Posts Tagged nursing ethics

Privacy, judgment and ethics aside, I have caring to do.

A few years ago I cared for an acquaintance. She was a friend of a friend who had been living out of the country for several years, but had come home to visit family friends. She was rushed in to the ED and before I even knew who she was I was delivering her 19 week old fetus. When I finally looked up to see the mother’s face I realized we knew each other. I said nothing. In that moment I didn’t care about what the College would say about caring for those you know when there was a real emergency to deal with. I held her hand as she passed the placenta and focused on stabilizing her blood pressure by putting in the largest IVs as I could.  I asked her if she remembered me and if she would prefer another nurse cared for her. She asked me to stay. I comforted her and showed her the baby she would never get to know. I checked on her every half hour that shift and came in early for my next shift to find out how she was. There was no time to feel sad until my shift was over and like the other children and babies and fetuses I have seen pass away, they stick around in my heart and mind a lot longer. There are those patients that stick with you, elderly or middle aged, etc, but I think most any emergency nurse can agree that child patients are the some of the longest lasting in our memories. And for me, the ones who haven’t even started in this world are forever imprinted.

I saw my acquaintance a few months later, she was home again, in the grocery store and she thanked me for what I had done for her and told me she would never forget me. The thank you warmed my heart but I knew she would no longer remember me as the girl she had a beer with when we were in our early 20s, but as the nurse who was there when she lost her baby.  Judgment, confidentiality, privacy, all of those ethical principles aside, perhaps that’s why we shouldn’t care for ones we know, even if just a little, because it affects us too.

I recently found out that she gave birth to a daughter and it’s amazing how happy I felt for someone I don’t really know to have had a baby.  I wanted to find a way to contact her to wish her well but elected not to as I didn’t want to be THAT nurse wishing her well, inadvertently reminding her of what she lost before.  Nevertheless, I personally take solace in knowing that despite all of the sad and terrible we see rarely hearing from these patients again, they do in fact have happiness and joy in their lives later on.

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When the Police Come Calling

The police are more-or-less a permanent fixture in every Emergency department. They bring in the drunks, the suicidal, the psychotic, the homeless and yes, the criminal, who have either sustained injuries as a result of their activities, or else have developed sudden (and convenient) cardiac symptoms upon their arrest. Most of us in Acme Regional’s ED will cooperate with the police to the point of expediting whatever they need us to do, which usually means filling out the Form 1 or medically clearing the patient. At the same time, most of are pretty clear that ED nurses and physicians are not an extension of the Police Service: police objectives and those of health care, to state the obvious,  are not the same.

It isn’t exactly mistrust. It’s more a wariness. There are ethical and legal issues involved. We cannot, for example, divulge patient information, so there is the constant dance of the police asking for information they know we won’t give them.  Come back with a subpoena, we tell them. They try anyway.

Then there is this: what do when the police bring in someone who, well, they’ve been beating on. It isn’t common, I should emphasize, but it isn’t so rare that it excites comment either. The police will say (nudge, nudge) the patient fell on the pavement while being arrested. Or banged his head while getting into the cruiser. Or the wall hit his face. Which may even be partly true. The patient usually says nothing at all.

So what do we do about it? Approximately nothing. We might document the injuries, in case there are  legal problems down the road. Or not. We are definitely not going to make any allegations about misuse of force. Who wants to travel that road, full of traps and pitfalls and paper by the mile plus, of course, the undying enmity of the local cops? I have seen a few pretty egregious cases, and we did exactly that — nothing. As well, I suppose many of us don’t want to second guess the police: I mean, who knows how things really go down, right? And we say, didn’t he deserve it anyway?

But how does this make anyone accountable? Including ourselves? And don’t we have a legal system in place to adjudicate innocence and guilt, and administer punishment?

It’s a moral swamp. And having thought about it long and hard, I’m not clear what, if anything, that can be done about it in practical terms. ED staff are not the guardians of the guardians. So we document. Poor excuse, I know.

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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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More on When Labelling Patients Causes Patients to Die

In the comments WhiteCoat (of WhiteCoat’s Call Room fame) strenuously objects to my take on the Anna Brown case:

Wow.

Someone on my blog suggested that I check out this post after I just posted about this story yesterday.

To all of you who think “something more should have been done,” what should that “something” have been? She had multiple tests and exams performed for the same complaint – including sonograms which showed no blood clots the day before she died. She was having the same pain in her legs since she was hospitalized the week before. Gold standard test for DVTs is ultrasound. Do we repeat the ultrasound every day? Every hour? What other testing was “necessary”?

