Unnecessary Urinary
Catheterizations and Lack of Informed Consent
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.
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. 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, 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. Check out
How A Patient Has a Right To Refuse a Urinary Catheter & Legal Options.
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, patients and their families must speak up and take steps to
ensure that a urinary catheter is not inserted. Again, the inability to
walk is not a reason to insert a urinary catheter.
Steps:
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) It would be prudent to have someone that is not employed by the medical facility such as your spouse present for your surgery to make sure that they do not give you any drugs especially Versed against your wishes to make you become unable to speak up
4) 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:
Why Consent For Urinary Catheters Should Be Mandatory By John Fisher
What Do You Know About Post-Op Urinary Retention? - Outpatient Surgery
Catheter Conundrum: Reducing Unnecessary Placement
Indications for indwelling urinary catheter use
Catheter patrols: a unique way to reduce the use of convenience urinary catheters
Why You Should Stop Overusing Foley Catheters
How
A Patient Has a Right To Refuse a Urinary Catheter & Legal Options
Stop Orders
to Reduce Inappropriate Urinary Catheterization in Hospitalized Patients:
A Randomized Controlled Trial