Ethics of foley catheterization?

[whopper]

I'm not trying to sound cute or funny.

If you got a guy with a history of drug abuse and he's got positive psychotic sx, and he's commitable, you're going to need a UDS to find out what drugs he's using.

So if the patient refuses a UDS can you catheterize him against his will?

Reason why I bring this up is in the crisis center I've worked at, some nurses have suggested this. I didn't know if this was allowable, but when the nurse tells this to the patient, they quickly change their minds and volunteer to do a UDS.

OK fine--but if we're not allowed to force a catheterization, aren't the nurses not allowed to state they'll force one?

Before you get mad at the nurses, no inpt unit in the area where I'm at in NJ will accept a comitted patient without UDS, and by state law you got to get them out of the crisis center in 24 hrs, you have to either get them to some inpt unit or discharge them. So its a case of damned if you do or damned if you don't.

Last night I was on call, and a similar experience happened, but this time the nurse (who was new) was ethically against suggesting a forced catheterization, so when I told her that this seems to be the norm at the crisis center, she got upset with me. I understood why she felt that way and it made me question whether or not we're doing the right thing. This type of thing had gone on for so long with attendings not challenging it, I thought it might've been ok. Now I'm not so sure.

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[raspberry swirl]

i have no legal advice to give, sorry, but i tend to agree that if you can't forcefully catheterize someone, then it doesn't seem quite right to threaten that you can ... its kind of like false pretenses or something. like coercing someone to testify to a crime by saying if they dont, you'll torture them. not to mention, you're playing on someone's ignorance- someone educated about medicine or law could call the bluff, but john doe off the street probably can't. the whole thing seems a little sketchy to me. but i definitely see why nurses were doing it- they have a job to do, and it gets the job done without hurting anyone. but in my opinion, it doesn't seem to be ethical.

 

[whopper]

I hate saying this but no matter the answer, I believe it'll still probably go on. I just want to know the "textbook" answer for myself.

There's a lot of things I've noticed that go on under the table that isn't right but happens because gaps in the laws & regs have made it so.

One doc I know told me of the limit of patients you can have on suboxone . When he successfully treated a patient on suboxone and stops the dosage, he'll allow one more to fill the open space and he says he always used to reach the max because there's a great demand for patients who need it.

So then one day he's on the max of patients and a patient that was taken off weeks earlier had relapsed unexpectedly.

The pt called him begging for suboxone and the doc, at his legal limit said he couldn't give any more out, but told the patient he would place him as 1st on the waiting list.

The next day the patient had overdosed & died. That doc told me he honestly felt the patient wouldn't have if he had given him the suboxone. The doc told me from that day on, if a similar situation happened he would give the suboxone and would be willing to face the music in court should he get in trouble to save the life of a patient. (He told me recently that the limit was increased to a point where this is now avoidable but you get the point).

I know its not the most parallel comparison, but the damned if you do, damned if you don't thing applies- the 24 hr time limit is real and is highly enforced in NJ, and it is to the patient's benefit to get them to an inpt unit. What else could they do?

(Before you suggest a serum drug test, they're refusing that too! The ER has to do a serum test-CBC/BMP before they give them to us, but often times the lab has thrown away what blood sample by the time they reach the psyche crisis center.)

 

[Anasazi23]

Yes, this comes up for me frequently too.
And like you, I have seen the same "threats" made to patients who aren't cooperative.

There have been times where I've admitted patients with Psychosis NOS simply because I couldn't tell if the symptoms were drug-induced or not, and they've refused a UDS.

Then again, I've seen ER attendings involuntarily cath someone under the guise of "I need to know what I'm treating." This seems to make sense when considering whether one should give romazicon/flumazenil or naloxone, for example.

I think, like in most circumstances, one has to consider what the plan of treatment would be for a patient, and if the cathetherization would provide useful information....which we often know it does.

I'd be lying if I said I've never threatened a patient that I'd have him involuntarily cathed if he didn't pee in a cup. 9 times out of 10 it works...and I wouldn't consider it unethical, since it avoids the potential harm or complication from a foley. One could make the same argument for IM meds...."Take this PRN of thorazine, or we'll have to give you a shot." One could further argue that it's empowering the patient to allow them a choice in this sense, and that it could be applied to the former.

 

[whopper]

I think, like in most circumstances, one has to consider what the plan of treatment would be for a patient, and if the cathetherization would provide useful information....which we often know it does.

