In the course of caring for a patient who was facing the potential of a liver transplant, Amanda offered this patient information regarding the availability of hospice as an alternative to this risky surgery with an uncertain outcome. It was clear to Ms. Trujillo that the patient did not understand the risks involved in this procedure, and she saw it as her professional duty to provide the appropriate resources and referrals to the patient so that she could make a fully informed decision. The patient subsequently chose to not undergo the procedure, and the physician who had planned and scheduled the surgery filed a complaint against Amanda and demanded that her license to practice be revoked.
Many of us in the nationwide nursing community are advocating for Amanda, and calling for the Arizona State Board of Nursing to cease and desist their actions which have deprived Amanda of her nursing license, brought her before the Board for disciplinary action, and requiring that she undergo a psychiatric examination. These actions are depriving Amanda and her daughter (she is a single mother) of their means of financial support, putting this small family at great risk of economic disaster.
The following is an open letter to the Arizona Board of Nursing, and was written by Kevin Ross of Innovative Nurse. I echo Kevin's sentiments, and urge all nurses and non-nurses who support Amanda's right to practice as a nurse to contact the Arizona Board of Nursing at 602-771-7800 or firstname.lastname@example.org, informing them that we are watching this case closely and will not allow Amanda to be treated unfairly or unjustly.
Below Kevin's letter is a legal briefing describing the events in question. After reviewing the case details, please feel free to contact the Arizona State Board of Nursing on the behalf of Ms. Trujillo. The Board can be reached at 602-771-7800 or email@example.com.
An open letter to the Arizona State Board of Nursing.
Disclaimer, I have not been directly contacted by Amanda Trujillo, MSN, RN, DNSc-NP(s), nor do I know her personally or professionally. I am also writing to you based on the information that I have available to me.
To the Arizona State Board of Nursing:
To whom it may concern,
I am writing to you on behalf of Amanda Trujillo, MSN, RN, DNSc-NP(s) regarding the case attached below. I have not been contacted directly by Amanda Trujillo, and I have neither a personal or professional relationship other than that she is a fellow nurse in need of my support.
Based on the information I have (to my knowledge the same case documents that you also have), I would like to ask the board to carefully consider the information presented by both Ms. Trujillo and her legal team. From my understanding, it appears that Amanda Trujillo evaluated the health status of her patient based on her own clinical assessments and also data collected while being treated by the medical team at Ms. Trujillo’s place of employment during this time. It also appears from the information that Amanda Trujillo provided health teaching, counseling, and advocacy for her patient, which to my understanding of the Nurse Practice Act is well within her scope of practice.
As a nurse and patient advocate, I make certain that each and every patient I provide services to does in fact receive the highest quality nursing care while on my case. It should go without saying, but part of this care involves my ongoing support to ensure that my patient is knowledgeable about their diagnoses, medications, and ordered treatment plan. It is my job to protect the health and safety of each and every patient that I come into contact with, and to advocate for their needs based on my clinical judgement.
I am not in any way assuming that the treating physician was negligent, however considering that this is, and should have been a collaborative approach in the patient’s care, Amanda Trujillo was making her own nursing diagnosis based on her clinical assessment, which again to my knowledge is within her scope of practice as a registered nurse. She apparently discovered a deficit in her patient’s knowledge about their treatment options, and it appears that she acted ethically in supporting her patient’s wishes to seek additional information, and referred the patient to a case management specialist as per protocol.
I realize that these cases can carry with them a great deal of emotion due to the sensitive nature that our number one priority as licensed nurses is to protect our patient’s health and safety. It seems that Amanda’s duty to uphold the rights of her patient is being challenged, and the circumstances in which this transpired seems to have been initiated and fueled by emotion, and not based on facts. I just ask that you please consider all of the information presented to you, evaluate this case objectively, and if Amanda Trujillo is exonerated from these allegations, that she have the opportunity to continue to practice professional nursing.
Thank you in advance for your time and your consideration in this matter.
