Are Hospitals Obligated to Help Patients Smoke?

[docB]

Yesterday had a patient present to the ED (where all American medical care is delivered) with a chief complaint of "Bacteria in my blood." Turns out she had just eloped/left AMA from a nearby hospital where she was getting in patient treatment for bacteremia. She said she had finally "had it" with not being able to smoke and told her nurse she was going outside to smoke. The nurse told her that hospital policy forbade her from leaving with an IV in place. The patient said she didn't care and was going so the nurse removed her IV (which was actually a PICC line) and told her that if she left she was going AMA and could not come back without going through the ER again. So, of course, the patient bailed and came to our ED to start over.

In my town the nurses are phobic about getting in trouble because someone uses a vascular access device to shoot their poison of choice. So this is not the first time I've seen a situation like this. Usually it just involves pulling the IV on an ED patient but I've seen other patients like this. We also get patients trying to sneek smokes in the bathrooms on a semi daily basis (have you every noticed how smokers don't think smoke smells at all?).

So, are hospitals and EDs obligated to provide their patients a way to smoke?

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[deleted87716]

What happened to nicotine patches?

 

[snoopy brown]

So, are hospitals and EDs obligated to provide their patients a way to smoke?

Re: Your actual question:Hospitals don't provide their patients a way to smoke, unless you want to view it strictly as a technicality. Hospitals are not allowed to hold people against their will for treatment (discounting of course people who are incompetent or who will harm others blah blah blah). Therefore anyone can sign out AMA for any reason at any time including to smoke. But that hardly means that hospitals are complicit in that activity.The main problem that physicians have (the ones that buy into socialized medicine, that is) is that they get torn between their belief that everyone deserves health care and their outrage that people are abusing their "generosity" in offering it. Unfortunately you have to accept that most of the people who cannot afford health care are the ones who are too stupid to understand health care, which is also why they are the ones who are stupid enough that they have about fifty medical conditions. That's why I vehemently oppose socialized medicine.But Re: a side question: Why would you care? It's about five minutes of extra work for you. You're not the admitting team and you don't take care of inpatients. The inpatient team will do the bulk of the work of readmission and care, which is why they will be pissed off.

 

[docB]

Re: Your actual question:Hospitals don't provide their patients a way to smoke, unless you want to view it strictly as a technicality. Hospitals are not allowed to hold people against their will for treatment (discounting of course people who are incompetent or who will harm others blah blah blah). Therefore anyone can sign out AMA for any reason at any time including to smoke. But that hardly means that hospitals are complicit in that activity.The main problem that physicians have (the ones that buy into socialized medicine, that is) is that they get torn between their belief that everyone deserves health care and their outrage that people are abusing their "generosity" in offering it. Unfortunately you have to accept that most of the people who cannot afford health care are the ones who are too stupid to understand health care, which is also why they are the ones who are stupid enough that they have about fifty medical conditions. That's why I vehemently oppose socialized medicine.But Re: a side question: Why would you care? It's about five minutes of extra work for you. You're not the admitting team and you don't take care of inpatients. The inpatient team will do the bulk of the work of readmission and care, which is why they will be pissed off.

I'm not sure you understand my question. I am asking if hospitals are or should be obligated to provide inpatients with an opportunity to smoke given that some patients will leave AMA rather than go without cigarettes. In the attempt to give care are we being stupid by trying to deny people something they are addicted to? I'm not sure how that becomes a socialized medicine issue. Your point about an admitting team might be relavent to academic centers but in many private practice settings once a patient leaves AMA they don't just get "readmitted" and there certainly is no team that does it. In my hospitals the fact that they left AMA means they don't bounce back to their previous doc. If, as in the above mentioned case, the patient goes to a different hospital the work up has to start over from scratch.

As for nicotine patches some patients just can't do without the real thing.

 

[snoopy brown]

I'm not sure you understand my question. I am asking if hospitals are or should be obligated to provide inpatients with an opportunity to smoke given that some patients will leave AMA rather than go without cigarettes. In the attempt to give care are we being stupid by trying to deny people something they are addicted to?

You're right I did misunderstand you. I thought you meant that by letting these people leave hospitals were helping them smoke. My mistake. But now that you've clarified I still disagree. It would be a folly for hospitals to aid someone in unhealthy behavior. What's next, letting them shoot up in the hospital? The hospital is merely an extension of a single physician in that regard. You give advice, the patient can take it or leave it. You lay out the risks of leaving versus the benefit (of being able to smoke/do drugs) and the patient is an adult and makes up their own mind. I'm not sure what the dilemma is here.