That was something I considered however from my understanding, you can only ignore consent if the patient needs that treatment/procedure immediately because it is a dangerous situation for the patient or others and such tx/procedure will solve that acute danger. A UDS won't do that. Yes IM Haldol will do that, IM Geodon will do that, a UDS won't.

You can for example cath a pt without their consent if their bladder is about to burst, but you can't for a UDS because it won't solve the acute agitation.

I just asked an attending---a REAL attending (as opposed to the ones that just want the patient to get processed ASAP and are willing to say anything to the resident that gets the patient out of there, even if its wrong info). This guy knows his stuff and is very good in forensics.

He told me in his humble opinion, although it is a reality that commonly happens, the textbook answer is forced catheterization for a UDS cannot be allowed because it will not acutely solve the dangerous situation, and just as patients (at least in NJ) even if commitable can refuse meds, they can also refuse procedures so long as they are not acutely dangerous. If they are acutely dangerous, they can be forced such interventions but only if the intervention is intended to solve the immediate danger at hand.

In NJ you can only force a medication on a committed patient if that patient is acutely dangerous to themself or others or property. Since a UDS will not acutely solve the patient's agitation, you cannot force it.

He also acknowledged that although this is in his opinion the standard based on his interpretation of the laws and the current precedents, he fully knows many doctors & nurses violate this and keep it hush hush.

Anyways, I'm satisfied with the answer but heck, let's still discuss this. This is one of those issues residents should be aware of because it happens and it is supposedly (at least in his opinion) unethical. Also, I cited the laws in NJ, it could vary in other states.

I'm going to ask one more doc--Jeffery Dunn (the director at my program, ranked the #1 teaching doctor in the state, and he does deserve this title, trust me on that). He knows his stuff too and he'll give me some good insight. Problem is I won't see him till Monday 3/12.

 

[Milo]

I just read an article on consent that touched on this topic.

To Sum Up:

General Consent - The patient's general consent to be touched. This type of consent can be implied or explicit. i.e., implied when the patient turns his head so you can examine his TM

Limited Consent - Medical battery charges were filed in Duncan v Scottsdale Imaging when the patient specifically refused any injection except morphine or demoral. The nurse knowingly injected fentanyl and damages were awarded.

Informed Consent - needed for procedures with risks, with the r/b/se discussion that we all love and know so well.

Anyway for your druggy with the foley: If he refuses and you shove that foley in anyway I believe it would be legally construed as medical battery.

Maybe if you did a two doc assessment and opinion regarding lack of competency to refuse you might be able to do it, but do you really want a UDS that badly?

 

[Milo]

I'd be lying if I said I've never threatened a patient that I'd have him involuntarily cathed if he didn't pee in a cup. 9 times out of 10 it works...and I wouldn't consider it unethical,

I don't think it's unethical either. I just wouldn't phrase it as threatening. It is really a discussion regarding informed consent. Involuntary commitment might be a natural risk that the patient would have to face for refusing adequate assessment and treatment of psychosis especially in situations where there is dangerousness involved.

 

[SoSoDefJeff]

I'm sorry for being ignorant, but how does the UDS change your management of the patient? Can you just treat him/her with an antipsychotic x 1 and then reassess?

 

[Anasazi23]

No, because sometimes an antipsychotic is at worst contraindicated and at best, non-helpful in treating an altered mental status of unknown origin.

The example I was trying to get at with my anecdote was one in which medical necessity does come into play...i.e. stupor or an obtunded patient that either appears grossly psychotic and/or catatonic, vs. opiate or benzodiazepine intoxication.

In other words, why start pushing haldol, geodon, prolixin, zyprexa, etc IM when you can give some naloxone and actually treat the condition.

That said, I'd find someone to be hard pressed to not be able to tell at least to some degree, the difference between even an atypical presentation of opiate intoxication vs. psychosis. As we know, there are many physical signs one can look for on exam.

 

[Hurricane]

Limited Consent - Medical battery charges were filed in Duncan v Scottsdale Imaging when the patient specifically refused any injection except morphine or demoral. The nurse knowingly injected fentanyl and damages were awarded.

Is touching the patient required for it to be battery?

