Friday, April 10, 2015

Lead A Horse To Water

Here's the text of a note I entered in a chart:
Patient refused placement of Foley catheter. Patient also refused to use urinal while in bed. Patient stated he intends to stand up to urinate. 
This RN and Dr. Foramen educated patient about the severity and instability of his neck fracture, that the external cervical immobilizer does not provide complete protection, and that attempting to stand or walk in his current condition presents a very high likelihood of spinal cord injury leading to death, nerve damage, loss of function, paralysis, organ dysfunction, or death. Patient verbalized understanding of these risks, and further repeated his adamant intention to stand and ambulate against medical advice.
(My nursing notes are professionally polite. What the patient actually said was, "I understand you, but I don't fucking care. I don't piss lying down unless I'm blackout drunk, and nobody is shoving anything up my dickhole. I'm standing up whenever the fuck I want. Pardon my fucking French.")

Profanity notwithstanding, this patient was in his right mind and in full possession of his faculties. He had no head injury. He was not mentally ill, confused, nor delirous. He wasn't even drunk (anymore). We did not have any justification to physically or chemically restrain him against his will. So, we very carefully documented that we educated him, and we asked him to sign a paper which listed the risks. Then we had to let him make his own choices.

I don't think he harmed himself the first time he stood. When his knees buckled, we carefully caught and supported him before he could fall. But if he keeps trying to move around before surgery, the fragments of his shattered cervical vertebrae will shift positions, and he'll wreck his spinal cord beyond what the neurosurgeons are able to repair.

And there's nothing I can do about it.

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