Archive for category Before I Start Throwing Things, I'd Better Write This Down

Fat Nurses Need Not Apply Revisited

More on the Texas hospital, Citizens Medical Center, which banned fat people from being hired. Citizens Medical Center, you might remember, made it policy to exclude new hires with a body mass index >35, and explicitly stated employees appearance should “fit with a representational image or specific mental projection of the job of a healthcare professional . . . free from distraction” for patients. Medscape has a video (sorry, couldn’t figure out how to embed) from a medical ethicist named Art Caplan with another point of view. Partial transcript:

Look, I’m all for trying to set a good example and I think there are plenty of businesses where being thin and being in shape really do matter. I guess if you run a modeling agency it is very important. But I’m not convinced, really, that putting in weight restrictions is the best idea in terms of sending out the right message or a necessary message to patients. Patients, I think, can work with their doctors to try to overcome common problems. Doctors see all kinds of patients with all kinds of habits and all kinds of lifestyles. I think patients can deal with seeing all kinds of healthcare workers with all kinds of habits and all kinds of lifestyles. If they want a thin one, they should be able to pick one, but I don’t think the hospital necessarily should have to say that only the thin ones can work here. [Emphasis mine.]

Really? That last bit sounds needlessly, well, stupid. Does he really think patients should be allowed to choose their health care providers on the basis of their appearance?  “Let’s see. . . ” one can imagine patients musing, “that nurse is too fat. Tht nurse is too old. That nurse is too. . . dark. That nurse is too male. That nurse is too Muslim. That nurse is too gay.” And so on. Apart from fostering bigotry and discrimination, and demeaning and devaluing staff, in practical terms, you’d soon run out of nurses. I mean, not every nurse looks is thin, white, young and female.

One more thing. I understand there is a role for hospital policies regulating appearance: hygiene, facial hair, tattoos, uniforms and jewellery are usually targeted. Fair enough. I also understand the need for an ethicist to weigh (so to speak) both sides of the issue, but isn’t there some point where, after all is said and done, you have to say evaluating people of the basis of their body characteristics  in general is just wrong? I don’t think that medical ethicist Art Caplan exactly said it was wrong. Making a value judgement, that employers treating nurses and physicians as human beings with inherent dignity and worth, is important. It might even be a good place to start.

[UPDATE] Also, too, these thoughts from a writer named Susan Pape at Policymic.com:

When I am in need of hospital care, I want the staff to be the best, hardest working, most talented, most caring available. I do not care if they are overweight. Employing health care providers on the basis of their competence is a matter of life or death …to me.

And.

Obesity is not a choice, and it is not immoral.

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Breastfeeding Makes Sane People Crazy

Why does any discussion of breastfeeding makes people a little insane? I don’t exclude myself: even I get a little agitated. Here are some examples of what I mean:

Exhibit A: a recent post on breastfeeding at KevinMD.com sparked a small flame war in the comments. Barbara Bronson, an RN wrote there:

A mother breastfeeds as she tends her produce market stall.

A mother breastfeeds as she tends her produce market stall. (Source: WHO)

And guess what? Our kids — now in their twentie [sic] – turned out just fine. They have no allergies. They are smart. They’re not fat. They’re healthy. They are kind, and funny and athletic, and you couldn’t pick them out in a crowd. But if you read some of the research and most of the women’s magazines, you’d think we’d be hauled in for heresy for disclosing this seldom-talking-about fact: in the end, whether you breast-feed or you bottle-feed, no one — not even a physician, a nurse, a teacher or a psychologist –  will ever be able to tell the difference.

[SNIP]

So that’s why I was pleased to see the World Health Organization announce that although they recommend breastfeeding for the first six months of life, they say it may not be a realistic option for many.  The report was published online March 14, 2012 in the BMJ Open.

The curious thing about this particular post is that it almost completely misrepresents the British Medical Journal article cited above. The BMJ article suggests an idealistic public policy approach to breastfeeding may be counterproductive — and only dealt with new mothers in a developed country. Bronson’s post managed to turn this important study into a disavowal of the World Health Organization’s breastfeeding guidelines. Of course, it said no such thing. (A far more accurate take on the BMJ article can be found on the Breastfeeding Medicine blog. Or just read the damn thing.) Not that is matters much: the debate degenerates into bomb-throwing between pro-formula-you-lactivists-are-Nazis and breast-is-best types. Who cares about the science, anyway — it just gets in the way of anecdotes and feelings.

(Yes, I am annoyed.)

Exhibit B: a city ordinance in Seattle protecting the rights of neonates to breastfeed publicly causes distress for those who prefer breastfeeding mothers to be unseen and unheard:

“We need to get to the point where breastfeeding is accepted by everybody,” said Schwartz of the Breastfeeding Coalition. Although businesses that break the law can face fines, she said the main goal was to educate people and change attitudes.

“It’s feeding your baby for heaven’s sake,” she said.

But advocates will have to overcome an ingrained hostility, as seen oozing in the comments on a KING/5′s story on the breastfeeding bill.