We have a patient on our unit who is on a forced med committment that includes "all antipsychotics, antidepressants and mood stabilizers" who previously did very well on Risperdal + Depakote. He was already on the max dose of Risperdal but he refused to take his Depakote because he was still paranoid as can be, and there's something he didn't like about the capsules. So someone brought up the possibility of putting Depakote Sprinkles in his food, but it was decided that it was unethical to medicate a patient without his knowledge, even if he's on a forced med committment. (Which, come to think about it, wasn't there some other court case where a patient was refusing meds and then later sued because he was locked up without getting any treatment?) Anyway, he eventually decided to take the Depakote for some unknown reason the other day, so the point became moot, and now he's about ready for discharge

But I was just wondering, would that be considered "battery" since you didn't touch him...

 

[sdn1977]

Forgive me if I'm ignorant of NJ's definition of "crisis center", but to go along with SoSoDefJef's (gosh - that's a lot of "s's"!) suggestion and to be devil's advocate - Whopper's pt is in a crisis center - not an ER.

Does a NJ crisis center really have haldol, geodon, prolixin, zyprexa on hand? Whopper, was your purpose to diagnose or to get him to the point of willingly going to an inpt unit? If the urine screen had come up positive - what would you have done differently in the crisis center? Likewise - if negative, what would you have done differently? Would he have agreed to naloxone? Somehow I doubt it if he was reluctant to do a urine screen.

Whopper - I've got a question about NJ's mh admission laws. If this pt did not make his way to your crisis center, but rather was transported to an ER by police or ambulance - would he not be admitted if he truly were a potential harm to himself or others? In that case...would a blood screen be done automatically in the ER?

Does being admitted voluntarily from home, crisis center, physician or any other venue make a difference from being admitted by police intervention? Does this force the pt to be faced with police involvement before medical tx can be given?

Again - sorry for the ignorant post, but our crisis centers here don't seem to get as involved in acute care as what you've described, altho it would certainly be a good thing if these cases wouldn't have to go thru an ER or the police as them seem to do here.

 

[whopper]

Not ignorant at all. Things vary per region.

The bottom line, and it has nothing to do with real psychiatry; inpatient units will not accept patients without a UDS. They won't because they don't want to be in a situation where their psychiatrist doesn't know the etiology of the psychosis (drugs? meds? chronic disorder?). An inpatient unit can deny someone going in for things like this.

And the crisis center has 24 hrs to get a patient out of the crisis center, once they get in or they must discharge them. Reason for that is to prevent patients from being unfairly kept against their will for an extended period.

So if a patient needs to go to an inpatient unit, and they don't want to give a UDS, the race against the clock has now begun.

You and your nurse need to get that patient out of the crisis center and into an inpatient unit or you'll be violating NJ law, or you will have to discharge a patient who is commitable (and dangerous).

The reality of the situation is that if the 24 hr mark is surpassed, of course we won't discharge the patient because someone can end up getting killed, but then what's going to happen is the state is going to come down on the hospital and start nitpicking with a fine tooth comb every single stupid thing they can find...relevant or not, plus the hospital can face a big fine --> which translates into the nurse and possibly the doc being fired.

However Anasazi's comments (which pertain to real medicine) also are relevant, but if it were simply about real medicine, the 24 hr time clock wouldn't be so much an issue.

would he not be admitted if he truly were a potential harm to himself or others? In that case...would a blood screen be done automatically in the ER?

If the pt were truly a danger, and brought in by law enforcement, by NJ state law the ER has to admit the pt but if he's committed a criminal act, then the police have to be with the patient at all times unless the police ROR the patient. The police can only ROR the patient if they believe the patient is not dangerous (e.g. the patient was shoplifting but shows no agitation), and it has to be approved by a judge. Unfortunately, the police in the past have ROR'd patients that were still dangerous because they can't stand sitting there for 12 hrs with nothing to do, or because the police honestly, but erroneously felt the patient wasn't dangerous, The judge, since they can only go on what the police report sometimes believe the police report which may have been fudged.

We have had a few situations where the patient was ROR'd and was still highly dangerous, and worse, they were not commitable (need to have a true AXIS I). So you got this guy who's willing to harm others but its not because of psychosis or bipolar or another Axis I illness. The dangerous pt was a sociopath-which is not an Axis I. So now you got a sociopath on your hands and no police to back you up, and you can't commit the patient, but if you discharge the patient, you're letting a dangerous guy go back into the community.