Your point about an admitting team might be relavent to academic centers but in many private practice settings once a patient leaves AMA they don't just get "readmitted" and there certainly is no team that does it. In my hospitals the fact that they left AMA means they don't bounce back to their previous doc. If, as in the above mentioned case, the patient goes to a different hospital the work up has to start over from scratch.

My point is that regardless of who the patient goes to, it's not to you. And you're not doing the H&P or writing the orders. In other words, you have a right to complain about it because you are doing more work. But it's so little that it's hardly relevant. The patient is coming with the diagnosis and it doesn't matter where you practice, I don't know of any ER physician who is calling the other hospital to talk with the primary team or obtaining medical records. Some places the ER has to write orders, but even that is relatively rare. So while I can understand the primary team going ballistic I'm not sure why you are, other than vicariously.

 

[docB]

My point is that regardless of who the patient goes to, it's not to you. And you're not doing the H&P or writing the orders. In other words, you have a right to complain about it because you are doing more work. But it's so little that it's hardly relevant. The patient is coming with the diagnosis and it doesn't matter where you practice, I don't know of any ER physician who is calling the other hospital to talk with the primary team or obtaining medical records. Some places the ER has to write orders, but even that is relatively rare. So while I can understand the primary team going ballistic I'm not sure why you are, other than vicariously.

HARRUMPH! Every patient I see in the ED results in work for me. In this case the patient showed up a loose history "Some kind of bacteria in my blood." and I had to do a whole work up in the ED try (unsuccessfully) to get records from the other hospital and get them admitted. Your post kind of sounds like you're implying that since someone other than the EP admits the patient there's no work done on the part of the EP for a patient who gets admitted. That's wrong. For the sake of the current discussion though let's focus on if hospital smoking policies should be altered to accomodate smokers rather than who does the work and has the right to be annoyed.

 

[devlyyn]

Our campus just recently went 100% tobacco free and we have definitely seen some issues with this. For example, we've had 911 calls and numerous security incidents regarding a patient who continues to go outside to smoke and choses to do so in or near the street in front of the hospital. Of course this is stupid and dangerous, but unbelievably she has an MD order to smoke so the nurses/staff cant do anything about it! And yes, she has been on the nicotine patch the entire time but it doesnt make any difference.

 

[snoopy brown]

Of course this is stupid and dangerous, but unbelievably she has an MD order to smoke so the nurses/staff cant do anything about it!

It's actually not unbelievable. It's what docB is talking about in this thread. One group of physicians feels that we should be doing anything we need in order to provide patients with care. In other words if we know they're going to leave because they want to smoke, let's let them smoke. That way we can at least treat them for the other thing they're here for.

The other group of physicians feels that it is only our responsibility to offer treatment and the patient also has a responsibility to take part in the treatment. In other words if they make a lot of demands using "or else I'm leaving" as a leverage then you let them leave. A lot of people are not willing to be manipulated in that fashion, nor to be the patient's parent.

It is wholly a matter of style and therefore there is no right answer. If you don't mind getting trampled on or if your sense of well-being is harmed by a patient being upset, by all means allow them to smoke.

 

[tibor75]

IF you allow a patient to go outside to smoke and that patient gets an MI and dies outside, you're liable. No idiot smoker has a "right" to leave their hospital bed to smoke.

 

[fab4fan]

I'm not sure you understand my question. I am asking if hospitals are or should be obligated to provide inpatients with an opportunity to smoke given that some patients will leave AMA rather than go without cigarettes. In the attempt to give care are we being stupid by trying to deny people something they are addicted to? I'm not sure how that becomes a socialized medicine issue. Your point about an admitting team might be relavent to academic centers but in many private practice settings once a patient leaves AMA they don't just get "readmitted" and there certainly is no team that does it. In my hospitals the fact that they left AMA means they don't bounce back to their previous doc. If, as in the above mentioned case, the patient goes to a different hospital the work up has to start over from scratch.

As for nicotine patches some patients just can't do without the real thing.

Who's supposed to accompany the pt. so he/she can go smoke? I sure don't have the time. If the pt is ambulatory and well enough to go outside to smoke, that's one thing, but what about those who would need assistance?

I don't think I'd have pulled a PICC line. That was a bit extreme. People go home with VADs all the time. If they misuse them and have an unfortunate consequence, oh well...

