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