Talk about a headache. Thank God these things only happen every few months, but darnit they still happen.

 

[Chewbacca Jung]

So it seems that you are stuck between a rock and a hard place-- rock being ethical issues and hard place being systems issues. If you were really interested in solving the dilema, it would require some changing of the system (or possibly cathing people against their will after giving them a roofie...) If there is a significant portion of you patients come from the ER, then there needs something worked out so that the ER doesn't send you patients until they are properly screened-- i.e. given a tox screen-- a good compromise would be to mandate that they tell the lab to hold the blood until you order the tox screen (which would really mean that they would find it easier to just get the tox screen themselves). If they don't get the tox screen, don't accept the patient, or send the patient back.

I don't know what to do with the cops... need something worked out so that they can easily come pick them back up-- maybe agree that they can leave more often as long as they pick them up. (don't know if that would actually work)

the other policy of needing a tox screen to admit-- that requires some communication and change of policy.

Legislation-- attack the capital...

anyway, I'm rambling now, but do something about what can be changed, accept what can't. I'm sure you've thought about half of this already, but ....

 

[whopper]

Chewie,

You actually gave the ultimate answer.

Its a problem that won't be solved unless the system is changed.
So either the law has to change, or the hospital has to institute an in-house policy that circumvents these problems.

The first won't happen for years.
The 2nd ain't going to happen in my hospital for years if ever. The ER docs and the psyche docs have their own rivalries--the more we push, the more they push back. A shame. They're not working as a team, they're working as if its a turf war. The real people that can cause a real fix are either part of the turf war or they're too lazy to solve the problem for real.

In defense of my program, this type of thing happens in almost every hospital I've seen. I actually love the program I'm in despite the things like this.

The issue with the cops, we can't do anything about it. The judge won't hear our side of the story and the cops for all we know will drive to the local dunkin donuts to give their report. If I ever saw a cop try to ROR a dangerous patient, and they were giving the report to the judge in my presence, I'd demand to speak to the judge while they were communicating with that judge on the phone. However most times I've noticed them do this, they seem to intentionally walk away from our prescence.

You can accuse me of being perhaps a bit conspiracist and accusatory against the police on this issue. I mentioned some of them do this because they don't want to sit there during the often 12 hr wait while we process the pt. I also completely acknowledge that some cops have ROR'd patients honestly thinking them to be safe when they in fact weren't. Trust me on this one, I've seen too many cops try to turf them onto us. I had one cop not know he was supposed to sit with the patient for several hours. He thought he could just drop the guy off to us. When he found out, he ran into the patient's holding room and threatened to beat the crap out of the guy because he was so ticked off he'd have to do that, especially when he had hours of paper work waiting for him that he wasn't be able to do because he was going to be stuck at the hospital. (Imagine that situation, callilng security to hold a police officer down to protect a criminal?!?!). Thankfully the police officer only threatened and after screaming threats for a few seconds calmed down.

(yeah I know that was wrong but what was I going to do? Call the cops to arrest one of their own?)

However other cops have been complete angels. One guy who drops them off to us always has his portable DVD player ready with a bunch of movies and he hangs out and jokes with us. Cops are like everyone else. Some of them are good, some of them blow. Just like doctors, when they suck, its really really sad because someone's life can be at risk due to laziness.

anyways my program director Dr. Dunn told me if we were stuck in a situation where we couldn't commit, and the patient was still dangerous, we'd have to discharge the patient, but to cover our butts, we would also have to use Tarasoff (contact anyone the patient stated he might harm) and contact the police and urge them to drop the ROR before discharging the patient. If the police don't drop the ROR, then report to them why you think the patient is a danger, they'll come in and either take the patient or just write a report and let the patient go after you discharge. You've done all you can.

This above paragraph I actually discussed in depth with Dr. Dunn and another attending of mine, Dr. Zwil who has discussed this issue at length with some very notable forensic psychiatrists who are nationally renowned. So at least on that issue, I feel confident this is as far as I can take it. Dr. Zwil actually did that to 3 patients and did discharge them.

 

[Milo]

But I was just wondering, would that be considered "battery" since you didn't touch him...

I have no idea.

 

[whopper]

I heard it actually could be considered battery, but again its something that's happening in a lot of hospitals and people are hush hush about it.

We had a guy in our unit and we gave him a haircut. The guy was dishevelled, very dirty, and had hair that probably hadn't been cut for years.

