Patients refusing catheterization

[epsilonprodigy]

Quick question: if a patient requires a c-section but refuses catheterization (straight or Foley) how is it handled? I've found a few articles that suggest it's safe to perform a c/s without a Foley, but none get into details about avoiding straight caths thereafter. Would this be possible with general anesthesia, and if so, can a patient elect this if it's the only way they'll consent to the c/s in the first place?

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[VisionaryTics]

Never seen a patient refuse a foley. I think if you explained to the patient that the foley helps prevent injury to the bladder requiring long-term catheterization, they would be OK with it.

 

[epsilonprodigy]

Hopefully this would do the trick. But, I imagine the patient I have in mind would have answered that she would be more willing to risk injury than consent to any sort of cath, and that she's still refuse at all costs even if bladder injury occurred. Not trying to play devil's advocate, but I can't say much more than that on here :-/ Just curious if this would take the possibility of a c/s off the table entirely.

 

[evilbooyaa]

Explain to the patient that they will be catheterized after they are asleep. I imagine the worst pain is when a foley is inserted, with some general uncomfortableness as it remains in.

I've seen tons of surgeries (and I'm sure the surgery residents on this forum can also attest) and I've never heard of anyone consenting against a foley. Yeah, they'll complain about it (and some patients will demand to have it removed or pull it themselves) after the fact, but never had anyone refuse it in the first place.

 

[cabinbuilder]

It's not like it's blood products.

You as the doctor have to anticipate potential problems, aka bladder injury.

Not sure why it would even be brought up to the patient, its part of the surgery? Are you going to let them refuse certain types of sutures, or staples, or drains, and dictate your case?

 

[epsilonprodigy]

Hope I'm not revealing too much, but I believe this patient planned on having the baby's dad policing for any surreptitious Foley placement. This was a tough one, and I don't know what came of it. What I do know was that the patient had every intention of refusing urethral catheterization in all circumstances, up to and including her death. It was complex, this patient was fairly well-informed but strongly felt this way. The above poster brings up a good point: what if a patient claims to have a moral or religious objection to the use of staples or something seemingly arbitrary....where do you draw the line? Can you give care that you feel is substandard based on patient demands, given that total lack of care would be worse?

 

[Smurfette]

Generally speaking, foley placement is a procedure that does not require signing a consent form. If the patient is awake and refuses, well, that's different.

I personally (as a surgeon) have never had anyone refuse outright to have it done while under anesthesia.

I suspect if you tell the patient that having a full bladder could affect visualization of the C-section, which could in turn compromise the health and safe delivery of her baby, she would be agreeable.

 

[cabinbuilder]

Hope I'm not revealing too much, but I believe this patient planned on having the baby's dad policing for any surreptitious Foley placement. This was a tough one, and I don't know what came of it. What I do know was that the patient had every intention of refusing urethral catheterization in all circumstances, up to and including her death. It was complex, this patient was fairly well-informed but strongly felt this way. The above poster brings up a good point: what if a patient claims to have a moral or religious objection to the use of staples or something seemingly arbitrary....where do you draw the line? Can you give care that you feel is substandard based on patient demands, given that total lack of care would be worse?

One would hope that this conversation would have come up prior to the C-section happening. I guess my take on it (and I will get slammed, I'm sure) is if you can't come to agreement and you as the provider don't think it's safe then that patient needs to find a different doctor. I for one will not put my license on the line for anyone who thinks they can be both the patient and the doctor and tries to dictate and circumvent safety.

My other take on this particular case is that I personally had a bladder injury during a C-section and I tell you taking that precaution with a foley is loads easier than recovering from a bladder surgery (took me a year) and I have never been the same after 14 years. Sometimes you just have to pull up the boot straps and stand your ground as the provider because you have seen the worse case scenario and it's your obligation to do your best to prevent complications. Either that or inform the patient you aren't willing to accept the risk of their request and they need to find another doctor.

