Is it within a nurse's scope of practice to override informed consent for PICC insertion if the patient cannot sign and there is no next of kin or delegate available to do so?
I encounter situations frequently where a temporary CVC needs to be removed per the bundle to prevent infection but there are still pressors running, or there are prn boluses of 3% saline ordered, or other similar situations in the ICU with sedated/intubated patients. At my facility, doctors will write progress notes or nursing communication orders to proceed with PICC placement without consent because the line is "medically necessary." If there were some type of PICC related complication, would the nurse be liable for placing it?
Thoughts and feedback are appreciated.
YOu should take this question to your hospital risk manager. The scope of practice is one thing but you must also consider how this is written in your hospital. Is it written as a policy statemet? If so, then no one - doctor, nurse, family, patient, etc - can alter, override, or change that policy. Policy statements are rules that are considered non-modifiable and nonnegiotable. To get them changed you must go back to the committee(s) responsible for those policies. This is why every wish or preference should not be written as policy statements. In the situations you described, can you get a family member on the phone to give informed consent? This is definitely a situation that requires risk management input or a change in the policy. Lynn
Lynn Hadaway, M.Ed., RN, BC, CRNI
Lynn Hadaway Associates, Inc.
126 Main Street, PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
What are you referring to when you are saying a temporary CVC needs removed "per bundle"? I have not seen any bundle for removing a CVC. I know we are to assess line necessity per shift,(remove any unessary lines) but....sounds like the current CVC line is still necessary with those medications being infused. We would only remove a CVC if; it was in the femoral and had been there for 24 hours(our policy) , the CVC line is suspected to be a source of infection or, if we thought the patient was going to have long term IV therapy or need of pressors and then we would consider replacing with a PICC line for long term use.
The later one; long term use is not an emergency or urgent procedure and therefore could be postponed till necessary legal actions or location of family or a designee was made. The other; suspect infection, or femoral or.....if the patient has no line and must have one then may fall under the "medically necessary" area where then we can have two physicians sign the consent saying this is a medical emergency and must be done in order to preserve the patients life. ( that is our policy). If it does not fall under "medical emergency" I am not having MDs sign consents or going without consents.
We also have a chain of command of who can sign consents; spouse, children, sibling, relative, close friend etc....it works its way down. If we are stumped or have any concern we too involve our case management department.
Gina Ward R.N., VA-BC
If all know attempts to contact family or POA fail...and if the urgency for the placement is deemed valid...we are allowed to get the patients staff physican (not resident or fellow...STAFF) to sign the consent invoking "Adminsrtative Consent"...but attempts to contact family and/or POA are well documented.
Thank you all for the feedback. I should not have said "per the bundle" because what I meant was per our policy. Femoral, pre hospital, or emergently placed catheters are removed within 24 hours, all other temporary catheters should be in no longer than 5 days. We usually exhaust all attempts at contacting family members, and then continue under an order from the physician that the line is necessary. I appreciate everyone's comments.
Colleen M. Cavallo, RN, VA-BC