More on Independent Judgement

Independent judgement may count for squat if the doc doesn’t listen to you. One of my spies in the Ontario health care system tells me the story of  a 60ish year-old woman, a known drinker, who came into an Emergency Department with an altered level of consciousness. Ethanol level comes back elevated, so end of story, right?

Unfortunately no. The primary nurse advocates for this patient. She’s seen cerebral bleeds, and she’s seen drunks, and she’s seen bleeds and drunks in the same person, and moreover, she has watched this patient subtly deteriorate for the last three hours. She tells the Emergency Physician, “Hey, this patient isn’t right. Her neuros are whacked. She needs a CT of the head.”

The EP is the sort of doc who, if a nurse said “Feces”, would say “Fudge, and please pass the plate.” He refuses to order the CT, and instructs the primary RN to discharge the patient.

The nurse absolutely refuses. The patient needs a CT, the nurse says.

The EP gets all huffy. Fine, he says. I’ll pull the IV and discharge the patient myself. Take that, you dumb know-nothing nurse!

Of course, you know the sequel. Patient returns a short time later, twenty times worse, coags are screwed, finally gets the CT, which (naturally) shows a cerebral bleed; she’s shipped to a Big Toronto Hospital, and blah, blah, blah — hemorrhagic stroke.

Independent judgement — where a nurse can effectively advocate for their patients — will only work in environments where there is a culture that treats the professional opinion and judgement of nurses (and other health care professionals) as valuable and meaningful in effecting good patient outcomes. Unfortunately, in many health care settings (the majority?), such as perhaps this Emergency Department, this isn’t the case. The quality of patient care accordingly directly suffers as a result.

I’m also reminded of an article I saw the other day about moral distress — the anxiety and suffering caused by being unable to act upon one’s own ethical values — and the risks it poses to nurses personally and professionally: dissociation, apathy, leaving nursing altogether. I suppose moral distress would include being discounted and minimized, advocacy being at the heart of ethical nursing practice. I wonder if there have been any studies linking patient outcomes specifically with moral distress in nurses, and if not, whether this would be a fruitful topic for investigation.


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  1. #1 by Cartoon Character on Sunday 12 September 2010 - 2152

    I remember attending a highrisk delivery and asking the snarky OB if we shouldn’t be calling the Peds….he adamantly refused. I asked again and once again he refused. So I said to him: “Ok..just so you know….I am charting that I asked twice and you refused twice…..” – he promptly changed his mind. It was lucky that he did because it was a baby that required a fair amount of resuscitation, never mind a PPH at the same time. My question is: why did I have to resort to a threat?

  2. #2 by Canuck on Monday 13 September 2010 - 0112

    And did the case go for review to the CPSO and the CNO? At one hospital in Ontario, a case similar to this (but involving a paediatric patient) was reported. It’s a bit more complicated, but here is the end result:

    The physician was cleared of any wrong-doing (the patient ultimately died), the hospital settled, and the nurse (who tried to advocate on behalf of her patient but was ignored) was reprimanded by the CNO for “failing to advocate for the patient”.

    They told her she should have refused to d/c the patient (which she did, but the attending physician sent him/her), keep the patient in the ER (should she have restrained the patient to the bed?) and called the Chief of Staff at home to discuss her “concerns”.

    We can advocate, be ignored, and STILL be blamed for the outcome.


    • #3 by torontoemerg on Monday 13 September 2010 - 1150

      I’m a little disturbed by the CNO’s response, but sadly, I can’t say I am terribly surprised. The CNO, I think, has a very unrealistic notion of how power and hierarchy works in most health care settings. I am curious, though, on what grounds and who reported this nurse to the CNO? The parents? The employer? The physician?

      • #4 by Canuck on Wednesday 15 September 2010 - 1718

        The family sued the hospital, MD and multiple nursing staff for wrongful death. Their child died and they were devastated. The CNO was notified, of course, after the family filed a formal complaint (they also filed one with the CPSO against the physician). The CPSO cleared the physician after two different investigations, but the CNO found reason to place an oral reprimand in the RN’s file.

        It’s upsetting -how far must we go as nurses to provide care, within the confines of our RN license? In this case, I feel like the RN was faulted for NOT acting as though she was an MD. Which she wasn’t. At some point, the CNO needs to realize we can advocate till we’re “blue in the face” but the disposition of the patient is ultimately (as it should be) at the discretion of the physician.

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