“Wanna feed your kid, great feed your kid, just don’t put up a bill board (sic) pointing to your saggy udders trying to get some attention,” wrote “freedomfrank” on the site.

“As far as I’m concerned, women with babies can get the (hell) out of any restaurant I’m in if they want to breast feed,” another commenter wrote. “You’re not special and we don’t give a rip that you have a baby.”

One woman wrote that she supported breastfeeding – had nursed her own kids – but just didn’t like it in public.

“I do not want to watch you when I am trying to eat or walking in the mall with my teen son,” she said.

A toddler breastfeeds while sitting on his mother's lap.

A toddler breastfeeds while sitting on his mother's lap. (Source: WHO)

(The measure passed.)

Exhibit C: suffer not the little children unto me. Rachel Stone writes:

When he was one year old and decidedly cherubic—with chubby pink cheeks and golden curls—my family visited Rome, and, of course, Vatican City. I was prepared with skirts and modest tops for visiting St. Peter’s, but I hadn’t considered for a moment that breastfeeding might break the rules of modesty. So when my little cherub was hungry, I settled cross-legged in a corner, in sight of Michelangelo’s Pieta—that haunting sculpture where Mary cradles the broken body of her Son—and began to nurse, identifying, maybe for the first time, with Jesus’ mom as I cradled by own boy. 

Seconds later, a uniformed guard came along, slapping his chest and saying, emphatically, “Latte, latte!? Latte? Uh, downstair! Uh, da batroom!” Of course: he wanted me to go breastfeed in the bathroom. Because nursing my son in that space was equivalent to a plunging neckline or a miniskirt.

All of this makes me a little crazy for the sheer stupidity. However, I get there is some deep cultural resistance antipathy to breastfeeding in the West and particularly in North America. I happen to think this ambiguity — where Facebook bans pictures of breastfeeding but permits hypersexualized pictures of busty women — is utterly idiotic and tied up in some bizarre societal notions about breasts and sexuality, but I understand that others’ mileage may vary.

(Source: WHO)

I get that nurses, midwives and other healthcare providers haven’t been the best at times supporting and encouraging new mothers to breastfeed. We nag, hector and finger-wag when we should be providing support and empathy.

But still, for all of that, breastfeeding is undoubtedly the best choice for most women and neonates. Yes, there are exceptions: neonates who can’t or won’t nurse, or physical, health or social/economic problems preventing the mother from nursing. But really, are theses exceptions so numerous to recommend formula as the equivalent choice for all neonates? To use an analogy, gold standard treatment for pneumonia is the prescription of antibiotics. Does the standard change because a few might not tolerate the drugs? It bothers me more than a little the nurse mentioned above would suggest bottle and breast are equivalent, whatever her own personal experience.

Something else which makes me unhappy: how the debate around breastfeeding is almost always framed from the perspective of middle-class women from developed countries like the U.S, Canada or Britain who have the resources to consider formula as a viable option. For most of the world’s women, the sheer logistics of bottle feeding are not feasible or realistic. These include consistent access clean water, soap, a stove, fuel, education, and nurse/midwife support, the formula itself and other supplies, or the money to buy it. According to the World Health Organization:

When infant formula is not properly prepared, there are some risks arising from the use of unsafe water and unsterilized equipment or the potential presence of bacteria in powdered formula. Malnutrition can result from over-diluting formula to “stretch” supplies. Further, frequent feedings maintain the breast milk supply. If formula is used but becomes unavailable, a return to breastfeeding may not be an option due to diminished breast milk production.

For many, if not the majority of women in the world, and especially the poorest, there is no option but breastfeeding. We should probably bear this in mind when discussing how “realistic” the WHO guidelines are.

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The Insanity of It All

Warning: my semi-annual politicalish post. When I read this, I admit I gawped:

$26,659: Our 2011 Medical Expenses

 Yes, you read that right. And we had insurance coverage for everyone last year, including daughter, 16, and my son who is 23 years old. Let me break it down for you:

    • Insurance Premiums……………..$14,179.04
    • Prescription Costs…………………$ 7,198.00*
    • Doctors Fees, etc…………………$ 2,068.49*
    • Eye care……………………………..$ 404.28*
    • Dental………………………………..$ 2,752.00**
    • Mileage……………………………….$ 300.00

* Costs in excess of insurance coverage.
** No insurance coverage.

Our medical costs in 2010 were $18,636. The principal reason why our medical expenses in 2011 increased by such a large amount was because our insurance premiums increased from roughly $7,000 in 2010 to over$14,000 in 2011.

This same crappy, expensive health insurance will likely be cancelled because my wife’s former employer has filed Chapter 11 bankruptcy and has filed a motion with the bankruptcy court to cancel all medical benefits for retirees and their families. My wife is classified as a retiree because she became disabled as the result of her pancreatic cancer, and the surgical chemotherapy and radiation treatments she received in 2006, and was unable to return to work. The story of her disability is described in detail at this link. Fortunately she is covered by Medicare, but we will lose even this crappy insurance coverage for myself, my daughter and my son.

I have a rare autoimmune disorder that unfortunately was not properly diagnosed until after the time had passed for me to file a disability claim with Social Security. Thus I am not eligible for disability benefits or Medicare. New York has a program for younger children that my daughter for which my daughter might qualify.