Kevin Ross, R.N., BSN
Please see the following for further details of the case:
BEFORE THE Arizona STATE BOARD OF NURSING
In the Matter of Registered Nurse License No. RN137552 issued to:
Amanda Trujillo, Respondent. )
RN/LPN INVESTIGATIVE QUESTIONNAIRE
DESCRIPTION OF EVENTS
(Nurse Practice Consultant, Ann Schettler)
Respondent Amanda Trujillo, by and through undersigned counsel, submits this Description of Events in response to a complaint filed against her in June of 2011 with the Arizona State Board of Nursing (“Board”) by Banner Del E. Webb Medical Center (“Webb”).
Description of Relevant Events
The allegations contained in the complaint arise from events that occurred on April 12th, 2011, when Ms. Trujillo was caring for a patient with end stage liver disease in the 3D Telemetry unit of Webb. Ms. Trujillo had been a registered nurse with Webb for approximately six months prior to the date of the alleged conduct and she normally worked the night shift from 7 a.m. to 7 p.m.
After assessing and communicating with the patient, Ms. Trujillo’s evaluation led her to believe that the patient did not fully understand what she had consented to when (pt) agreed to go forward with an intensive transplant evaluation scheduled to begin at Banner Good Samaritan Medical Center the following day. Based on her nursing assessment, Ms. Trujillo gathered patient education materials and spoke with the patient regarding the transplant evaluation, the waiting period and the commitment needed in following a lifelong self-care regimen. After their discussion, the patient expressed a desire to learn more about hospice care because (pt) was uncertain she was willing to take the necessary steps to maintain a successful organ transplant. Thus, the patient inquired into whether (pt) could speak with a hospice representative. Ms. Trujillo then placed an “order” for a case management consult with a hospice representative. Ms. Trujillo did not believe that requesting a case management consult was a medical order requiring physician permission; she believed the consultation was for educational purposes in order to give the patient a broad understanding of her options.
As a result of the additional information given by Ms. Trujillo, the patient determined (pt) did not want to go through with the liver transplant evaluation or resulting transplant procedure. When the doctor treating the patient found out about the patient’s wishes to forgo the evaluation he was unhappy that the patient had changed (pts) mind and determined that the education given by Ms. Trujillo was the underlying cause of the patient’s change of heart. He accused her of going beyond her scope of practice by entering a physician order without permission (“ordering” the case management consultation). As a result of the accusation, Ms. Trujillo was placed on administrative leave by her nursing director, Venus Gaines, and was eventually terminated by Webb.
Ms. Trujillo believes she was well within her scope of practice to assess the patient’s understanding of (pts) plan of care. She was not acting outside her scope of practice by educating the patient (deferring all questions outside of her scope to the medical team), once she determined the patient had a gross misunderstanding of what (pt) had agreed to participate in. Ms. Trujillo believed that the case management “order” she placed on the patient’s behalf was not a medical order that needed physician permission. Each step of the treatment provided by Ms. Trujillo to the patient will be analyzed below.
It is standard practice for Ms. Trujillo to ensure her patients understand their medications, plan of care and treatments. While fully reviewing the patient’s medical record Ms. Trujillo read a progress note entered by the patient’s primary care physician from earlier in the day that noted a “transplant evaluation is the only viable option outside of Hospice.” Utilizing the standard nursing process of patient assessment (assessment, diagnosis, planning, intervention, evaluation), Ms. Trujillo asked the patient a number of open-ended questions regarding (pts) hospital stay, medications, liver disease, procedures, etc. Ms. Trujillo asked the patient if (pt) had received any information or teaching regarding the proposed transplant evaluation. The patient, to Ms. Trujillo’s surprise, responded that (pt) did not understand (pts) disease, plan of care or what a transplant evaluation entailed. The patient asked Ms. Trujillo if she could provide some information regarding the disease and any less invasive choices that would allow (pt) to go home and be with (pts) family. Based on this request Ms. Trujillo determined the patient had a knowledge deficit regarding (pts) disease and the choice to receive palliative care.
Having assessed the knowledge deficit related to the patient’s routine medications, disease process, associated tests and procedures, the plan of care for transplant evaluation and palliative care options, Ms. Trujillo proceeded to print out patient educational material from Banner’s website that addressed those areas. Additionally, she printed out education materials from Banner’s transplant website pertaining to what to expect during a transplant evaluation and what to expect after a transplant. Ms. Trujillo also provided materials related to hospice care per the patient’s request. Ms. Trujillo, concerned about the patient’s lack of understanding of (pts) treatment regimen and the option for comfort care, discussed her education of the patient with her clinical manager, Frances Fausto, who readily supported Ms. Trujillo’s plan of care and interventions.