Hospitals are here to provide health care. I don't think we're obligated to cater to every whim. What about the pt. who has a couple shots of Jack Daniels every night before bed? Should we provide that as well?

 

[fab4fan]

It's actually not unbelievable. It's what docB is talking about in this thread. One group of physicians feels that we should be doing anything we need in order to provide patients with care. In other words if we know they're going to leave because they want to smoke, let's let them smoke. That way we can at least treat them for the other thing they're here for.

The other group of physicians feels that it is only our responsibility to offer treatment and the patient also has a responsibility to take part in the treatment. In other words if they make a lot of demands using "or else I'm leaving" as a leverage then you let them leave. A lot of people are not willing to be manipulated in that fashion, nor to be the patient's parent.

It is wholly a matter of style and therefore there is no right answer. If you don't mind getting trampled on or if your sense of well-being is harmed by a patient being upset, by all means allow them to smoke.

A pt who threatens to leave over smoking does not disturb me in the least. Do these people honestly think that's going to make us rush around to be able to take them outside for a cigarette? Nope. "Buh-bye."

It's a moot issue at my facility anyway, as we are now 100% smoke-free: No smoking anywhere, and that includes patients, visitors and staff.

 

[docB]

I agree with Fab4 but we do cater to everyone's bad choices already. Bariatric ambulances, methadone, condoms for teenagers, "They're gonna do it anyway!" We already cater to so much BS. If patients are leaving because they can't smoke are we obliged to make allowances. The point about giving the alcoholic booze every night is interesting. We're not obligated to give them booze but we are obligated to treat their DTs. Might someone argue that we should give them booze to forestall the DTs?

I am interested in how a facility prohibits its employees from smoking. Do they just take longer smoke breaks to hoof it al the way off campus? Are they allowed back in even though they reek of smoke? Many of my nurses smoke and patients frequently complain about the smell but the ones who do tend to be whiners clinging to the "multi chemical sensitivity" deal so no one pays much attention.

 

[angel80]

Our hospital just went 100% smoke free in July. NO ONE (pt, visitors, staff) is allowed to smoke anywhere on the campus. I have no idea where the employees go to smoke. My guess is that they smoke on the edge of campus.

 

[Artful Dodger]

I've seen it all.

Hospitals can only change your lifestyle habits if you're at an unconscious or vegetative state.

anyhow, I've seen a patient smoke outside with an IV bag leashed in his path. he looked hungry for it too!! lol @ desperate smokers.

 

[dpmd]

There are hospitals out there that won't let a patient outside with an IV in (to smoke, or just to get out of the room for a little bit)? The only people we don't let outside are those on strict bedrest for whatever reason. If they are ambulatory and not on a hold (psych or law enforcement), they are free to go wherever they want. The crazy ones get their smoke breaks under supervision, and the ones who need help can go out with an aide if there is one available. Do we try to convince them not to smoke? Yes. Is it worth it to kick people out if they aren't able to comply? Not really. We will take care of them after they smoke, just like we will take care of them if they head outside and score. Also, there has been more than one patient in the hospital that gets beer with their meals. Why treat them for withdrawal only to have them start drinking the moment they leave the hospital, when you can avoid the problem with a little PBR or milwaukee's best. You can counsel and advise all you want, but unless people are ready to change it won't do a bit of good. In the mean time, why make your life more difficult (or the lives of your colleagues).

 

[Miami_med]

The short answer to this question is no, with he possible exception of those being held against their will.

 

[Hurricane]

Hospitals are here to provide health care. I don't think we're obligated to cater to every whim. What about the pt. who has a couple shots of Jack Daniels every night before bed? Should we provide that as well?

No, but we ought to have them on CIWA or at least with some prn Ativan available so they don't withdraw.

A lot of psych patients smoke, and different inpatient units (which are usually locked) deal with this in different ways: supervised smoke breaks, smoking rooms at otherwise smoke free hospitals, nicotine replacement, etc. Personally, I think that while smoking obviously has many adverse health effects, inpatient admission is not the appropriate time to address this issue.