Because the insurance exchanges required under the Affordable Care Act will not go into effect until 2014, it is unlikely that my son and I can find insurance until then, assuming that the Supreme Court doesn’t find the ACA unconstitutional.

Basically one large every two weeks for medical expenses. Can any American defender of the status quo tell me why this isn’t completely insane and morally bankrupt? Or any Canadian admirers of U.S. health care — I know you are out there — tell me why the American system is superior in the fair and equitable provision of health care?

Just askin’.

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When Labelling Patients Causes Patients to Die

I found this story how a homeless woman died very disturbing:

Anna Brown wasn’t leaving the emergency room quietly.

She yelled from a wheelchair at St. Mary’s Health Center security personnel and Richmond Heights police officers that her legs hurt so badly she couldn’t stand.

She had already been to two other hospitals that week in September, complaining of leg pain after spraining her ankle.

This time, she refused to leave.

A police officer arrested Brown for trespassing. He wheeled her out in handcuffs after a doctor said she was healthy enough to be locked up.

The throwaway, disposible patient

She told officers she couldn’t get out of the police car, so they dragged her by her arms into the station. They left her lying on the concrete floor of a jail cell, moaning and struggling to breathe. Just 15 minutes later, a jail worker found her cold to the touch.

Officers suspected Brown was using drugs. Autopsy results showed she had no drugs in her system.

Six months later, family members still wonder how Brown’s sprained ankle led to her death in police custody, and whether anyone — including themselves — is to blame.

There seems to be no simple answer.

Actually there is a very simple answer. At some point in her care, a nurse or physician decided Anna Brown deserved to die. I don’t mean literally a health care professional wrote Anna Brown’s chart, “This patient deserves to die.” But someone decided — a nurse, a physician, or maybe it was a collective, Emergency Department judgment —  that because Anna Brown was homeless, because she was black, because she was poor, because she had made multiple visits, because she was still in pain, because she advocated for herself by making a fuss, because she possibly had (undiagnosed) mental health issues, she was not entitled to proper care.

She was labelled. She was drug-seeking. She was crazy. She was a frequent flyer. And that killed her as surely as if a nurse had bolused potassium chloride.

I will tell you why I think this is true.  Because Anna Brown had made repeated visits, and no one took her seriously. Because she told staff about her increasing pain, and no one believed her. Because she was unable to walk, and no one thought to ask why. All of these are enormous waving red flags for any emergency department health care professional, and neither physician nor nurse did anything about them. That’s the thing about labels: they contain their own little subjective judgements about patient care, and obscure the obvious.

If Anna Brown had been a middle-class white woman with a nice home, a job and a car, I am willing to bet — no, I know the outcome would have been different — or at least, she would not have died, gasping for air, from a pulmonary embolism on a cold jailhouse floor. There certainly would not have been any of this Kafkaesque horror of being in obvious distress with a deep vein thrombosis, about to throw a clot, and being utterly unable to get help at the very place where you might expect it.

I will let the public in on a little secret. We all do it. Each and every one of us. I don’t exclude myself. We all label patients. It is deeply embedded in the culture of health care to the point where it is an accepted practice. We all call patients drug seeking and crazy and frequent flyers and failures-to-die and failures-to-cope. We laugh at them. Hell, there are whole blogs and books devoted to the art of ridiculing patients we have already labelled. (Though when you think about it, there is nothing quite as charming as making fun of  human beings who are powerless, is there?) Has any one ever thought labelling patients might cloud and impair clinical judgment? Or that it dehumanizes patients and is just plain wrong?

There is also this from another blogger who writes:

But the way Brown died was not the result of a few bad choices. It was the result of a myriad of institutional violences: white supremacy, the broken health care system, police brutality and the prison industrial complex, the racism and classism of the child welfare system, ableism and its intersection with racism, dehumanization and criminalization of (suspected) drug users, and the lack of housing as a human right, among others. Anna Brown did not die with the dignity we afford to human beings, but with the contempt we reserve for garbage. And a woman’s humanity is not just forgotten and cast aside with no systemic reason.

[But go read it all.]

Don’t think I have much to add.

[Via.]

[UPDATE: A long time reader suggests instead of the word label, I should use "profile," as in "racially profiling." Once upon a time I might have thought the word unnecessarily inflammatory --- but now I am not so sure.]

[UPDATE II: Small corrections to syntax. Hobbit not cooperating.]

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Arizona is Where Educating Patients is Bad, Bad, Bad: An Amanda Trujillo Update

Just a few words about Amanda Trujillo.  Jennifer Olin at RNCentral.com has detailed at the latest twists and turns of her case. I won’t repeat everything, but I want to comment instead on the Arizona State Board of Nursing’s latest action. The BoN has added a further charge that Trujillo has misrepresented herself as “an end of life” specialist because she counselled and educated patients about end of life care, using the materials provided by her employer, Banner Health.

