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I just read [your column] in the Dec. 17 issue of NurseWeek. The overall emphasis was on how patients have the right to be in control. With the way health care is giving so many rights to patients, is it not the place of health care to just give patients options and not go over the patient's authority? That is one issue that has come up in many DNR/DNI cases when the patient has an advance directive requesting DRN/DNI and the family requests otherwise.

~E.N.

If a patient has executed a valid advance directive that requests a DNR/DNI status, the family has no authority to change that directive. In most states, only the patient can revoke the advance directive. Ignoring the patient's advance directive can be a criminal offense in some states.

In the absence of an advance directive, most states allow the spouse or eldest child to inform the physician as to what the patient would have wanted in the situation and the physician has the authority to make the decision. Some states even permit certain family members the right to execute an advanced directive on behalf of the patient. Every nurse should be familiar with the law regarding advance directives in the state in which she or he practices.

Role of chaperones

My question is regarding the chaperone for pelvic exams. With a male clinician performing the exam, can the chaperone be male or female and does the chaperone need to be a medically trained individual?

~J.M.

The purpose of the chaperone has changed over the years. Originally, a female chaperone was present to comfort the female patient. Now, the chaperone is present to protect the clinician from any accusation of wrongdoing. The chaperone is now a witness.

The answer to your question may lie in the provisions of the liability insurance policy of the clinician performing the exam. A male obstetrician might be required to have a female employee present during the exam. Absent any insurance requirements to the contrary, both the sex and medical training of the "witness" should be irrelevant (i.e., any person can be a witness). The decision as to the sex and training requirements of the chaperone should be left to the clinician performing the exam if that clinician is a private practitioner. If the exam is performed in a clinic or hospital, the requirements should be determined as a matter of written policy.

Dispensing medications

I work in Wisconsin, and apparently it is the practice in smaller institutions for nursing supervisors to go into pharmacies to get medications when the pharmacist is no longer on duty. Smaller acute care facilities do not have 24-hour pharmacy service, although a pharmacist is "on call."

Nursing supervisors not only are expected to get meds that are missing from patient drawers or that were accidentally wasted, they also have to get medications on new admits. I have read the Nurse Practice Act and could not find anything that says a nurse can dispense medications.

~C.C.

The practice you speak of is not confined to your state, but is endemic anywhere there are small facilities. To protect yourself, however, you do need to bring this practice to the attention of both the nursing and pharmacy boards of your state for a determination as to the scope of nursing practice in your state.

It is my understanding that as long as the medicine you are "dispensing" is labeled in unit-dose quantities, you are not engaged in the practice of pharmacy. However, you are not permitted to place a liquid medicine in a bottle and label it or otherwise repackage or relabel any drug. The rules may be different in different states.

Possible termination

I have refused to float to a critical care unit. I explained to my nursing supervisor and even the unit director about my lack of experience and training in telemetry. Despite this, they insisted on sending me there. Now, I'm facing possible termination.

I would like to know the legal implications of their conduct and my position. Many other nurses are being thrown into unknown and many times hostile units due to short staffing. Please let me know how to act in these situations.

~S.B.

You were right to refuse to accept responsibility for patients requiring care you couldn't safely provide. As I understand your letter, you did go to the critical care area and took responsibility for patients and you face possible termination in spite of that.

If you belong to a union, follow its policy on this. If you have no union and you still have some room to maneuver, the policy manual might be helpful to you now. There should be a job description for a nurse in that critical care area and it should mandate at least a basic course in dysrhythmias. Ask the person who may fire you about this requirement. Other basic requirements also may be listed that you do not possess and that you might also discuss with this person. If you have already been terminated, file a grievance or whatever else is available to you as a terminated employee and get a lawyer.