Take schizophrenia, for example. Something like 80% of schizophrenics smoke, and numerous studies have shown that nicotine improves memory, concentration, and negative sx of schizophrenia, symptoms our current arsenal of antipsychotic meds don't treat very well. Which is probably why so many of them smoke, as a form of self-medication, and not something you can effectively address in a few days. Smoking also decreases the serum level of antipsychotic medications by as much as 50%. So you've got a severely ill schizophrenic who is sure to resume smoking as soon as you discharge them, and you ban them from smoking during their admission while you get them stable on antipsychotic meds. All you've done is 1) added nicotine withdrawl to their list of acute problems, 2) added a source of conflict that may interfere with rapport or any behavioral therapy you might want to try and 3) gotten them stable on a medication dose that will be effectively lowered once they go home and start smoking again, making it more likely they'll relapse and end up back in the hospital.

So, I let my patients smoke, unless they have a history of setting themselves on fire or something...

 

[docB]

So I've had another spate of patients who have left AMA because they were not allowed to go outside and "get some fresh air" ie. smoke and it reminded me of this thread. Several of these were from the chest pain observation unit. I've also had a number of people who have bailed when we wouldn't feed them while they waited for their CT Abdomens for their 10/10 belly pain.

My issue with all this is that there is certainly liability is letting patients wander around the parking lot with IVs and often drips to smoke. It's bad practice to let possible surgical candidates eat. But it's also bad when people leave AMA and don't get whatever care we think they need.

Where is the middle ground?

 

[Rendar5]

I think it's an interesting problem.

Why do we care so much that we give people a hard time and don't allow rapid readmittance for something like a smoke break? Is this a control thing or something? sure we don't need to be taken advantage of, but is it really worth the extra work we create for ourselves and the patient by making them wait 12 hours, adding extra patients to an already crowded ED which uses up time of the Emergency PHysician from other patients? Making the nursing staff and the admitting staff fill out tons of paperwork again? Losing half a day's worth of treatment? Spending an hour trying to convince the patient not to go and explaining how he can die if he goes AMA?

Why not just have a policy set in paper that you can give to every patient?

"You're allowed one free readmittance a week for a smoke break, your IV will be taken out, you will have needles put back in, you are doing this against medical advice, you realize interrupting your treatment and/or smoking my be detrimental to your health and may actually kill you (we are not kidding). But you are an adult and are free to risk your own life if that suits you.
"If you do this a second time in a week, you will not be allowed back in, you may go back to the emergency department for potential a 6-24 hour wait before you have another bed. You will have many blood labs drawn again unnecessarily, you will start everything over again from scratch. We cannot offer you better service than this because our service is geared towards your health, not your need to smoke. You may die if you treatment is delayed because of your actions. Have a nice day. Here is the customer service number to complain about our policies 555-5555"

 

[fab4fan]

Yesterday had a patient present to the ED (where all American medical care is delivered) with a chief complaint of "Bacteria in my blood." Turns out she had just eloped/left AMA from a nearby hospital where she was getting in patient treatment for bacteremia. She said she had finally "had it" with not being able to smoke and told her nurse she was going outside to smoke. The nurse told her that hospital policy forbade her from leaving with an IV in place. The patient said she didn't care and was going so the nurse removed her IV (which was actually a PICC line) and told her that if she left she was going AMA and could not come back without going through the ER again. So, of course, the patient bailed and came to our ED to start over.

In my town the nurses are phobic about getting in trouble because someone uses a vascular access device to shoot their poison of choice. So this is not the first time I've seen a situation like this. Usually it just involves pulling the IV on an ED patient but I've seen other patients like this. We also get patients trying to sneek smokes in the bathrooms on a semi daily basis (have you every noticed how smokers don't think smoke smells at all?).

So, are hospitals and EDs obligated to provide their patients a way to smoke?

I have neither the time nor the patience to help someone go out and have a smoke. If they can get outside and smoke on their own, great. And if they crack their head on the sidewalk while they're standing outside smoking, that's their own dumb fault. I'm a nurse, not a babysitter.

It's time to stop this mollycoddling of patients. The "customer service" aspect has gotten out of control. I'm glad hospitals have at least become sensible enough to establish "smoke-free zones."

I sure wouldn't have been crazy enough to pull a PICC line, though. That's a bit extreme. I hope she had an order to do that.

 

[fab4fan]

So I've had another spate of patients who have left AMA because they were not allowed to go outside and "get some fresh air" ie. smoke and it reminded me of this thread. Several of these were from the chest pain observation unit. I've also had a number of people who have bailed when we wouldn't feed them while they waited for their CT Abdomens for their 10/10 belly pain.

My issue with all this is that there is certainly liability is letting patients wander around the parking lot with IVs and often drips to smoke. It's bad practice to let possible surgical candidates eat. But it's also bad when people leave AMA and don't get whatever care we think they need.