TorontoEmerg – think of all the patients you see with back pain requesting narcotic pain medications. Do you order serial MRIs on them to rule out the possibility of cauda equina? Or tumor? If so, what is the medical basis for the testing? If not, why? I’m assuming you don’t. When you miss the one patient who has a tumor and becomes paralyzed, you’ll be harangued because “obviously” the patient had something wrong and you neglected to address it. Yet once you tell the patients that they won’t be receiving any narcotic pain medications, many of the patients in severe pain stand up, curse at you, and storm out of the emergency department.

You say that Ms. Brown was “unable to walk.” The article showed that a nurse saw her standing the same day that she couldn’t walk. How many patients do you see who come to the emergency department and can’t get out of their car when they arrive? That’s a “red flag” that something is wrong. Do you order a million dollar workup on all of them? How many patients do you see who have had dozens of normal CT scans for their chronic abdominal pain? Is that proper medical care? I could go on and on, but you get the point.

The problem is that your post suffers from horrible hindsight bias. You knew the outcome and now you’re bashing the people who treated Ms. Brown because they didn’t have the ability to look into the future to see what would happen.

Yes, the outcome was horrible. Yes, there were miscues and miscommunication. I’m sure that Ms. Brown was “labeled” as someone trying to game the system. Society “labels” every aspect of our lives every day. President Obama is “liberal.” Ron Paul is “crazy.” Pit bulls are “dangerous.” Doctors are “rich.” Baby pandas are “cute.” Doing so doesn’t make us bad, it makes us human. Someone who was articulate and polite to the providers and to the police may have been treated differently. One of my readers said this was the “perfect storm” of events leading up to Ms. Brown’s death.

To say that Ms. Brown didn’t receive proper care or that her complaints were ignored is just wrong. I’m betting if you ordered all the testing you think Ms. Brown should have received on all of the patients who walked through the doors at your emergency department, *you’d* be the one being ridiculed.

I appreciate WhiteCoat taking the time to post such a lengthy reply. He fully explicates many of his points on his blog. I won’t editorialize much here, because I think his perspective is important to how we discuss cases like Anna Brown. I don’t share his point of view for a number of reasons, but I do agree with him that labelling people makes us human. The trouble starts, for me at least,  when we allow our interior — and often unrealized — biases to influence our care.

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Easter 2012

Happy Easter.

One thing you may or may not know about me, dear readers, is that I’m a retired Catholic. Like many other people, I left because what some Catholics would call “below-the-belt” issues, but also because the (ongoing) sexual abuse scandals, the treatment of women, and the utter hatred and contempt shown to our gay and lesbian brothers and sisters by the Church hierarchy. I guess I simultaneously rejected the Catholic Church’s authority to be the final arbiter of my conscience on these issues, and any denied actual belief that the Church’s position on these any of these issues was tenable. Or humane. Or Christian.

But still, I won’t pretend my nursing practice hasn’t been deeply influenced and illuminated by Catholic ethics. Here’s one way they are. Call it my personal theoretical basis for practice. The Works of Mercy:

Images of the Works of Mercy by Ade Bethune, a well-known liturgical artist.

For me, anyway, the works of mercy are a pretty good touchstone for what’s good and valuable in nursing practice: there isn’t one of them that doesn’t touch some aspect of nursing. Inevitably, your mileage may vary. And of course, many Christians reject them outright.

 

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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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Sleepy Sleepy Nurse

MY EMERGENCY DEPARTMENT COLLEAGUES are a youngish group as a whole, compared to me, that is, and most of them have school-aged children. A subset of this group of have traded shifts so they’re substantially working a straight night shift line,* in order to attend to family obligations. Almost all of these, I think, are coming in exhausted. I’m not talking I-missed-an-hour-because-little-Tiffany-woke-me-up, but exhausted. Bagged. Corpses-are-livelier tired. Black circles under the eyes. Uncommunicative to the point of being catatonic. Most work a 12-hour night, go home, get the kids off to school, catch a couple of hours between tending to the ones still at home, cook lunch and dinner, clean house, what-have-you, and still come in for another night.

