Wednesday, May 1, 2013

Informed Consent for Urinary Catheterization
by Misty Roberts



Informed Patient Consent Is Missing From Urinary Catheters

A urinary catheter is a hollow flexible tube inserted into the bladder to drain urine. This catheter drains urine from your bladder into a bag outside your body. Common reasons for a urinary catheter include staff convenience, urine leakage (incontinence), urinary retention, certain surgeries such as prostatectomy, and surgery lasting more than three hours. Staff Convenience is a very common reason for the use of indwelling catheters, and one which is recommended against by many universities and government organization. There is the perception that it is more convenient for nurses to place a catheter rather than take the patient out of the bed several times a day to change bed sheets and clothing, to help him/her to use a bed pan or walk to the bathroom, and to change diapers. Nurses should never use those reasons to catheterize patients. Foley catheters are not appropriate as a treatment for incontinence.

Many people feel that urinary catheterizations are an invasion of their bodily privacy even if they are done by a nurse or doctor of the same gender especially when they are not really necessary. Patient modesty is not the only concern with urinary catheters. You easily get infections or injuries from urinary catheters. Urinary catheters are the number one cause of hospital-acquired infections. About 80% of hospital-acquired urinary tract infections are related to urinary catheters. About 10% to 30% of male urinary catheterizations result in urethral injury. Check out complications that can occur from urinary catheters.

While it is true that some hospitals and medical facilities have worked to decrease the number of urinary catheterizations on patients due to concerns about infections, many medical facilities in the United States continue to do many unnecessary urinary catheterizations. Outpatient Surgery clinics typically do less urinary catheterizations than hospitals.

Urinary catheter is standard for many surgeries that do not really require them at some medical facilities. One man who had a simple neck surgery in a Georgia hospital was very upset and embarrassed when he woke up and discovered that he had a urinary catheter. He was not even asked for consent to have the urinary catheter inserted. Urinary catheter is not necessary for a simple neck surgery. When his daughter asked the nurse why he had a Foley catheter, the nurse replied by saying he needed one because he could not walk. A patient’s inability to walk is not a reason for a urinary catheter. Unfortunately, what happened to this man is pretty common at some medical facilities.
Some patients have urinary catheters inserted when they go under anesthesia and then removed before they wake up so they are unaware that they had a catheter unless they find out from their records or had difficulty urinating or felt burning sensation as they urinated after they woke up from surgery.  I feel that this is very unethical.

Some medical facilities allow nursing students to practice inserting urinary catheters on patients under anesthesia without their consent. This is very unethical. This unethical practice violates a patient’s wishes for modesty and could cause complications such as blood infection, Urinary Tract Infection, urethral injury, etc. Because nursing students have limited experience, they are more likely to injure patients they catheterize. While it is true that nursing students need practice with urinary catheterizations before they graduate from nursing schools, nursing school students should only do urinary catheterizations that are absolutely necessary under supervision of an experienced nurse and with a patient’s consent. Nursing schools should have their students do urinary catheters on mannequins as much as possible. Every nursing school should have a urinary catheter simulator such as a male catheterization simulator.


When is urinary catheter medically necessary?
Neurogenic bladder, acute urinary retention that cannot be resolved, acute bladder outlet obstruction, oliguria due to hypotensive shock, end of life comfort care of a terminal patient, certain surgeries such as prostatectomy and hysterectomy, prolonged surgical procedure (not a few hours) with general or spinal anesthesia. Most surgeries are less than 3 hours long so most surgery patients should not be catheterized at all.

Different types of anesthesia and effects on bladder functions:

Local Anesthesia – This type of anesthesia has no effect on bladder function at all so there is no need for a urinary catheter if you have local anesthesia. You should strive to have surgeries such as hand, wrist, etc. with local anesthesia if possible. Even knee surgeries can be done with local anesthesia now.
General Anesthesia – In short surgeries that are not longer than 3 hours, there is usually no effect on the bladder. The bladder will become distended in longer cases and the patient could become incontinent over time.