 

[Winged Scapula]

Although I've never had a fully informed and REASONABLE patient refuse a Foley, in this case with evidence that husband will be "policing" her care, I'd say that the OB would be wise to refuse to perform her CSxn.

It sounds like a set up for litigation IMHO even if no injury occurs.

 

[Gastrapathy]

The patient would never know?!?!! until she gets a uti, asks a nurse, sues you, your malpractice doesn't cover a criminal act and you go bye bye.

 

[cabinbuilder]

I guess I have low tolerance for this kind of thing. It comes up a lot when having to medevac a patient who could possibly die. The medevac will NOT take a patient without a foley in place. It has been many times where the patient says, "I ain't having a tube".

Ok, so I give them the choice, I will call the plane and tell them not to come. stay here and die.

OR, put the tube in and survive another day.

OMG, I just can't take it some days. I'm such a B...... but the patients live.

If the women in labor doesn't want a foley then why isn't she birthing at home with a midwife and be done with it?

Let the lashing out begin. Sigh..........

 

[Gastrapathy]

That's your call. Turn the plane around if the dip**** won't listen. But doing a procedure without consent will result in no lube colonoscopy for you. The kind of person who refuses a foley is exactly the kind who will **** you.

 

[cabinbuilder]

That's your call. Turn the plane around if the dip**** won't listen. But doing a procedure without consent will result in no lube colonoscopy for you. The kind of person who refuses a foley is exactly the kind who will **** you.

Yes, I totally agree with you. Just the ridiculousness got to me. I am not one to force a patient to do anything they don't want to, however, I also am not one to give in to demands and will walk away as they seal their own fate. We all went to school too long to let someone's stupidity dictate our future.

Love this line, BTW. May have to use it sometime 🙂 will result in no lube colonoscopy for you

 

[anonperson]

Quick question: if a patient requires a c-section but refuses catheterization (straight or Foley) how is it handled? I've found a few articles that suggest it's safe to perform a c/s without a Foley, but none get into details about avoiding straight caths thereafter. Would this be possible with general anesthesia, and if so, can a patient elect this if it's the only way they'll consent to the c/s in the first place?

It's a ridiculous request from a patient perspective. Could you technically get away with no foley in a routine primary C/D that takes 35 minutes? Yeah, probably. But what happens when the surgery takes longer, you end up with massive hemorrhage, etc. That 35 minutes can easily become 90 minutes or longer. Now you're dealing with a rapidly expanding bladder right where you need to operate and you have no idea if the patient's urine output is reasonable or not etc.

There's no such thing as "Just a" (just a c-section, just a lap chole etc)

Besides, most patient's get a spinal with a C/D and have the foley placed right after so they don't feel anything. It comes out within 12-24 hours and then it's out.

 

[epsilonprodigy]

I guess I have low tolerance for this kind of thing. It comes up a lot when having to medevac a patient who could possibly die. The medevac will NOT take a patient without a foley in place. It has been many times where the patient says, "I ain't having a tube".

Ok, so I give them the choice, I will call the plane and tell them not to come. stay here and die.

OR, put the tube in and survive another day.

OMG, I just can't take it some days. I'm such a B...... but the patients live.

If the women in labor doesn't want a foley then why isn't she birthing at home with a midwife and be done with it?

Let the lashing out begin. Sigh..........

LOL, I like your style. So the consensus, it seems is that you simply can't safely do a c-section without one. Furthermore, it appears that situations like these are when you as the physician get to say "my way or the highway." I just wonder, though...let's say said patient continues to refuse, thus you refuse to perform a c/d. Patient dies, or infant has a terrible birth outcome. Will your refusal to provide what you deemed to be substandard care come back to haunt you in court, since the outcome you were trying to avoid ended up happening anyway? Would they try to say, "oh, you should have just gone ahead without the Foley, and MAYBE things would have been fine, as opposed to foregoing the procedure altogether when you knew that doing so was dangerous?"