Where is the middle ground?

This is the stuff I'm talking about. "I have abd. pain," then they give you grief when you ask them to drink the contrast or need them to be NPO.

You know what? Fine. Do what you want, but you're not going to get your test. You can't have it both ways. It's like the people who would show up for surgery after eating a full breakfast and say, "Well, you have drugs that can take care of that, don't you?" Geez Louise, what part of NPO did you not get?

Sorry for the first response; I didn't realize I replied to an older post.

 

[Droopy Snoopy]

Our hospital just went 100% smoke free in July. NO ONE (pt, visitors, staff) is allowed to smoke anywhere on the campus. I have no idea where the employees go to smoke. My guess is that they smoke on the edge of campus.

That's how it worked at my medical school, for awhile anyway. At any given time the smokers, complete with gowns and IVs, could be seen lining the sidewalks around the campus. That along with all the cigarette butts and dead grass gave a rather less favorable impression of the hospital than I'm sure was desired, so they re-installed designated smoking areas after about a year.

 

[RGMSU]

So, are hospitals and EDs obligated to provide their patients a way to smoke?

No, if they're looking for a full-service Hilton hotel, they stopped at the wrong place. Medical consumerism is the trend we need to stop before it starts. Period.

 

[docB]

No, if they're looking for a full-service Hilton hotel, they stopped at the wrong place. Medical consumerism is the trend we need to stop before it starts. Period.

I think that boat has sailed. It was bad enough when we just had Gallup and Press-Ganey and the like but now with HCAHPS even CMS is getting into the "patient satisfaction" act.

 

[RGMSU]

I think that boat has sailed. It was bad enough when we just had Gallup and Press-Ganey and the like but now with HCAHPS even CMS is getting into the "patient satisfaction" act.

Patient satisfaction is one thing. I believe this example goes a bit beyond that. I would be happy if physicians started exerting their influence again, instead of always resigning themselves to the status quo. Our salaries are going down - oh, well, there's nothing we can do about it. Respect for our profession has fallen - oh, well, there's nothing we can do about it. For a bunch of incredibly bright people, we sure don't know how to stand up for ourselves and get what we want. My point is that when we see trends such as medical consumerism burgeoning, we should exert our influence to stop it rather than resigning ourselves to the fact that it's occurring. Physicians resigning themselves to a status quo imposed by outsiders is a big part of the mess they find themselves in today.

 

[docB]

Patient satisfaction is one thing. I believe this example goes a bit beyond that. I would be happy if physicians started exerting their influence again, instead of always resigning themselves to the status quo. Our salaries are going down - oh, well, there's nothing we can do about it. Respect for our profession has fallen - oh, well, there's nothing we can do about it. For a bunch of incredibly bright people, we sure don't know how to stand up for ourselves and get what we want. My point is that when we see trends such as medical consumerism burgeoning, we should exert our influence to stop it rather than resigning ourselves to the fact that it's occurring. Physicians resigning themselves to a status quo imposed by outsiders is a big part of the mess they find themselves in today.

It's worse than physicians just resigning ourselves to it. Many are actively joining in. I cite as examples the multitude of docs opening various forms of cash practices from Botox/Dermabrasion to medical weightloss to concierge medicine. I'm not even against these types of enterprises in theory but they are examples of the effects of the medical consumerism you're talking about.

 

[RGMSU]

It's worse than physicians just resigning ourselves to it. Many are actively joining in. I cite as examples the multitude of docs opening various forms of cash practices from Botox/Dermabrasion to medical weightloss to concierge medicine. I'm not even against these types of enterprises in theory but they are examples of the effects of the medical consumerism you're talking about.

Yes, there are many physicians who have fostered the greedy, wealthy doctor stereotype that is about to result in us all getting a pay cut.

 

[docB]

Yes, there are many physicians who have fostered the greedy, wealthy doctor stereotype that is about to result in us all getting a pay cut.

I don't know that I'd indict those docs for what they're doing. I think they are a symptom of the problem. They are proof that the current system is onerous enough that many docs are venturing out into risky territory rather than continue to put up with the bs.

 

[RGMSU]

I don't know that I'd indict those docs for what they're doing. I think they are a symptom of the problem. They are proof that the current system is onerous enough that many docs are venturing out into risky territory rather than continue to put up with the bs.

Hah, I actually don't necessarily indict them. If physician salaries decrease too much, I might want to practice boutique medicine as well, so I can pay my loans off at some point.