Spinal Anesthesia - Spinal anesthetics block activity along the nerve fibers that travel between the nerve centers of the brain and the bladder. Patients lose the sensation to void about 1 minute after being injected with spinal anesthesia, but will continue to feel dull pressure as the bladder reaches full capacity. In addition, the ability to contract the detrusor muscle is lost 2 to 5 minutes following the injection of local anesthetics and still persists even after bladder sensation is fully recovered. Spinal anesthesia with long-acting local anesthetic therefore contributes more to POUR (Post Operative Urinary Retention) than spinal anesthesia with short-acting local anesthetic, since the inhibitory effect of spinal blockade on bladder function lasts longer. Patients receiving spinal anesthesia with short-acting local anesthetic are often able to void shortly after outpatient surgery and are ready to leave the PACU quickly. (Source: What Do You Know About Post-Op Urinary Retention? - Outpatient Surgery) If you have spinal anesthesia, you should request spinal anesthesia with short-acting local anesthesia to reduce your chances of urinary retention.
Any bladder issues after surgery are most likely due to narcotics used for pain control.
Every patient should use the bathroom before surgery takes place. Most surgery patients are asked to not drink anything for at least 6 hours before surgery so their bladders are empty.

Patients who might become incontinent should be given the option of wearing disposable waterproof underwear or boxer shorts. You can buy them before you come to the hospital.


Why is there no informed consent for urinary catheters?
No informed consent is required for urinary catheterization. Despite the common use of urinary catheters and the well-known risks of complications associated with urinary catheters, patients are not asked to sign a written consent that discloses the advantages and disadvantages of urinary catheters. Rarely are patients informed verbally of the risks of urinary catheters. Another concern is that many patients care deeply about their modesty and would not want a urinary catheter to be inserted by an opposite sex medical provider.

John Fisher, a medical malpractice lawyer in New York shares in his article (Why Consent For Urinary Catheters Should Be Mandatory) that in evaluating hospital care throughout New York, he has not seen a single consent form for urinary catheters. Since patients with urinary catheters have a much higher chance of getting a urinary tract infection than those who do not have a catheter, the question must be posed: why is there no informed consent for urinary catheters?
Do patients really give “implied consent” to urinary catheterization?

Physicians and nurses will explain the patients give “implied consent” to urinary catheterization based on the theory that urinary catheterization is a common and routine part of hospital treatment. However, informed consent is important for urinary catheters for the following reasons.
  • Urinary catheter complications pose such a common and significant risk to patients.

  • Urinary catheterization is an invasive procedure and embarrassing for many patients who value their modesty. Every patient should be given the option of having a same gender nurse or doctor for the catheter insertion if it is absolutely necessary. Check out how male urinary catheterization and female urinary catheterization are done.
Once given information about the risks and benefits of urinary catheterization, the patient can make a fully informed decision whether they wish to accept the risk and if they want a same gender nurse or doctor to insert the catheter.

What is the downside of consent for urinary catheterizations? A little more paperwork and time for hospital nurses, but isn’t a fully informed patient worth this minor sacrifice? Patients should be informed that urinary catheter insertion involves the risk of complications, facts about how invasive the procedure is & their option for same gender nurse, and a specific consent relating to the pros and cons of a urinary catheter should be signed by the patient.
If the patient is incapable of making decision about urinary catheter, a family member should be asked for consent.
How to Refuse a Urinary Catheter?

Because there is no informed consent for urinary catheters and urinary catheter is standard for many surgeries and sick patients who cannot move at some hospitals, patients and their families must speak up and take steps to ensure that a urinary catheter is not inserted. Keep in mind that the inability to walk is not a reason to insert a urinary catheter.

Steps To Ensure That No Urinary Catheter Is Inserted:

1.) Request that no urinary catheter be inserted in writing. Write all over your surgical consent form that you do not consent to urinary catheter and that your underwear may not be removed at all for surgeries that do not involve the genitals. Try to get the consent form the day before surgery if possible.
2.) Talk to the surgeon, nurses, and everyone that will be involved in your care about how you do not permit a urinary catheter to be inserted and that your underwear must stay on.
3.) Type up a document saying that you do not consent to a urinary catheter and make several copies to give to everyone involved in your care.
 
Sources:

Misty Roberts is the president / founder of Medical Patient Modesty (http://www.patientmodesty.org), a 501c3 non-profit organization that works to improve patient modesty.

15 comments:

Anonymous said...

Many catheterizations have been placed against
patients wishes. One such patient sued and was
awarded $250,000.