Cabinbuilder, if you don't mind my asking, did you get a bladder injury even with a Foley? How scary! This happened to my mom too! Hope you're okay🙂

 

[cabinbuilder]

LOL, I like your style. So the consensus, it seems is that you simply can't safely do a c-section without one. Furthermore, it appears that situations like these are when you as the physician get to say "my way or the highway." I just wonder, though...let's say said patient continues to refuse, thus you refuse to perform a c/d. Patient dies, or infant has a terrible birth outcome. Will your refusal to provide what you deemed to be substandard care come back to haunt you in court, since the outcome you were trying to avoid ended up happening anyway? Would they try to say, "oh, you should have just gone ahead without the Foley, and MAYBE things would have been fine, as opposed to foregoing the procedure altogether when you knew that doing so was dangerous?"

Cabinbuilder, if you don't mind my asking, did you get a bladder injury even with a Foley? How scary! This happened to my mom too! Hope you're okay🙂

Yes, even with a foley. I had severe endometriosis that caused my bladder to adhere to the uterus. It tore when they tried to resect it off. No one's fault. Is what it is.



If a patient is refusing, of course you have them sign a release stating they are refusing medical advise and cover yourself. I had a lady in Alaska who I had medevac'd a few months earlier for liver failure. She showed back up in the ER hemorrhaging from her colostomy. First thing out of her mouth was "you are not putting me on a plane again". Her Hg was 6 (I had 4 units of blood in house) and no way to get more. Ok, I'm all about patient's wanting to die at home but she didn't get it that she was dying. She wanted to be stabilized with fluids and go home. I told her straight that I was fearful that she would die in the next 24 hours and she needed to let her husband know her decision because I was not in the position to save her life if the bleeding didn't stop on it's own. Nursing staff called me 2 hours later and she got on the plane. Before anyone bitches about my management there's way more to this story and this lady needed GI, gen surg, and renal consults ASAP due to labs, etc. The bleeding was just the tip of the iceberg.

 

[siliso]

Cathing people post-induction of anesthesia should solve 99% of these issues. And, having been cathed for c/s both after and before induction (one spinal, one general) I can testify that it is the humane thing to do even if the patient is unconcerned in advance. Don't believe anyone who says it doesn't hurt, because it sure as f**k does. If not, I guess you decide how emergent is the surgery vs. how high is the risk of bladder injury and decide from there.

 

[siliso]

Also, why did the person so oppose a urinary catheter? "Can you tell me about your concerns about a catheter?" It's not just the right USMLE answer, it can also help you understand and either reassure the person about their specific fear, or consider alternatives as appropriate.

 

[link2swim06]

So let me get this right:

1. They are allowing you to cut them open with nearly a 8 inch incision including multiple layers of muscle and fat.
2. Cut their uterus open.
3. Remove a baby and sew everything back together....

but will not let you put a small plastic tube about 5 inches into their bladder under full spinal anesthesia?

 

[Gastrapathy]

If you think that's the most irrational request any of us have had this week, you'd be sadly mistaken. I just had a patient leave AMA before endoscopy for a variceal bleed because the nurses took his booze. Saved me a trip in overnight. Patient is probably dead. I'm not a parent. I would have scoped him for free but I can't help it if he's back on the street before I get there.

 

[cabinbuilder]

If you think that's the most irrational request any of us have had this week, you'd be sadly mistaken. I just had a patient leave AMA before endoscopy for a variceal bleed because the nurses took his booze. Saved me a trip in overnight. Patient is probably dead. I'm not a parent. I would have scoped him for free but I can't help it if he's back on the street before I get there.

Yep, all day, every day.

