lives with when this traumatizes them.

My colleagues and I follow them in all the aftermath. I have yet to run into a single client that said, “gosh I’m so glad that hospital forced care on me that I didn’t want while drunk.”

That’s not said.

I have been to the gravesite of one who the retraumatization they face at the hands of people who’d toced themselves into his body while he was drunk led to him ending his life.

I have helped on a Cade of one very bright deaf woman who had multiple procedures forced on her against her will because they assumed her deafness meant she was incapable of consent. She had a UTI. That’s it. They deemed her request for an interpreter invalid because she could speak, and spela well. But they also deemed her incompetent of making her choices.

She was fully able to consent.

These situations abound.

Rarely are forced medical procedures done with any respect. The laughter and verbal abuse of patients in distress was ridiculous.

Most addicts are trauma survivors. If you choose you make the choice to force your will upon them, do it with regard and respect for the cost of that on them. Yes they made their choices, you don’t need to make it worse. I am the one who has to help them pick up the pieces for the months and years to come afterwards.

If you are going to take over the will and control of other humans, understand it comes with a very severe cost.

And know, the tide is changing. Consent is going to matter more and more. Not less. It’s time for healthcare to let patients be more responsible for their choices. It’s time for healthcare providers to have a much greater respect for the value of consent.

If you just want to keep doing what you are doing... you will...

 

[PotatoMedic]

Google. You can find many cases in many states where courts have rules that forced catherization of drunk patients is a violation of patient rights.

There are hundreds and of cases like this all over the country. Nah, it doesn’t work to try to wash away the harm that savior complexes do by saying it’s a litigious society.

People get drunk.

You don’t always have to save them against their will.

Let them be drunk. Let them say no. So what?...

You are correct, there have been many lawsuit proving that forced Cath of a drunk patient is not right.

But I do not believe we are talking about the drunk guy who got dragged into the ER because he is hardly responsive to verbal stimulation and swinging at staff because he is an a**. The times I have seen "forced" caths performed is when we have an agitated violent patient who is having a behavioral crisis and we need to know what if any drugs they are on, or the patient who took an unknown number of drugs and is semi lethargic but still semi responsive.

You are right, for the purely drunk guy... Let them be drunk. But we are also legally required to only release them when they are able to care for themselves, and when they are in the hospital we also cannot just let them die.

My advice to you is to not join a community to attack us. If you want change be constructive and not accusatory. Maybe it is just how I'm reading it at midnight but your posts seem to have a strong agenda without much constructive dialogue.

 

[Survivor2222]

I do have an agenda. To make it clear: consent needs to matter more than it typically does.

My agenda doesn’t make my position invalid.

 

[Akulahawk]

People get drunk.

You don’t always have to save them against their will.

Let them be drunk. Let them say no. So what?

I'm an ED RN. We don't go a single shift without having drunk people show up. The vast majority of the drunks we see aren't the folks that get a bit drunk and are still somewhat functional. The majority of the drunks we get are the ones whose BAC is at least 4x legal limit. Most of these drunks can't stand, let alone put together a coherent thought. Most cannot come close to articulating a plan of self-care when they arrive. Do we catheterize seriously drunk patients? Yes. All the time. Do we catheterize all drunk patients? No. If the drunk person can follow directions, they can provide the urine sample themselves. Why do we need the urine? We need to know quickly if there's something other than ethanol in their system. A urine drug screen provides this information very quickly. If we need a definitive level, we can get it from blood but that can take a while.

We also can't turn them away. That's an EMTALA violation because they're now on hospital grounds. I don't suppose you're advocating that a hospital break the law and incur significant fines because you want them to leave a drunk person alone, are you?

Until the drunk patient is sober enough to be able to articulate a plan of self care that's workable (and, if they're still legally drunk, have someone that can come get them), the hospital is required to keep them and provide care for them. We put those patients into a very special category: "Metabolize to Freedom." Once they're sober enough, out the door they go. Do note that I didn't say "completely sober" but rather "sober enough."

For that matter, you could replace "drunk" with "high" or be regarding any number of intoxicating substances.

Here's another side of the problem you might not have considered: Substance Abuse patients can also very commonly be Psych patients that are attempting to self-medicate. People that are having an apparent psych issue could very simply be having a substance abuse/toxicity problem. Methamphetamine psychosis happens. It's actually pretty rare that we see a psych patient that's having an acute psych issue that isn't also positive for one or more drugs and I'm not including THC on this... I've been an in an urban ED and I've had ONE patient that was acutely psychotic that was completely clean. One patient.

Most of those patients know the routine and it includes providing a urine sample. The vast majority know they'll have a positive drug screen. We don't cath most of those unless they're combative and have to be put into restraints (standard of care) or are lethargic enough that they can't stand or sit unsupported and can't follow directions well enough to provide a urine sample (standard of care). How many of them end up with an actual foley cath? Very few. Most are either straight cathed or they're I/O cathed.

Is providing necessary care and doing necessary procedures always "nice"? No. Will I force a procedure on someone that is able to refuse? No. Is forcing certain procedures and "care" upon people sometimes necessary? Yes, under certain conditions, and I will do it when necessary.

Now then, when someone is able to refuse the care and they actually do refuse, even if refusing is a very bad thing, we allow them to refuse. We teach them what they need to know (and we often do very in-depth teaching on this) so they can refuse with full knowledge of what will happen if they refuse. I've had patients leave AMA, and I knew they'd be back somewhere within the next 24 hours because their symptoms would be worse and would likely die because of the delay of care caused entirely by their own choice.