This is pretty outrageous, and I think, an abuse of process. Let me elaborate from my point of view as an Emergency department nurse. In the course of any shift I may give advice and education on:

  • wound care and dressing changes — but I am not a nurse specialist on wound care and dressings
  • casts and splints — but I am not a specialist in orthopaedic nursing
  • diet for cases of gastroenteritis — but I am not a dietitian
  • prescriptions — but I am not a pharmacist
  • preparation for diagnostic imaging — but I am not a radiography tech
  • advise first time pregnancies on the benefits of breastfeeding — but I am not a lactation nurse
  • head injury routine — but I am not a nurse specialist in neurology
  • treatment of fever in children — but I am not a paeds nurse

Now according to the Arizona State Board of Nursing, I am representing myself as a specialist in all of these areas, and probably a few score more that I haven’t listed. By the considered, professional judgement of the nursing leadership inhabiting the halls of the Arizona State Board of Nursing, I should just shut up, because I am clearly qualified to do squat.

The Arizona State Board of Nursing evidently believes nurses educating patients on anything is beyond their scope of practice. And by extension, nurses educating patients puts patients in danger.

Ridiculous?

Absolutely. And this is why this latest charge is a trumped-up nonsense. Nursing as a profession would cease to exist in Arizona if nurses had to meet the stringent requirements the BoN now apparently requires, if nurses need some sort of official certification as “specialist” before providing education of any sort. The “position” now put forward by the Board of Nursing is contradicts widely accepted nursing practice. Providing health teaching is the standard of care around the world. This is what nurses do. In my jurisdiction, you can be disciplined for not providing appropriate education.

Jennifer Olin puts it this way:

This just makes no sense. Trujillo may be interested in end-of-life issues, she admitted herself that she had provided such information to patients previous to the one involved in this incident with no objections from physicians or hospital management. In fact, that evening, she even cleared her plan of care with the clinical manager.

This is not claiming to be a certified specialist. We are nurses. We are expected to know quite a bit and, more importantly, how to find information for our clients and ourselves. The information Trujillo provided was pulled straight from the information banks of the hospital’s own computer system.

Exactly. This is what we know as nurses. We educate. To claim otherwise is to run against the experience and practice of millions of fully qualified and competent nurses. The Arizona Board of Nursing knows this too. They are nurses, after all. You can only conclude the Board is grasping at straws at this point, hoping to harass or intimidate Trujillo into submission.

The next step is an evidentiary hearing, for which the Board of Nursing has not yet set a date. As of next month it will be a year since this business started. The wheels of justice grind slowly, it’s said. Let’s just hope they grind as finely as advertised.

One more note: I spoke at length with Amanda yesterday, and she is very well and in good spirits. Her lawyer has asked her not to comment publicly further on her case, so I can’t relay what she told me. However, I will say the story grows more convoluted by the day and there is far more going on than can be publicly mentioned. So stay tuned!

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A Nasty, Medically Unnecessary, Coercive Procedure

This is just grostesque:

A Republican supermajority has muscled two of the most restrictive anti-abortion bills in years through the Virginia House, despite bitter yet futile objections from Democrats, with one GOP delegate deriding most of the procedures as “matters of lifestyle convenience.”

You want to put what where?

[SNIP]

And the ultrasound legislation would constitute an unprecedented government mandate to insert vaginal ultrasonic probes into women as part of a state-ordered effort to dissuade them from terminating pregnancies, legislative opponents noted.

“We’re talking about inside a woman’s body,” Del. Charnielle Herring said in an emotional floor speech. “This is the first time, if we pass this bill, that we will be dictating a medical procedure to a physician.”

The conservative Family Foundation hailed the ultrasound measure as an “update” to the state’s existing informed consent laws “with the most advanced medical technology available.”

The Oklahoma legislature passed a similar law a couple of years ago. Full disclosure, in case you didn’t know it: I dislike abortion, but I’m strongly pro-choice. Even if you are strongly against abortion on moral or religious grounds, I would like to know how a medically unnecessary, coercive, invasive procedure can be ethically justified in order for a patient to receive health care? (I think we can safely dismiss the Family Foundation’s reasoning as spin.) And if the patient is a 13-year-old rape victim, how is this not despicable and evil?

Another question I would like to ask: if you’re a health care professional, would you excuse yourself from participating or facilitating in enforcing this law?

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Why Nurses are Furious about the Amanda Trujillo Case

The case of Amanda Trujillo has generated a great deal of passionate commentary across the nursing blogosphere. Trujillo, as you may well know, is the nurse who was fired by Banner Health Del E. Webb Medical Center for requesting multi-disciplinary hospice care case management consult for a pre-transplant patient with end-stage liver disease. The request angered the patient’s physician — not the transplant surgeon, incidentally, nor someone with any knowledge of transplant surgery — who complained to Trujillo’s manager. After her termination, the hospital subsequently reported her to the Arizona State Board of Nursing for exceeding her scope of practice. If the Board finds against Trujillo, she may well face the loss of her license or other sanctions; in the event, her nursing career would be finished. Superficially, at least, an open and shut case, or least this is how Banner Health would like to project the controversy. Scratch the surface a little and matters change considerably.

