Critical reflection of the refusal of cannulation for a patient with severe dehydration and vomiting
This essay aims to critically reflect on the experience of an encounter with a patient suffering from severe dehydration and vomiting. To structure the work, I will use the Gibbs reflective cycle as I believe it offers a thorough breakdown of the experience and a chance to fully interpret my actions and lead my future practice (Gibbs, 1988).
A female patient, who we will refer to as Mrs Y to protect her identity, aged 79 was admitted to the ward after being diagnosed with severe dehydration and vomiting. The patient lives in a facilitated care home and has mild dementia. No other confounding conditions were reported. Upon admission the patient’s blood pressure was abnormally low, 104/49mmHg, so hypotensive. Pulse rate was high at 118 and tachycardic. Serum sodium levels and blood urea nitrogen were 145 mEq/L and 25 mg/dL respectively with serum creatinine below 3 mg/dL. The patient was visibly pallid and seemed to be suffering from mild dysphasia. This could be due to the dementia diagnosis but was highlighted as a symptom upon admission. Mrs Y was able to confirm her name upon request but was not able to recall her birthday or where she lived. She was slightly distressed and not compliant when consent was asked to insert a cannula to start the re-hydration process. Mrs Y also refused to drink any water as she was concerned about inducing further instances of vomiting. As the trainee nurse charged with caring for Mrs Y, I spent a period of 25 minutes talking with her to try and alleviate her concerns and encourage her to let us insert the cannula. After being unsuccessful in my attempts to encourage her to let us proceed, and due to the urgency of her deteriorating condition, I made the decision to contact Mrs Y’s next of kin, her daughter, to ask her to come down to the hospital and encourage the patient to allow us to treat her. Untreated severe dehydration can lead to hypovolemic shock and cause irreparable kidney damage and even death. Fortunately, the daughter arrived very quickly and after only 10 minutes of contact with her daughter we were able to begin treatment. Cannulation did prove difficult due to the dehydration, as lack of circulating fluids causes the veins to close and shrink. After unsuccessful attempts of insertion at the basilic and cephalic veins in the antecubital fossa, successful cannulation was found at the saphenous vein near her ankle. Mrs Y was admitted for a period of 2 days, where upon she was administered cyclizine to stop episodes of vomiting and 20 mL/kg of an isotonic crystalloid fluids. This was successful in bringing Mrs Y’s blood pressure back up to a more suitable level and reducing her pulse rate. Early indications show there is no lasting damage to her kidneys and she was discharged back into the care of the facilitated care home.
Throughout out my involvement in the care of Mrs Y, I found myself feeling very worried and concerned for her health. When caught early enough, and treatment started quickly, severe dehydration can be reversed. But due to Mrs Y’s refusal to consent to the treatment needed it proved very difficult to start treatment. I was worried about her going into shock and causing irreversible damage to her kidneys, or worse her death. I do understand the need for consent to be given before health care providers complete any procedures on a patient, but sometimes I believe the need for treatment out ways the need for consent. Due to Mrs Y’s age and diagnosis of dementia, surely health care workers must be able to make the decisions that best suit the patient. Because Mrs Y had only recently been diagnosed with dementia, and it being classified as mild, she had not yet lost the right to autonomy, so still fully retained the right to refuse any procedures she wanted to.
Optimal bodily functions are controlled by a balance of water and electrolytes. When healthy, this balance is controlled by renal, metabolic, and neurological functions (Suhayda and Walton, 2002). Elderly people are more vulnerable to a disruption of this balance, and in the case of Mrs Y, she was not only elderly, in a care home, but also suffered from a vomiting bug. Dehydration affects a large number of elderly patients, especially those within care settings. It can exacerbate and contribute to already diagnosed medical conditions and cause confusion, disorientation and severely impair quality of life (Begum and Johnson, 2010). Mrs Y’s admission observations pointed to very severe dehydration, with possibility of hypovolemic shock. Low blood pressure points to a severe lack of fluids in the blood, causing the kidneys to try and retain as much fluid as possible to make up the volume in the blood, leading eventually to damage of the kidneys (Alkhatrash & Sreeharsha, 2020). A higher pulse rate is when the heart beats more to try and increase the blood being pumped around the body. If blood pressure falls to low, the brain, kidneys, liver, and other vital organs are starved of oxygen, which leads to shock and the body systems to start to shut down (NHS, 2021).