PT

Medical Patient Modesty said...

PT,

Do you have a link to the article about the patient who was awarded $250,000? If so, can you please share the link.

Hospitals need to work on cutting down on urinary catheterizations.

Misty

Anonymous said...

Excellent article and site Misty. Thanks for all of your time and research. I'm a fan.

LG

Joel Sherman MD said...

A very thorough and well researched article.

Anonymous said...

Misty

I will try to find the article as it was about 8
years ago that I read it online. The patient was
a paraplegic who refuse but it was forced upon
him. It should be noted that urinary catheters
improperly placed have caused deaths in patients.

PT

Scott Griffin said...

I take extreme caution when I use a urinary catheter. I make sure that I have the most up to date equipment for a urinary catheter. So many people don't know how to properly set on up let alone use it. You need to be educated before using a urinary catheter.

Anonymous said...

Here is an interesting blog that links to the JAMA article it draws its information from:

http://well.blogs.nytimes.com/2007/12/19/making-hospitals-pay-for-their-mistakes/

Anonymous said...

I was thinking about the mechanics of urinary catheterization, and did a search. I found these two articles, one dealing with catheterizing a female and the other dealing with catheterizing a male. The tone of both was pretty ribald (even more so in the latter), and I wouldn't want the guy catheterizing me or anyone dear to me, male or female.

I'd guess it's one of the most intimate procedures one can undergo at the hands of a nurse. It's an extreme intrusion for a man or boy to have a female stranger grip their penis. Yet it appears that the nursing profession regard it lightly.

What a shame.

Anonymous said...

If you go to 1:30 in this video it seems she is admitting they sometimes do them for the staff's convenience:

http://www.youtube.com/watch?v=DQQTKrTSLAE

Medical Patient Modesty said...

I wanted to share with you all about a female CNA that made very disturbing comments to a lady, LKT at a hospital recently. LKT shared this on Dr. Bernstein’s blog the other day:

“I had a disturbing personal conversation with a CNA at my local hospital this week, quotes of which I thought I would share here. I was asking her about where she went to school. She revealed that she had gone from working at a local non-medical business to working in ICU after her six-week course at the community college. She had in fact just finished her recertification. She then proceeded to tell me that she really wants to get her CNA II training next because she "really wants to shove a catheter into a man" while making arm gestures as to how she would do it. She then said, "not women though (making a grimace) just men". She then smiled and said, "I'm mean ain't I". I was so struck by these comments that I felt physically ill. Many of the comments/stories from this blog flooded my mind as to how male patients are treated by female medical staff. By the way, this was no twenty something, this was a middle-aged woman. One of my comments to her in response was that I was shocked that they would allow someone with such a low level of education to perform such an invasive procedure that has potential to injure patients. Blank stare. This experience and others after working in the medical field for the last eight years has taught me that no amount of "professional" training/certification guarantees good moral character and trustworthiness. Knowing what I know, if I were male, I would never, ever let a female insert a urinary catheter in me.” LKT

This CNA reminds me so much of the “Juicy Nurse” . It is very clear that this female CNA has no respect for male patients. I believe that male patients are mistreated by female medical staff far more than we can imagine. Most men won’t speak up or file complaints when they are mistreated and that’s why we rarely hear about abuse / mistreatment of male patients by female medical staff in the news. It is also scary to think about how this female CNA may injure some male patients due to her lack of experience and compassion & respect for men. The truth is so many urinary catheters are actually unnecessary. I personally do not think that they should allow CNAs to insert urinary catheters. I found this discussion: Please enlighten me, is the cna allowed to insert urinary catheter in any state? very interesting. Some states apparently do not allow CNAs to do urinary catheters.

LKT is correct that no amount of professional training guarantees good moral character and trustworthiness.

I was very honored to help a man who was concerned about modesty during colonoscopy to take steps to ensure that his wishes for modesty and all male team were honored recently. He spoke to the head nurse (female) and the doctor and they were willing to accommodate his wishes for colonoscopy shorts, no sedation, and an all male team. In fact, he said that the female head nurse said that they wanted to do whatever to make him comfortable. It is very clear she is a compassionate nurse.

Misty

Joel Sherman MD said...