These nurses scare me a little. We all know about the health effects of working shift, and consistently getting fragmented sleep while on a two or three day run of nights probably isn’t the best for personal wellness. Studies of have linked shift work and poor sleeping patterns to higher levels of cancer and metabolic syndrome. But more importantly, what about the patients? On balance, nurses aren’t doing their patients any favours by coming in sleep-deprived.  One study suggests cognitive and psychomotor impairment correlates with sleep loss. Seventeen hours of wakefulness is the equivalent of having one or two drinks.  After 24 hours, the alcohol equivalent goes up to two or three drinks.To put it bluntly, who would think of going to work having a few drinks? But we do, clutching our Tim Horton’s coffee like a talisman. But then there’s also this: there’s good evidence sleep deprivation contributes to medication errors. For nurses who had poor/ interrupted sleep

the odds of reporting any accident or error were twice as high for rotators [i.e. day/night] as for day/evening nurses. Rotators had 2.5 times the odds of reporting near-miss accidents. After adjustment the effect of rotating on medication errors was reduced from 2.2 to 1.8.

Considering we work in a profession that depends on judgement, clarity of thought, decision-making, organization, information gathering and processing, and critical thinking in general, you might think we would be more concerned with the consequences of sleep deprivation. But we aren’t — we seemed to be trapped in a professional culture which tells us to suck it up, while demanding perfection at the same time — and neither, it seems, are our employers.

One last thought: I have to wonder, where are the spouses in all of this? I get that it is probably far easier for most nurses to arrange their schedules around their spouses as far as child care is concerned. But I think it also speaks volumes about the perceived value of nursing that the professional issues surrounding sleep deprivation — and nursing in general — are ranked rather lower than the spouses’ ability to juggle their schedules. We maybe haven’t come as far as we think.

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*In unionized Ontario hospitals, which is to say, the vast majority of hospitals in the province, nurses must be assigned 50% shift.

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Why Physicians Should Care about Amanda Trujillo

[This post appeared last week, in slightly modified form, at KevinMd.com. Nice to see it’s generating a huge response and vigorous debate there. TE.]

For the past month, the case of Amanda Trujillo has resonated deeply among nurses, triggering an avalanche of postings on Facebook, Twitter and in the nursing blogosphere. Trujillo is the Arizona nurse who was fired in April 2011 after providing education and making a hospice care consult request for an end-stage liver disease patient. This patient was slotted for pre-transplant evaluation and had poor understanding of the disease process and treatment options. Trujillo filled in the gaps for this patient. Trujillo then requested, at the patient’s own wish, a hospice team consult, documented her actions appropriately, and left a note (it was night shift) for the primary physician.

These actions — the education and the hospice team consult — drew the wrath of both the primary physician, who demanded her dismissal and her license, and also her nursing director, who told Trujillo she had “messed up all the doctors’ hard work and planning for the surgery.” The patient-requested hospice care consult was cancelled. Trujillo’s employer subsequently fired her, and reported her to the Arizona State Board of Nursing for exceeding nursing scope of practice, though in fact, nurses previously had ordered a hospice care consult without consequence. In short, many nurses believe Trujillo was fired for educating and advocating for her patient.

These are the bare bones of the story. (Further details can be found here and here.) The debate among nurses — sometimes heated — has common themes around the limits of nursing practice, the meaning of nursing advocacy, and how nurses in trouble are left high and dry by the professional organizations that purport to represent them. Well and good. But why should physicians care?

Before I answer that question, let me tell you about my own practice as a nurse in a busy Toronto Emergency department. I work shoulder-to-shoulder with some of the best physicians I have ever known. Our goal is give excellent care and treatment to every patient we see. In order to do this job well and effectively, I need some tools — like the freedom to educate and advocate for my patients — and recognition that my judgement and accountabilities as a nurse are quite separate, if related, to those of physicians.

More importantly, I need the confidence to know I can engage in collaborative practice — and this in not just a one-way street, by the way — with my physician Emergency department colleagues. This is not a theoretical proposition, incidentally. If I tell an ED physician, for example, that a patient’s needs are largely social, and I have arranged for social work, and if she discounts or minimizes my concerns, and cancels the referral, then the patient suffers in the end. If I tell her that in my nursing judgement, the patient is crashing, and she ignores me, the patient dies. Being an effective patient advocate and practising collaboratively with physicians (and patients too, I might add) is good patient care. Yet doing my job well is precisely the same sort of advocacy which got Amanda Trujillo fired and reported to the Arizona State Board of Nursing.

Physicians should be concerned about Amanda Trujillo for this reason: ultimately her case is about providing good patient care.  There are, of course, obvious serious issues about patient autonomy and the ability of hospitals and physicians to override patient decisions about their own care. Many physicians might sympathize with Trujillo’s arbitrary firing, or see in her case a reflection of their own professional concerns about the role of large health corporations in their day-to-day practice.