So why are nurses so furious? Part of it is the apparent coincidence of any number of other, seemingly random bits of information outside the direct narrative of Trujillo’s story. The fact that the Arizona State Board of Nursing chose to deem Trujillo’s attempt to defend herself publicly as “retaliatory behavior”  just as her story was becoming part of the general conversation, and then ordered a psychiatric evaluation is one of those seemingly random bits. This struck me particularly. Suspicious minds might see a pattern to punish Trujillo for speaking up by publicly labelling her mentally disturbed (and in health care, as any nurse will tell you, acquiring that label is doubly damning.) For myself, I will be content to note that throughout history calling people crazy is a traditional means of discrediting those challenging authority and marginalizing dissent.

And there are other random bits: that the Arizona Board of Nursing (for example) chose to inform Trujillo’s doctoral program of the ongoing investigation just last week — some ten months after the initial complaint. The apparent close linkages between various facets of the nursing “leadership” in Arizona, which I am told is known as the “Circle of Death” for woe to any nurse who crosses it.  The secrecy, the opacity of all the institutional players, from Banner Health to the Arizona Nurses Association. The sense of arbitrary and coercive behaviour from any of these. Separately, they don’t amount to much — but together? Suspicious minds, as I said, begin to see patterns.

But there are far more substantive issues the firing of Trujillo raises. Take, for example, the matter how and why Trujllo was fired. From Trujillo’s account, it was arbitrary and unjust. Trujillo acted, she says, in good faith; her intent was to help the patient make an informed choice about his treatment options; she had made the same request for similar cases previously without consequence or objection; there was no hospital policy positively forbidding nurses to make this request. The only difference, it appears, was the physician’s annoyance, that as Trujillo’s manager put it, Trujillo had “messed up all of the work they had done, and that the doctors were nowhere near going down the hospice route.”

So there is this, a manager’s buckling under physician pressure, to do something about this turbulent nurse, a nurse who was trying to conscientiously to do her duty —-  which happened to conflict with the plans of the physician. But that is not even the really bad part. Let me put it in this way by citing an example that has weighty consequences for both nurse and patient. If nurse commits a serious medication error, best practice anywhere is for the hospital administration to do a root cause analysis. The purpose of this analysis is not to apportion blame, but to prevent the error from ever happening again. 

Once the root cause is determined, there might be changes to existing policies and procedures, and there might be education. Almost always, there is some sort of remediation of the nurse involved, because responsibility for a medication error is ultimately a shared responsibility from the nurse who administers the medication to the senior managers who are responsible for policies ensuring patient safety. For Trujillo, there was none of this — just security escorting her off the premises.

A reasoned, measured response to Trujillo’s actions, using root cause analysis, might suggest change and clarification of existing procedure for ordering case management consults. Instead, we have a nurse whose offence is so grievous that the hospital chose to fire her and then report her to the state Board of Nursing. To put it another way, even if Trujillo was completely in error in her interaction with this patient, and exceeded her scope of practice, what exact demonstrable harm was done to the patient?

I am puzzled why a clerical error — which I think is the worst possible cast one could put on Trujillo’s actions — merits termination and Board of Nursing discipline, while a serious medication error generally would not. It’s the gross inequity of outcomes which is so troublesome. Please note, in this context, nurses are generally fired and reported to regulatory bodies when there is concern they are a danger to the public.

So you have to ask yourself this simple question: even if you accept Trujillo exceeded her scope of practice, was firing her and then reporting her to the Board of Nursing proportionate to the supposed misdemeanour? Acting rashly, inequitably, without reason, and disproportionately, to my way of thinking anyway, is central to any definition of arbitrary and unjust behaviour.

We are also angry that Trujillo apparently was penalized for acting as her patient’s advocate and for attempting to ensure her patient could act with autonomy. This has serious implications for all nurses, because hobbling any nurse’s ability to act as advocate seriously jeopardizes patient care and safety. But first, the word “advocate” has been bandied about so much I want to inject a little clarity as to what exactly nurse-as-advocate means in the context of end-of-life care. This is what my own regulatory body, the College of Nurses of Ontario, says:

Nurses advocate for their clients and help implement their treatment and end-of-life care wishes. However, a client’s request to receive a treatment does not automatically bring with it the obligation for the nurse to provide the treatment.  A nurse is not obligated to implement a client’s treatment wish if it has been determined that the treatment will not benefit the client and is therefore not a part of the plan of care.

The College — no slouches in the matter of nursing ethics, by the way — goes on to tell us that that nurses act as advocates by ensuring patients have informed consent when implementing multidisciplinary care plans and by (says the College)

acting on behalf of the client to help clarify the plans for treatment when:

  • the client’s condition has changed and it may be necessary to modify a previous decision;
  • the nurse is concerned the client may not have been informed of all elements in the plan of treatment, including the provision or withholding of treatment;
  • the nurse disagrees with the physician’s plan of treatment; and
  • the client’s family disagrees with the client’s expressed treatment wishes

I think this is fairly standard nursing practice anywhere, and how all of us understand advocacy, whatever the stage of life. It is needful to point out the College phrases its language as nurses “must” not “may.” In other words, advocacy is not optional part of nursing practice. And what about patient autonomy? One of the four pillars of health care ethics, patient autonomy is the right of all patients to make informed decisions about their care and treatment, and necessarily implies outcomes matter most importantly for the patient, not the health care team. Nurse advocacy, it hardly needs to be said, is an important part of ensuring a patient can act an informed autonomous way.