We were later told that cutting a patient's hair could also be considered battery because in some instances people do it to punish people (think V for Vendetta when Evey gets her head shaved!)

 

[Anasazi23]

On a somewhat related note...

We have children on the inpatient child ward that often refuse medication. Now, taking a child to court, in my and their experience is apparently infinently more rare than taking adults. We had a child who is nearly emaciated, is bradycardic, will not be taken back by regular peds, from where was discharged...and he's with us. He's refusing food stating he wants to die, and of course, is refusing any medication.

The peds people did what they could, within reason, to put a couple of pounds on this 10 year-old...NG tube, ensure, etc.

So naturally, I say, get some liquid celexa, and squirt it down the kids's throat. They tell me that we can't do this since "even children can refuse treatment." This makes absolutely no sense to me. I bring up the daily occurance of something we all remember from MS-III peds clinic. You come at a kid with a needle, and they start bouncing off the walls, screaming and running around. Eventually, the kid is held down, and given the shot.....because he needs it.

No one ever just throws up their hands and put the syringe away, saying, "Whelp, the kid is refusing treatment...sorry. I'm out."

So why would it be different for this life-threatening life situation?

I think the answer again stems from legal vs. medical reality. Incidentally, the kid was d/c'd on oral tablet celexa last time, and that lasted exactly 1 day, after which he again stopped eating, and wound up back on the peds floor soon thereafter. I'm inclinced to give zyprexa IM daily at this point, until an SSRI or some reasonable substitute is agreed to. Might seem harsh...but it's safer than letting a kid who hasn't reached formal operations dictate treatment.

 

[whopper]

Wow, another example.

I love hearing about these, because when I'm in these situations for the first time I feel trapped. The books tells you to do one thing but practical reality is pushing you the other direction.

Hadn't had the child patient thing you mentioned happen to me yet, but at least I feel a bit more armed when it will happen in the future.

 

[yiyayiya]

I'm not trying to sound cute or funny.

If you got a guy with a history of drug abuse and he's got positive psychotic sx, and he's commitable, you're going to need a UDS to find out what drugs he's using.

So if the patient refuses a UDS can you catheterize him against his will?

Reason why I bring this up is in the crisis center I've worked at, some nurses have suggested this. I didn't know if this was allowable, but when the nurse tells this to the patient, they quickly change their minds and volunteer to do a UDS.

OK fine--but if we're not allowed to force a catheterization, aren't the nurses not allowed to state they'll force one?

Before you get mad at the nurses, no inpt unit in the area where I'm at in NJ will accept a comitted patient without UDS, and by state law you got to get them out of the crisis center in 24 hrs, you have to either get them to some inpt unit or discharge them. So its a case of damned if you do or damned if you don't.

Last night I was on call, and a similar experience happened, but this time the nurse (who was new) was ethically against suggesting a forced catheterization, so when I told her that this seems to be the norm at the crisis center, she got upset with me. I understood why she felt that way and it made me question whether or not we're doing the right thing. This type of thing had gone on for so long with attendings not challenging it, I thought it might've been ok. Now I'm not so sure.

Legally, I don't know where he stands but normally a competent adult patient can refuse any treatment he wishes regardless of the consequences. If any member of the medical profession then forces this treatment on him they will find themselves in front of the medical council and also in court on battery charges. Just because a medical professional does not like a patients decision it does not mean they can do anything about it. The patient decides what happens to him, noone else.

 

[michaelrack]

One doc I know told me of the limit of patients you can have on suboxone . When he successfully treated a patient on suboxone and stops the dosage, he'll allow one more to fill the open space and he says he always used to reach the max because there's a great demand for patients who need it.

So then one day he's on the max of patients and a patient that was taken off weeks earlier had relapsed unexpectedly.

The pt called him begging for suboxone and the doc, at his legal limit said he couldn't give any more out, but told the patient he would place him as 1st on the waiting list.

The next day the patient had overdosed & died. That doc told me he honestly felt the patient wouldn't have if he had given him the suboxone. )

Did the doctor assess the patient in person? There is more than one treatment for opioid dependence. The doctor could also have referred the patient to another doctor for suboxone or hospitalized him.

 

[notdeadyet]

Just pointing out that this thread is 6 years old.

 

[F0nzie]

whopper lives on!