Patient Abuse...

There was an incidence at my clinical the other day that just made me want to quit and get out of this clinical rotation stat! Here's a little synopsis of what happened:

My preceptor and I had a patient, I will call Jane, that the nurses had labeled “a pain.” She is 19 years old and a first time mother. She was married to an older man, which was also pointed out by many of the nurses, and this new family was in a lower socioeconomic status. I wouldn’t normally point out the socioeconomic status except for the fact that it seems to make a difference in the care received and the rights a patient may have.

My preceptor and I were walking down the hall to the postpartum area when this women, whom I perceived to be a nurse (from her demeanor and attire), came walking past us talking very loudly and was obviously upset. “I can’t believe this girl! I can’t believe she is going to refuse these blood tests; it’s ridiculous that she would do this to her baby! I swear if she doesn’t let us take her blood, I’m calling child protection services because this is crazy!” The patient that she was upset about was our patient for the day, Jane. Then we heard the story from the other nurses on the floor. Jane did not have much prenatal care and refused many of the standard blood draws done in pregnancy including blood typing, most likely because of her self-stated fear of needles and I think because of her being young and not understanding the implications of testing. As a result, her health care team did not know her Rh status. Blood typing will alert staff if a mother is Rh negative. If the baby is Rh positive then there are risks for future pregnancies and infants as the mothers’ body can produce antibodies against the baby.

My preceptor and I entered Jane’s room to discuss the testing with her. The nurse stood at the end of the bed to address the patient lying in bed and I sat down next to Jane. My preceptor proceeded to use scare tactics and to threaten the patient to submitting to the test. The nurse spoke in an authoritative and condescending tone as she explained the consequences to the patient. “I have to make sure you understand what you are doing. You are avoiding one poke so your baby can have at least six, do you understand? You have a choice, but you baby doesn’t—you can refuse this test, but we have a legal right to draw blood from your baby and there is nothing that you can do about that and it will take at least six pokes to complete all the tests your baby will need because we don’t have your blood type information. If you are Rh negative and your baby is Rh positive, than we to treat you or your future babies can die. If you are Rh negative and your baby is Rh positive than we can give you a shot to protect your future children. Do you understand that if do not allow us to take your blood than you will not have anymore babies!? Do you understand that?! They will die; you will not have any more children!” (I was not able to write down this exchange immediately, but this is very close to the exact exchange). I was pretty amazed as I sat there listening to this transgression as I knew that the nurse was lying about some of the information and I found the treatment of this patient to be unethical. Patients have the right to refuse. I believe that if this patient was older, more affluent, educated, or understood her rights as a patient this may not be the case. I also have a feeling that this kind of treatment is not necessarily a one time incident.

Jane didn’t say anything; she just lay in the bed with a defiant look on her face. My preceptor than left the room and I sat and tried to talk with Jane on more of a friend-to-friend level. She was very afraid of needles, so afraid in fact, that she had a natural childbirth the night before. As far as I can tell, that was the only reason she didn’t have an epidural—not because she was striving for natural childbirth, but because she was that afraid of needles. I also got the impression that Jane did not deal well with authority figures and was very, very immature for her age. I tried to understand Jane and treat her like an adult and be her friend and ally. After talking with her about the test and how we could use the smallest needle, she could squeeze my hand, and it would be over before she knew it, she was beginning to change her mind (I had realized at this point the informed refusal would not be a viable option unfortunatly). Then, in walked the irate women from the halls earlier. She introduced herself as a Pediatrician and began pretty much the same drill as my preceptor. I made a mental note to find out if this woman really was a doctor, I just couldn’t believe it. She also proceeded to try to coerce the patient with out offering the facts of the test or risks versus benefits. After her talk I followed her out of the room as she again vented about what a pain this patient was and how she couldn’t believe her and what a “psycho” she was.

In the end, with about 20 minutes to spare, Jane did decide to go through with the blood draw. I stayed in the room with the phlebotomist as she did the draw and reassured Jane that she was doing great and the worst part was over. It turns out that woman is a Pediatrician; I just could not believe how unprofessional a doctor could be. The fact is that patient had a right to refuse that test, but she also had the right to fair and unbiased information. I feel that the correct way to address this situation would have been to present the facts about Rh factor. The facts are that 15% of the population are Rh negative and that 17% of Rh negative women who are exposed to Rh positive blood ever make antibodies. In those instances, fetal autoimmune hemoloysis can develop. Results can range anywhere from mild anemia to life-threatening conditions such as hydrops fetalis. These facts are a lot different then stating “you will never have anymore children, they will die.”

The next morning in shift report Jane’s name came up again. One of the nurses asked if she would be going home today. A nurse responded that the Pediatrician would call and find out if the babies temp was stable today and if so, then the baby could go home with its mother, if not the baby would stay and the mother would go home. Another nurse asked “why? They don’t usually do that, how unstable is the temp?” The nurse responded that the Pediatrician had to spend a bunch of time convincing the mom to have a blood draw and this was probably pay-back.

It scare the hell out of me to know that health care professionals will hold personal grudges against patients and give them different treatment as a result. Unfortunately I am sure that this kind of treatment is not that uncommon. I feel that it is very important for me as a nurse to set an example by being fair and professional in my practice. There will be times when I will not necessarily agree with decisions my patients may make regarding their care, but it is not my responsibility to force people to make decisions I think they should make. My job is to provide the facts as we know them in a fair and unbiased way so that my patients can make informed choices on their own care.