So we have a situation where Trujillo was practising under universally accepted nursing standards, using the nursing process and nursing judgement, made a nursing assessment, educated her patient, in order that the patient could make an informed decision about his treatment options; in short, she acted to preserve her patient’s autonomy, and then was punished in the worst possible way for her attempts to be, well, a good nurse. Here’s her account, drawn from her lawyer’s representation to the Arizona Board of Nursing:

Having assessed the knowledge deficit related to the patient’s routine medications, disease process, associated tests and procedures, the plan of care for transplant evaluation and palliative care options, Ms. Trujillo proceeded to print out patient educational material from Banner’s website that addressed those areas. . .  Ms. Trujillo also provided materials related to hospice care per the patient’s request. Ms. Trujillo, concerned about the patient’s lack of understanding of (pts) treatment regimen and the option for comfort care, discussed her education of the patient with her clinical manager, Frances Fausto, who readily supported Ms. Trujillo’s plan of care and interventions. . .

Ms. Trujillo and the patient reviewed the materials over the course of the night.  After a full review of the materials the patient stated, “Had I known everything I would have to go through and the commitment I would have to make, I would not have agreed to the transplant evaluation.” The patient inquired into whether there was anything else (pt) could do besides enduring more tests, procedures or surgeries. Ms.Trujillo then explained hospice care services and the differences between symptom relief care and end of life care. The patient expressed serious concern that (pt) would not be able to commit to an extensive aftercare regimen following the transplant by stating “at this stage in (pts) life (pt) just wanted to be around family.” The patient requested to visit with a representative from hospice in order to ask some questions and gain additional information that would assist (pt) in making a more informed decision regarding (pts) course of care.

Ms. Trujillo placed a note in the chart pertaining to the assessment of knowledge deficit, the specific education provided and the palliative care discussion, in addition to, the patient’s request to see a case manager from hospice. She used the SBAR (Situation, Background, Assessment and Recommendation) format of report required in Banner policy when she handed off care of the patient to the dayshift nurse, alerting the nurse that the patient requested more information prior to being transferred to another facility for a transplant evaluation.  She also alerted the dayshift nurse that there was a nursing note in the record for the doctor to read that detailed what occurred over the course of Ms. Trujillo’s shift with the patient.

I am not seeing a lot of daylight between a world-respected professional regulatory body’s standards of nursing practice and Trujillo’s actions. I personally would do no different. Which brings us to the exact point of what disturbs and angers so many nurses: when hospitals run roughshod over a nurse’s professional and ethical judgement, when they refuse to acknowledge a nurse’s central ethical duty to sustain patient autonomy, there does not seem to be any point to acting as a professionals at all. Or maybe, that’s the real message hospital corporations want to send: that front line nurses aren’t really professionals, and larger questions of ethics and patient care are better left to higher beings — physicians, corporate managers and our nursing “leadership.”

This is why we are passionate about Amanda Trujillo. This is why we are so angry. The issues raised by the Trujillo case affect each of us, because this is how we practice nursing. By keeping patients — their wants, desires, needs, autonomy — front and centre.

Advocates for Amanda Trujillo — and I include myself in that number — have been criticized for jumping the gun, for not waiting for the other side of the story, for surely Banner Health and all the rest will have their speak. I concede the point. I accept I may be wrong. Not all facts are apparent, and some will never come out. (By the same token I am not clear what further details are needed to come out in order to form a reasonable conclusion about the situation. This isn’t the Pentagon Papers, or use a more modern reference, a WikiLeaks cache dump.) My sense of the situation, however, is that Amanda Trujillo’s position is far nearer the truth.

I say this not because of the documentation, or because I have spoken to Trujillo about her case (and five minutes on the phone with was enough to convince me of her utter veracity), or because she makes herself readily available to her supporters — she spoke with me for over an hour last evening despite an exhausting day, and was able to answer with clarity some very probing questions —  but because, sadly, her case follows the same pattern of abuse we have seen in other cases almost too numerous to count: arbitrary and vengeful behaviour from health care corporations, official investigations, attempts to discredit nurses and nursing and after a long time and huge financial and personal cost to nurse involved, vindication. And this is what frightens so many nurses: what happened to Trujillo and all the rest can easily happen to any of  us, and in the process, chip away at our collective professional integrity. So a lot of us in the nursing blogosphere and through social media are determined to hold the feet of Banner Health, the Arizona Board of Nursing and all the rest to the fire. The fact so many of us are so vehemently engaged in this issue speaks volumes about our determination to uphold the integrity of our beloved profession.