 

[evilbooyaa]

LOL, I like your style. So the consensus, it seems is that you simply can't safely do a c-section without one. Furthermore, it appears that situations like these are when you as the physician get to say "my way or the highway." I just wonder, though...let's say said patient continues to refuse, thus you refuse to perform a c/d. Patient dies, or infant has a terrible birth outcome. Will your refusal to provide what you deemed to be substandard care come back to haunt you in court, since the outcome you were trying to avoid ended up happening anyway? Would they try to say, "oh, you should have just gone ahead without the Foley, and MAYBE things would have been fine, as opposed to foregoing the procedure altogether when you knew that doing so was dangerous?"

I think this is a valid question that should hopefully be answered by those more experienced with surgery (if possible). If a patient refuses a foley (or another case, like no blood transfusion in a placenta previa/accreta C-section) can an OB/GYN be sued for not being willing to do the surgery without a foley/blood transfusion? Is it different when the life of the baby is also on the line? Does getting them to sign a waiver saying they do not want a foley (or blood transfusion) against medical advice make the bladder injury (or death of mother) after a C-section a non-viable option for a lawsuit?

To Gastropathy: Patients who leave the hospital AMA are a completely different beast (and IMO much easier to handle since they have no leg to stand on for a lawsuit). I think a patient dictating specialized care that goes against the standard of care is the worry here.

 

[Smurfette]

It depends on the situation.

You can tell the patient to see another provider. However, if the patient is about to deliver and you are the one on-call, you can't really refuse to do the right thing. If the patient can safely deliver sans foley, that's one thing (you can refuse to do an elective cesarean procedure), but in an emergency, you are going to get sued for non-action if the patient needs a C-section and you refuse and something bad happens.

Having the patient sign a waiver, unfortunately, will not necessarily protect you from legal action.

Refusing blood products is a common scenario (lots of Jehovahs out there) and you proceed with whatever you need to do, knowing you can't transfuse. Usually these patients accept the risk of death due to religious reasons and it is known in their community that death is a risk. I don't think doctors are as worried about getting sued in this situation so much as dealing with a potential bad outcome that could have been prevented with a blood transfusion. It limits our ability to care for the patient, so it adds stress and paranoia. Regarding pediatric patients, the transfusion thing is more complicated. I am referring to adults.

Refusing other random things, for random reasons, is murkier. Patients can refuse lots of things, but without "firm" basis (i.e. religion, terminal illness wanting palliation only, etc.), many change their mind when adverse outcome is imminent. Or their family gives permission once the patient is no longer able to do so. It puts the physician in an awkward position (will the patient sue if you do it and they survive?), and the delay to change the decision often results in delayed care, and, as a result, poorer outcomes and higher risk to the patient. Unfortunately, the 'unreasonable' patient tends to have unreasonable expectations, and are very frustrating to physicians to care for. Not to mention, is likely more litigious.

How do you guarantee that you won't give a patient a foley, when any number of scenarios could require it (patient ends up intubated, bladder injury repaired, needs ureteral injury repaired/stented, urinary retention issues, etc.). You can't. But you can't not cath a patient in these situations. Essentially, you can't agree "no matter what" because of the unforeseen possibilities.

 

[epsilonprodigy]

I'm not trying to be cryptic, but suffice to say that, given this patient's extremely traumatic history, I was a bit surprised to learn that urethral catheterization was not contraindicated. I suppose a better way to say it, was that the benefits outweighed the risks (of course, the patient would have said otherwise if you put the psychological "risks" on the table.)

I am concerned about giving any more detail than that due to HIPAA. As you might have guessed, this case was a real outlier in many ways.

This is the kind of stuff that "goes bump in the night" for us young-uns....*sigh*

To the earlier poster who suggested secretively placing an intra-op Foley....are you serious?! Pretty sure they could nail you for assault and battery, maybe even sexual assault... in addition to the obvious licensure issues. As a woman and mom, if anybody did that to me, it would be they that ended up with something going IN to one of their "OUT" holes... just saying😱

 

[foley12]

This is one of the hardest aspects of OB. Normally I am all for letting dumb@$$es have a bad outcome due to their own stupidity; However there is an innocent baby in there so sometimes you just have to push the envelope a little.