It is well known that the elderly is more susceptible to suffering from dehydration. As we age, our ability to sense thirst decreases and the water and sodium balance in our body changes (Schols et al, 2009). It is also thought, rightly or wrongly, that those living in care homes are more likely to develop dehydration through lack of care and ignorance by staff members. Patients with dementia and other brain conditions, are also more likely to suffer with dehydration. A study by Gaspar, 1999, found that in two 24-hour periods at a care home, water and food intakes were studied and out of 99 residents, only 8 received the standard water intake required. As Mrs Y was suffering from a vomiting bug, it is hard to say whether this was the case at the nursing home where she resided. What can be said though, is if Mrs Y’s carers would have noticed the signs of dehydration sooner, she would have been able to receive treatment earlier, lowering the risk of any serious outcomes.
The other issue that needs to be evaluated is how a patient’s lack of consent can have a detrimental effect on the ability of the health care staff to perform potentially lifesaving procedures. Cannulation is a relatively risk free and simple procedure. It is now being carried out largely by trained nurses and is the second most common invasive procedure carried out in a hospital (Lavery, 2003). Most people are deemed to be competent to make decisions regarding their own bodies by law. In certain circumstances though, this consent can be removed and given to a next of kin or appointed member in charge of the patients care. For consent to be removed, their needs to be assessments carried out by health care workers, and for them to deem the person incapable of making their own choices. Three separate pieces of legislation apply, the Adults with Incapacity (UK) Act 2000, the Mental Capacity Act 2005 for England and Wales, and the Mental Capacity Act (Northern Ireland) 2016. The main principles of these that relate to this scenario are: capacity is presumed unless proven otherwise, an irrational decision does not equate to the absence of capacity and all practical steps to help a person to make a decision must be taken. Issues of consent must be taken seriously, as it is a criminal offence to carry out a procedure on a person if they have refused it.
In this case I was able to help the patient make the right decision. Granted this wasn’t by me talking to the patient and informing her of the repercussions of her actions, but by making the decision to ask a trusted family member to come speak to her. Realising that Mrs Y was very confused, scared and not feeling in the best frame of mind to make this decision, meant I could determine that maybe seeing a loving family member who she trusts, and respects would help the situation. I do wish though that I would have been able to help the patient come to the decision to allow consent, without the need to ask for help from the family member. Although I do believe this was 100% the right choice to make, because prolonging the treatment any longer could have led to irreversible medical damage, if no family member was available to come, things could have gone very differently.
I will work on my ability to communicate and convey medical options to patients. I will use videos from the internet to analyse how to effectively communicate with patients who have diagnoses of dementia. I will also aim to implement a diary of my interactions, to record key factors that do and do not work. This will allow me to have a bank of techniques to try when dealing with differing scenarios. I will also make sure I observe other qualified members of the team to see how they interact with the issue of informed consent. Studying legislation on consent will also help me to see how and why these rules are in place, to aid my understanding. As previously mentioned, although I understand we were unable to move forward with treatment for Mrs Y, I was concerned that her refusal would lead to further harm. Making sure I don’t try and make the decisions for patients is imperative to being a trained nurse, and even though I would never intentionally go against a patient wishes, the desire to help them is strong. So, making sure I am fully versed on the law regarding consent is a must and something I will make sure I will work on immediately.
Alkhatrash, A. A. & Sreeharsha, N. (2020) Hypovolemic Shock Related to Sepsis. Case Report, Pharmacology Online, Volume 3 pp 440 – 443.
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