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Department: ETHICAL PROBLEMS

ETHICAL PROBLEMS

Salladay, Susan A. PhD, RN

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doi: 10.1097/01.NURSE.0000419433.37804.c7
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PATIENT ADVOCACY

Transfusion confusion

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I was present when a healthcare provider asked my patient for consent for a blood transfusion. I knew that this patient, who'd never completed grade school, wouldn't understand the medical jargon she was using and couldn't read the transfusion brochure. The patient agreed to the transfusion and signed the consent form, but I doubted his consent was really “informed.”

Instead of speaking up at the time, though, I waited until the provider left the room, then voiced my concerns to her. Because I waited, I think she was more receptive to my views, and I expect she'll avoid this problem with future patients.

I can't help but think that I would have helped my patient more if I'd spoken up while the provider was talking with him, but I'm reluctant to risk angering a healthcare provider I work with every day. What's the right approach?—N.Y., MASS.

Nursing involves making judgment calls in such situations. What's “right” often depends on good communication and diplomacy. I recommend advocating for patients immediately, if you can do so effectively. For example, in the situation you describe, you might have held out the open brochure to the patient and said, “Dr. Jones, I like this brochure because the pictures show a patient getting a blood transfusion safely, right in his own room in bed. Maybe I can get some I.V. supplies to help explain more about transfusions.” This simple intervention offers the chance for more discussion and clarification without upsetting anyone.

Patient advocacy usually involves some degree of risk. Deciding how much risk you can manage is part of nursing. When you speak up to advocate for a patient, you may risk being misunderstood or angering another healthcare provider, but that's a risk you sometimes need to take.

ADVANCE DIRECTIVES

No guarantees

A neighbor found my home healthcare patient, DL, a 78-year-old woman with end-stage chronic obstructive pulmonary disease, unresponsive in her back yard and called 911. After a lengthy hospitalization, she was discharged back home.

DL is upset because her carefully prepared advance directives were seemingly disregarded, as she found herself in the hospital intubated and on a mechanical ventilator against her express wishes. How can I advocate for her and other patients in similar situations to ensure that her wishes are honored?—W.A., MINN.

Some patients assume that advance directives automatically guarantee no unwanted emergency resuscitation or treatment. But emergencies such as a car crash or a foreign body airway obstruction can result in unexpected acute care.

Even with careful preparation, things may go awry. For example, a hospice patient was prepared for his impending death at home and his family fully understood his desire to avoid resuscitation and hospitalization. Yet when this patient unexpectedly began to hemorrhage from his mouth and nose, his family panicked and called 911. The patient died in the hospital on a ventilator—the very situation he'd dreaded and hoped to avoid.

Help your patient talk through handling unexpected events. Some patients choose to wear necklaces or bracelets that identify their medical condition, identify their healthcare provider and a surrogate with durable power of attorney for healthcare, and state refusal of life-prolonging measures. But explain to your patient that first responders may not be able to honor such requests in every circumstance; responders must follow their agency's established policy and procedure.

Encourage DL to make a list of friends and neighbors who may need to know “what to do if...” At the same time, help her understand that advance directives can't address all emergency situations.

© 2012 Lippincott Williams & Wilkins, Inc.