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
Overutilization
of indwelling urinary catheters and the development of nosocomial
urinary tract infections
Medical Disclaimer: The information
on this web site is for educational purposes only. It is not
intended in any manner as professional medical advice. You should
consult a healthcare provider to determine the appropriateness
of the information on articles about medical procedures for
your own situation, or if you have questions or issues regarding
a medical condition.
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