 

[Rendar5]

I'm not trying to be cryptic, but suffice to say that, given this patient's extremely traumatic history, I was a bit surprised to learn that urethral catheterization was not contraindicated. I suppose a better way to say it, was that the benefits outweighed the risks (of course, the patient would have said otherwise if you put the psychological "risks" on the table.)

I am concerned about giving any more detail than that due to HIPAA. As you might have guessed, this case was a real outlier in many ways.

This is the kind of stuff that "goes bump in the night" for us young-uns....*sigh*

To the earlier poster who suggested secretively placing an intra-op Foley....are you serious?! Pretty sure they could nail you for assault and battery, maybe even sexual assault... in addition to the obvious licensure issues. As a woman and mom, if anybody did that to me, it would be they that ended up with something going IN to one of their "OUT" holes... just saying😱

not sure what being a mom and a woman has anything to do with being pissed at someone inserting a foley in you while you're asleep. 9 times out of 10 it's the men who are more pissed off at me for finding a foley in them when they arouse from their delirium or drug-induced AMS (I work in the ED). That said, if someone outright tells you no foley under any circumstances and if it will cause you problems, you need to document it religiously and have the patient sign an appropriate AMA form that states their understanding of the consequences and the meaning of those consequences. "permanent bladder dysfunction, incontinence, need for further surgeries, permanent cath placement". You can AMA a test or procedure just as much as you can AMA leaving the hospital or your ED.

 

[epsilonprodigy]

not sure what being a mom and a woman has anything to do with being pissed at someone inserting a foley in you while you're asleep.

LOL, fair enough!

 

[siliso]

This is why we have shared decision making and autonomy, I think. You can evaluate the medical/surgical/statistical risk of cath vs no cath, but you can't evaluate what the damages would be to the patient's mental health or bodily integrity. If the patient refuses the procedure despite full and sensitive counseling about the risks of no foley and the possible ways to make foley insertion and removal less traumatic, you can't do it because it is battery and wrong to stick things in people's urethras without consent. Then you do your best not to injure the bladder, just like you do your best not to have a JW hemorrhage. If the surgeon is unwilling to proceed and it's an emergency, call another surgeon or an ethics consult. I don't think it would be ethical for a surgeon to refuse to do an emergently needed cesarean due to concern over bladder injury...better that than baby/mom death.

But if you seem like you don't give a crap about her reasons or her PTSD or whatever it is and make it clear that you think she is irrational and stupid, you definitely won't get to a deal. If you negotiate with sensitivity, you might or might not.

 

[debvz]

Pre-operatively explain and consent them for possible suprapubic catheter placement if they're that adamant about no foley.

In all reality, if the bladder is really that blown up in your face that it's impeding progression of your operation, can't you just stick it with a fine needle and decompress it? I'd probably oversew my stick site, but in reality, such a small hole should close up without issue.

 

[AdamAustin]

One is assuming that this patient is afflicted with some kind of urinary tract infection or other ostacle that is causing the need for a catheter, otherwise it would not have been recommended in the first place.

I think the guy must be a total nut case if he is unprepared to trust his medical advisers. Perhaps he need to find another hospital.

 

[evilbooyaa]

One is assuming that this patient is afflicted with some kind of urinary tract infection or other ostacle that is causing the need for a catheter, otherwise it would not have been recommended in the first place.

I think the guy must be a total nut case if he is unprepared to trust his medical advisers. Perhaps he need to find another hospital.

Incorrect. Foleys are standard procedure in abd. surgery, especially C-sections, because of the proximity of the bladder to the uterus. Inserting a foley allows the bladder to adequately decompress so there isn't a bulging bladder getting in the way of vision of cutting into the uterus. Most of these patients have no urinary tract infections pre-operatively. Part of the operation is to "bring down the bladder flap" which is essentially separating it from the uterus (without tearing, preferentially) and retracting it safely away from the tools used to slice the uterus open to remove the baby.