Misty,
Yes that anecdote is very disturbing. It's hard to imagine any medical personnel confiding that to a patient. But she will surely be fired eventually if she makes that a habit.
I am not aware of anyplace where CNA's are allowed to put in Foley's. It is usually done by nurses.
But it is not impossible. After all for decades it was customary that orderlies put in Foley's in men and their training is not any better.

Medical Patient Modesty said...

Dr. Sherman,

The female CNA actually made those comments to LKT who is a volunteer at a hospital. I wonder if the CNA would have made those comments in front of her supervisor. I certainly think that this CNA needs to be fired.

I was well aware that orderlies did not have that much training. But I noticed on Dr. Bernstein's blog that at least one man shared that he would rather to have an inexperienced male than a female nurse with 30 years of experience participating in male intimate care on him.

Misty

Medical Patient Modesty said...

I wanted to let everyone know that a law student who is a former RN did an article about legal options for patients who do not want urinary catheters. Check out this article: A Patient Has
a Right To Refuse a
Urinary Catheter
.

Misty

Anonymous said...

Thank you for your article & your many other helpful blog write ups. I suffer from ptsd as a result of being forcibly catheterized, held down by a room full of men & women as I screamed "NO" repeatedly. I was very sick- septic, pneumonia, & a near fatal infection in my heart- but at that point I had control of my bladder & was making it clear that I wanted to go to the bathroom. Their reason for forcing this on me- my iv wasn't long enough for me to go to the restroom...? There was no medical need whatsoever for the cath and I made my refusal to consent loud and clear yet I was held down as I kicked, screamed, pleaded. Not that it wouldve been ok otherwise, but to top it off I had been previously sexually assaulted so to wake up in an ICU not knowing where I was completely naked and uncovered from the waist down and then having a room full of people hold me down and spread my legs open was particularly traumatizing and sexually violating. Meanwhile my husband and friend who had brought me to the hospital did nothing to try to stop them from doing this to me despite my refusal- I won't let my husband touch me as a result of this, & I'm sure in time it will ultimately lead to the end of our marriage. The hospital and NYSDOH complaint processes will just make me relive it more than I already do and force me to talk out loud about what I can't verbalize without sobbing &/or becoming violently ill, & I know those complaints almost always lead to absolutely nothing. I don't have the "perfect" case or history so legal recourse isn't feasible, & even if it was it would do nothing to undo the trauma that's been done. To top it all off, as a result of this experience I am going without necessary follow up care because I can't bring myself to go to a doctor & talk about it (I have a hard enough time conveying the basic emotional info related to my ptsd to my psychiatrist). What is left of my life is shattered- flashbacks, nightmares, inability to function, panic attacks, dissociation, etc etc. My family misses me, hell I miss who I used to be, but I feel dead already, hopeless, ashamed, disgusted, worthless. I have "I do not consent _____" written in sharpie on my body should I ever become sick & be brought to the hospital unbeknownst to me again. I really wish my friend had never brought me to the hospital, I was just a day or 2 from being dead, I never would have needed to go through all of this. I've already explained to my kids that if I got sick again I wouldn't be coming back alive, I love them more than anything but my heart mind & body are not strong enough to go through that medical rape again, & if kicking and screaming that no i do not consent isnt enough protection for me then obviously there isnt any way to guarantee that it wouldnt happen again. All of this because it was just basically more convenient for the staff. If only they had been respectful of patient rights & treating people humanely as you seem to advocate through your blog, who knows how many less people would be traumatized, harmed physically & mentally, & how many more people wouldn't hesitate to get the help they medically need but are too afraid of what they'll be subjected to. Education & prevention are key, but where do those of us who've already been wronged, raped, & spat out of the machine that goes "ping!" go?

M Banterings said...

Here is a simple solution; if catchers are "common and routine," once ever 3 years, as a part of provider license renewal, they shall act as a standardized patient.

There should be no issues since it is so routine, besides how many do they insert every day. Perhaps we should film the learning procedure for patient education.

I am going to place this catheter in you, first I am going to show you a video of my last license renewal, where I was catheterized. This video will show yow what to expect.

I guarantee that this would change the way catheters are used.

The added benefit is that current providers would be furthering medical education, the same way doing pelvic exams on anethesitzed patients, filming patients in the OR, etc. furthers medical education.

-Banterings