But for me, as a nurse, the issue boils down to whether the health care industry can tolerate highly educated, vocal, critically-thinking, engaged nurse-collaborators who, in the interest of their patients, will constructively work with — and challenge, if necessary — physicians and established treatment plans. Or does the industry just want robots with limited analytical skills who blindly and unthinkingly collect vital signs and carry out physician orders? More importantly, which model presents the best opportunity for excellent patient care?

For me and most nurses, the answer is obvious. What about physicians?

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Just Lie Back and Think of Florence — Or Not

Nurse K, possibly the doyenne of nurse bloggers, gives her two cents on Amanda Trujillo. Her advice is to surrender:

Yes, I’m going to say it: Forget advocating.  Be humble.  Be honest and consistent.  Go through the process.  Listen to your attorney.  Your most important asset as a terminated person is an unrestricted nursing license and lack of bitterness.  Get advice from your attorney and mentors about what to say in job interviews about your termination.  Rehearse your answers to the question of “why were you terminated from Banner Health.”  Don’t decide that you’re never working for a hospital again and you don’t care what anyone thinks. You’re a single mom on welfare with a termination on your record; you don’t have the luxury of being picky. 

This termination was not about who can order a case management consult.  This was the typical crap that I saw every day.  Someone important (in this case, the surgeon who was to perform the transplant) [it was a gastroenterologist, not the transplant surgeon,  incidentally — ed.] looks bad or is pissed at someone for something and demands a termination and the thing spirals out of control.

This type of stuff is a hospital culture problem and certainly needs to stop, but a terminated employee is not going to stop anything like that, so don’t expose yourself to the world as a fired person with a chip on their shoulder. 

Well, fair enough. You pick your battles. What she’s suggesting is that for Amanda Trujillo, maybe this wasn’t the hill to die on. This is true in some, maybe even most, cases. It is excellent advice, in fact. I have a friend whose employer reported her to the College of Nurses of Ontario  — the semi-equivalent of state boards of nursing — for a serious med error that contributed to the death of a patient. She went through the process, humble and contrite, and received a formal written caution and oral reprimand.  Her employer supported her through her rehabilitation, worked out a mentorship and learning plan with her; she took a refresher course on medication. She is still practicing. This is how the system is supposed to work, right?

To paraphrase Queen Victoria, just lie back and think of Florence. I don’t think I am caricaturing Nurse K’s position here, not much anyway. Most times, silence is golden and discretion is the better part of valour, and all those other platitudes your mother taught you.

But then, this isn’t a conventional case. Let’s review for minute: Trujillo offers a patient information regarding an organ transplant and arranges, as per usual practice and at the patient’s request, a hospice care consult; this angers a physician; she is arbitrarily fired for exceeding her scope of practice in ordering this consult, which was inside her scope the day before; no one was harmed or put at risk, except, perhaps, the physician’s ego; Banner Health, Trujillo’s employer, reports her to the Arizona State Board of Nursing for practicing outside scope of practice  which — I can’t say this enough — was practicing inside scope of practice the day before; the case languishes for months and months in some sort of bizarre Board of Nursing limbo; then the moment Trujillo’s case caught the attention of some ratty-end nurse bloggers, the Board of Nursing orders a psych consult, evidently because publicly defending yourself makes you crazy; the Board of Nursing subsequently (and in a highly dubious fashion) informs Trujillo’s university she’s under investigation, then denies it despite clear proof to the contrary; and now the latest buffoonery, a new accusation from the Board of Nursing that Trujillo has “misrepresented” herself as to her academic credentials.

If this is a typical case, we are all in trouble.

And there’s this observation: isn’t shutting up and going away what employers and managers and nursing boards expect front line nurses to do? Don’t make trouble, nurses. It’s unbecoming. It will just make things worse — yes, for you. Don’t advocate for yourself — because — we will call you crazy. You will be screwed over — and you will like it!

The thing is, even before all the fuss, it’s hard to imagine how this could have gotten worse for Amanda Trujillo. If the fix is in, if you’re being railroaded by your employer, and the state Board of Nursing (as Nurse K says) is shady and duplicitous, being demure and helpful and willing to take your lumps is not going to help you. And why in the name of everything that is sacred and good should you help someone who is seeking to harm you? And as for meekness and docility now? Seems rather besides the point now.

In any case, nurse as silent martyr is not a great image. Nurse as battered wife is worse. Advocacy for yourself, and for your profession is sometimes not one of many bad choices, it is the only choice. Because of circumstances yes, but also because it is right. And as Nurse Ratched points out, often it only takes one pebble to start an avalanche.

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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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