Can a Nurse Perform a Procedure on a Confused Patient?

Carolyn Buppert, MSN, JD

Disclosures

October 29, 2013

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Question

My patient needs a PICC but seems too confused to understand and give consent. Can I proceed?

Response from Carolyn Buppert, MSN, JD
Healthcare attorney, Boulder, Colorado

The nurse who posed this question provided additional details about the situation:

I am a vascular access nurse and am wondering what I should do when my patient in long-term care can't give clear consent on placement of a percutaneously inserted central catheter (PICC). This patient is his own "responsible party" and does not have a power of attorney for healthcare. His baseline mental status is alert and oriented to person, place, time, and event, but he is now confused, probably because he has a urinary tract infection. I can't get informed consent from him because of the confusion, and I don't think it is appropriate to place something invasive without getting the patient's consent. My colleague feels that she can ask his wife for consent, but I disagree. The patient's wife is not listed as the person who can make healthcare decisions for him. And what if he didn't have a wife, but perhaps a nephew who was listed as an emergency contact only? Would you get consent from that nephew? My concern is that if this patient regains his alertness and becomes fully oriented after 2 or 3 days of intravenous therapy, he might be upset because he did not give consent for a PICC. Or, what if complications from its placement occurred, and he never gave consent?

This situation raises a series of questions that can direct the nurse's thought process. I will get to those questions below, but the most important question that needs to be addressed is: What is the alternative? If the PICC line is medically necessary to treat the urinary tract infection, and without it the patient could die, then wouldn't both the patient and any other involved party think the reasonable action would be to get the best level of consent one can get under the circumstances and go ahead?

If you try your best to inform the patient and get consent, even if his comprehension is questionable, and you back that up by informing the patient's wife or closest available relative of the situation, and document who you have talked to, what you said, and their reactions, I cannot imagine that you would be found liable for any lack of informed consent.

Here are the more detailed questions which, in my opinion, should guide your decision-making:

How necessary is the PICC line? If it isn't necessary, don't do it. Use some less invasive method for administering medication. If it is necessary, and necessary in a timely way, go on to the next question.

Is this an emergency? If it is not an emergency, then perhaps the PICC line can wait until the patient is no longer confused. If the PICC line is the only effective way to treat the cause of the patient's confusion, then you can consider this an emergency. If it is an emergency, then informed consent is not needed and the clinician can proceed. When the emergency is over, the clinician needs to get informed consent for whatever treatment comes next.

Does the closest available relative agree that the PICC line is a reasonable course of treatment? Although the wife or emergency-contact nephew doesn't officially hold the patient's power of attorney, they are interested close associates of the patient, and one would think that if they were informed of the plan for the PICC line and did not object, then if the patient becomes alert and is unhappy that he has a PICC line, the relative could put the situation in context for the patient and assure him that it was the best course during the time the patient was confused. I know of no cases where a clinician faced with the fact pattern presented here was sued for not getting informed consent for a PICC line.

Some hospitals have policies on informed consent, and some mention PICC line insertion. If your hospital has a policy, make sure you follow it. If there is no policy, perhaps you can help the hospital draft one.

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