 

[anonperson]

I think this is a valid question that should hopefully be answered by those more experienced with surgery (if possible). If a patient refuses a foley (or another case, like no blood transfusion in a placenta previa/accreta C-section) can an OB/GYN be sued for not being willing to do the surgery without a foley/blood transfusion? Is it different when the life of the baby is also on the line? Does getting them to sign a waiver saying they do not want a foley (or blood transfusion) against medical advice make the bladder injury (or death of mother) after a C-section a non-viable option for a lawsuit?

To Gastropathy: Patients who leave the hospital AMA are a completely different beast (and IMO much easier to handle since they have no leg to stand on for a lawsuit). I think a patient dictating specialized care that goes against the standard of care is the worry here.

Signing a waiver/consent is irrelevant. A patient can always start a lawsuit and start the process. Whether it will have any merit in the courts is another question altogether.

When I have run into these situations in Labor and Delivery, I will always touch base with the hospital's risk management department to get their input on the situation. I had a patient last year with an epidural who was verbally abusive to staff and myself. She had an epidural and refused interventions in the form of augmentation of labor, foley catheter etc which impeded me being able to care for her. I just documented the hell out of everything and let risk management know about the situation.

You can't cure stupid.

 

[Raffie]

Hello:

Someone said;

"Generally speaking, foley placement is a procedure that does not require signing a consent form."

Being as invasive and personal as this procedure is it should (if the patient is conscience and can legally make decisions for him or herself), ALWAYS not only require verbal but require written consent every time it's performed. We need to get this into HIPPA regulations or the government needs to make it law.

I personally will never consent to urethral catheterization under any circumstances at any time also. I fully understand why there may be a need for one however, I've read about all the down side that can come of it and have talked to patients that have had it done to them and I have decided it's not for me.

If I bring an advance directive with me to the hospital that states "NO urethral catheterization at any time without prior written consent from patient" and I write on the surgical informed consent form "NO urethral catheterization under any circumstances at any time during this surgical event" and the staff puts one in against my direct wishes before going into theater or in theater after I'm under sedation or in the PACU, the action taken would lead to an expensive lawsuit.

I'm against urethral catheterization in the hospital for the simple reason it's extremely invasive & I don't know ANYTHING about the person
that's going to put it in.

I have all the respect in the world for doctors and nurses but having MD, RN, or even CNA after your name means nothing when it comes to such a personal event.

How do we know how experienced this person is that is going to do this procedure? We don't know and I for one, am not about to take their word on something so invasive and personal. I don't know you and you don't know me so this procedure isn't happening.

Maybe if there was a database patients can access somewhere that has stats on how many successes and how many failures hospital staff have had doing this procedure it might ease patients minds a bit.

One can go online to numerous places to check on physicians but I've never seen an online site with public access that rates nurses for procedures they perform.

For this kind of invasive procedure, maybe that's what is needed to help put patients more at ease with this process. A database setup by each hospital. Patients who know or think they might have to endure this procedure could then access the database and check out the credentials of the person performing the task. Just something that says how many times they've done it successfully & how many failures.

Until I have irrefutable proof you've done it successfully many times over, I will always decline a urethral catheterization simply because if they make a mistake (and mistakes happen in hospitals ALL the time), I'm the one that in the end will pay dearly.

As an alternative to urethral catheterization I've started to research the possibility of maybe a suprapubic catheterization if catheterization needed in an emergency. Otherwise, I have watched all the self-catheterization videos over & over and believe if push came to shove after surgery & I was home and needed relief, I would be willing to self-cath if I had to. I would just need to know where to get the supplies needed. I know it's ify but if it's done wrong at home, it's on me.

Thanks for listening.

Regards,
Raffie

 

[GoSpursGo]

I don't see any reason to bump a 3 year old thread, and in any case SDN is not an appropriate place to have this discussion. Thread closed.