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What Breast Cancer Is and Is Not

Susan G. Komen Run for the Cure doesn’t have much of a direct presence on this side of the border, so I could watch the recent public relations train wreck here with a sort of Olympian dispassion and, I have to admit, grim satisfaction. Frankly I’ve never been a fan of  Komen’s “pinkwashing” everything related to breast cancer, which seemed to both infantilize breast cancer sufferers and trivialize the larger social and health care issues related to the disease. Breast cancer sufferers need dignity and real research, I think, not pink ribbons used as a marketing tool for corporations. My mother died of breast cancer, you see, and my mother-in-law had a lumpectomy and radiation therapy six years ago, so I tend to wear these things on my sleeve.

So this video, which is making the rounds on the Interwebs, provides an antidote to all of Komen’s nonsense, and spells out as much dignity and courage as one could want in a YouTube video. Warning: delicate flowers easily offended by surgical scars may want to leave the room, or at least avert their eyes.

 

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UPDATE: Minor editing/typo fixes. The first post by Android phone clearly leaves much to be desired, but as Samuel Johnson says, “It is not done wellbut you are surprised to find it done at all.”  Note to self: grow opposable thumbs. TE.

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The Persecution of Amanda Trujillo

In the ugly, grey world of hospital balance sheets it’s almost a commonplace that physicians generate revenue while nurses represent a cost. Fancy procedures and sub-sub-specialties bring generous income streams, in terms of charging (and profiting) from the provision of a multitude of related services, such as nursing, while nursing itself, because it generates no revenue, is a burden to the bottom line.

It’s also commonplace, that in certain health care institutions, the power structure, the hierarchy of heath care, is so rigid (and fragile) that any challenges to that hierarchy — such as a nurse questioning the God-like omniscience of a surgeon — must be ruthlessly suppressed.

Amanda Trujillo

So when a nurse interferes with the revenue stream, dares to challenge the organizational power structure, hospital’s only logical recourse is to utterly destroy the nurse’s career. Take the case of Amanda Trujillo. Engaging in standard, no, gold standard nursing practice, following hospital procedures and using hospital materials, Trujillo correctly ascertained a patient facing end-stage liver disease did not understand a proposed transplant procedure or its consequences, and desired palliation instead. According to usual practice at this institution, and with the support and knowledge of her immediate manager, she requested a multi-disciplinary team consultation to create a care plan.

Amanda Trujillo tells the story herself:

My name is Amanda Trujillo. I’m a registered nurse of six years , specializing in cardiology, geriatrics, and end of life/palliative care. Back in April of this year 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. 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). The patient also had no idea that they had a choice about whether they had to get the surgery or not or that there were other options. They asked about hospice and comfort care and I educated the patient within my nursing license and the nursing code of ethics. The patient requested a case management consult to visit with hospice to explore this option further in order to make a better decision for their course of care. I documented extensively for the doctor to read the next day and I also passed the info on to the next nurse taking over, emphasizing the importance of speaking with the doctor about the gross misunderstanding they had about the surgery. The doctor became enraged, threw a well witnessed tantrum in the nursing station, refused to let the patient visit with hospice, and insisted I be fired and my license taken. He was successful on all counts.

Let’s be clear about this and speak plainly: when the transplant surgeon primary physician found out about this course of events, mindful perhaps of lost fees, but heedless (it seems) of any apparent conflict of interest, and in fact, of any basic recognition of the principle of patient autonomy, he threw a temper tantrum, and demanded the job and licence of Nurse Trujillo.

The administrators at  Banner Del E. Webb Medical Center, heedless both of any apparent conflict of interest on the part of the surgeon primary physician, and in fact, of any basic recognition of the principle of patient autonomy, complied with this request. In the best tradition of blame-the-nurse, these faceless administrators — and I sincerely hope there are no nurses among them, because if there are, they are a complete disgrace to our profession — fired Amanda Trujillo. They then reported her to the Arizona State Board of Nursing, on the grounds that the request for the case management team somehow constituted a “medical” order, and therefore Trujillo exceeded her scope of practice. It’s important to realize these (hopefully-not-nurses) administrators designated this particular order as a “medical” order somewhat after the fact.

Very disturbing is the sheer maliciousness of the hospital administration at  Banner Del E. Webb Medical Center. Think about it for a minute. Even if you accept — and this is a  long stretch — that Trujillo exceeded her scope of practice, is the appropriate, measured response to ruin her practice, when the “error” was made in the best interest of the patient, in way that recognized and validated the patient’s right to autonomy?

Yet at some point an administrator decided the only appropriate, measured response was to utterly destroy the career of this nurse by screwing her over so royally she could never practice again.

(Nice job, Banner Del E. Webb Medical Center! I guess the best thing about this hospital you can say is that it it’s an awesomely bad, ugly, abusive place to work, if they would throw a nurse under the bus to appease a physician having a temper tantrum. It almost goes without saying that a place that is bad and ugly for nurses to work in doesn’t do much better for patient care. The case, in the event, pretty well makes that much clear.)

Amanda Trujillo’s hearing at the Arizona State Board of Nursing was supposed to have been yesterday. It was postponed for two months for a psychiatric evaluation because — wait for it — defending one’s self publicly on the Intertubes constitutes “retaliatory behaviour.” No, seriously. In the old Soviet Union, dissidents used to be labelled insane to discredit and marginalize them. Pretty well much the same obtains in modern nursing. Defy a physician, you get fired, you get investigated, and you get labelled crazy. And the Arizona State Board of Nursing facilitates the abuse, because as we all know, health care institutions never lie, and never have ulterior motives.

Nice.

So you want to be a nurse?

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Amanda Trujillo’s full story can be found here at Vern Dutton’s site.

Her Twitter feed is here.  Trujillo’s Twitter account seems to be deactivated this morning (26/01/12).  

Amanda’s new Twitter feed is here.

A Facebook page in her support is here.

Email the Executive Director of the Arizona State Board of Nursing, Joey Ridenour, RN, MN, FAAN: jridenour@azbn.gov

Complain to Banner Health here.

Nerdy Nurse’s perspective is here and here.

Please spread Amanda’s story as widely as possible. Every nurse is vulnerable to mistreatment.

UPDATE: 

Minor spelling corrections. Anyone know where I can purchase a hobbit to proofread?

Also:

Emergiblog:

Nurses not only eat their young, but God help you if the almighty Medical Establishment gets ticked off.
Nurses talk a great game. In the Halls of Academia and the Ivory Towers of Those Who Claim to Advance The Profession, it’s all “Nursing Is An Independent Profession” and we tirelessly “Fight For Our Right To Practice To The Full Extent Of Our Education And Training”.
Unless you’re down in the trenches doing patient care every day and someone gets angry that you have dared to advocate. And if that Someone is a Doctor, well, the bigwigs scatter to the four corners of the ring.
Musn’t create controversy.
Hell, they aren’t even standing on your side of the arena.

From Kim we also learn that the president of the Arizona Nurses Association (email the Executive Director, Robin Schaeffer: robin@aznurse.org) is the nursing director of Banner Del E. Webb Medical Center. Hence the deafening — and telling — silence of that organization.

And also Jennifer Olin. And NurseKeith.

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“We Will Now All Be Unwilling Participants in a Social Experiment That Will Undoubtedly Place Canadian Lives at Risk”

My thoughts exactly, from Alan Drummond of the Canadian Association of Emergency Physicians. His full statement on the proposed repeal of the Gun Registry.

It is regrettable that we, as a nation, are about to embark on an unwelcome social experiment. The Conservative government has been very clear that they intend to finally abolish the gun registry. This is regrettable in so far as it is clear to Canada’s emergency physicians that the gun registry has, in fact, worked and the number of deaths from inappropriate firearms use has dropped dramatically since the institution of the Firearms Act. The government has consistently portrayed this act as a victimization of rural long gun owners, conveniently ignoring the clear scientific evidence that rural suicides with long guns are the principal issue in the tragic toll of Canadian firearms deaths. So we will now all be unwilling participants in a social experiment that will undoubtedly place Canadian lives at risk. Our question to our government is that relative to the perceived inconvenience and cost of registration, what will be the true cost, in direct human suffering, of their ideologically driven and scientifically bankrupt legislation.

Some inconvenient statistics, nicely compiled by the CBC:

Homicide by firearm
Firearm homicides, 2009: 179 (0.53 per 100 000 or about 30% of all homicides)
Firearm homicides, 1991 (the year stricter gun control was introduced):271 (0.97 per 100 000 people)
Types of firearms homicides, 2009:
Rifles or shotguns: 18% (36% in 1999)
Handguns: 69%
Prohibited firearms: 13%
Since 1995, when the gun registry became law, until 2009, the reduction in homicides by long guns: 52%
Spousal homicides caused by shootings, 2000-2009: 167 (23%)
Reduction in the rate for spousal homicides involving firearms from 1980 to 2009: -74% from nearly 3 per million spouses in 1980 to less than 1 per million spouses in 2009, according to Statistics Canada
Share of firearm-related spousal homicides involving a long gun: 50%(The rate of long-gun spousal suicides dropped about 80% between 1983 and 2009.)
Share of family-related homicides of children and youth (7 to 17 years), by shooting, 2000-2009: 26%
Of the last 18 police officers killed in the line of duty, as of August 2010, number killed by long guns: 14 (78%)
Suicide by firearm
Number of firearm-related suicides involving a long-gun, 2004: 475 ( 5.4 times the number of suicides with handguns)
Change in number of firearm-related suicides since the introduction of stricter gun laws in 1991 (as of 2009): -43%
Change in number of firearm-related suicides since the introduction of the Firearms Act in 1995 (as of 2009): -23%
Increased likelihood that a home where there are firearms is the scene of a suicide, than a home without a gun: 4.8 times (based on a 1992 U.S. study in the New England Journal of Medicine)

Incidentally, for you fiscal conservative types, the cost of treating a gunshot victim is about $450,000.

So, on one side of the debate, we have scientific and statistical evidence on the efficacy of the gun registry, expert opinion from health care professionals and the police, the physical and emotional cost of trauma, hundreds of deaths prevented and, on the other side, the hurt feelings of rifle owners. That’s pretty well what it boils down to, right?

[Update 29/10/11: Fixed formatting problems.]

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