Ms. Trujillo and the patient reviewed the materials over the course of the night. After a full review of the materials the patient stated, “Had I known everything I would have to go through and the commitment I would have to make, I would not have agreed to the transplant evaluation.” The patient inquired into whether there was anything else (pt) could do besides enduring more tests, procedures or surgeries. Ms. Trujillo then explained hospice care services and the differences between symptom relief care and end of life care. The patient expressed serious concern that (pt) would not be able to commit to an extensive aftercare regimen following the transplant by stating “at this stage in (pts) life (pt) just wanted to be around family.” The patient requested to visit with a representative from hospice in order to ask some questions and gain additional information that would assist (pt) in making a more informed decision regarding (pts) course of care.
Ms. Trujillo placed a note in the chart pertaining to the assessment of knowledge deficit, the specific education provided and the palliative care discussion, in addition to, the patient’s request to see a case manager from hospice. She used the SBAR (Situation, Background, Assessment and Recommendation) format of report required in Banner policy when she handed off care of the patient to the dayshift nurse, alerting the nurse that the patient requested more information prior to being transferred to another facility for a transplant evaluation. She also alerted the dayshift nurse that there was a nursing note in the record for the doctor to read that detailed what occurred over the course of Ms. Trujillo’s shift with the patient.
Case Management Consult
As a relatively new nurse to Banner, Ms. Trujillo self-educated in order to work within Banner’s policies and procedures. She found no specific policy or procedure regarding end of life care that prohibited her from obtaining case management consultations for her patients. She also could not find any policy or procedure that gave a formal definition of a “physician order” or what nurses could order and what they could not. In fact, Ms. Trujillo had ordered hospice consultations for her patients on numerous occasions prior to this incident without any objections from other physicians or Webb administration. She entered the “order” with a note stating, “per patient request, patient wants to visit with hospice representative for more information.” In fact, the computer system in place at Webb allows her to click a box that further specifies “Nurse Ordered,” which she did on this occasion.
The only reason Ms. Trujillo’s actions turned into allegations of unprofessional conduct is because the primary care physician on this case, The Dr. initiated an angry public display when he found out that the patient had changed (pts) mind regarding the transplant. Ms. Trujillo was surprised when the nursing director, Venus Gaines, went so far as to tell Ms. Trujillo that the physician was angered because she had, “messed up all of the work they had done, and that the doctors were nowhere near going down the hospice route.”
This was not a medical order. This was a nurse trying to help a patient become better informed about a life changing procedure and (pts) right to choose what direction (pts) care would go. Ms. Trujillo’s actions were well within her scope of practice and she conscientiously kept her line of teaching within the boundaries of her scope of practice by taking care to utilize the proper channels to obtain patient teaching materials and advising the patient to ask the doctors about more complex questions she was unable to answer as a registered nurse.
The patient had the absolute right to self-determination regarding her course of treatment, as illuminated in Senate Bill S. 1052, the Bipartisan Patient Protection Act, after receiving additional information regarding her disease. Ms. Trujillo, working within her scope of practice and the nurse’s code of ethics, honored and protected that right when she abided by the patient’s requests to the best of her ability.
Accommodating a patient’s request for a consultation with a hospice case manager does not require a physician’s order. No medication was requested, no equipment was needed, and no procedures were required. A patient simply wanted to speak with an expert regarding her options for comfort care and end of life care, so that (pt) could make the best decision about (pts) future.
It is standard knowledge that the Cerner electronic health records system in place at Webb contains a box that states, “Nurse Ordered.” Why would this box exist if nurses were never allowed to “order” anything? The Complainant contends that Ms. Trujillo overstepped her scope of practice by ordering the consult; however, it is standard practice of the hospital to allow nurses the freedom to do the exact thing alleged in the Complaint.
Ms. Trujillo was allowed to order case management consults on numerous occasions prior to this and was never told by the hospital that this practice was not allowed or outside the scope of her practice. It is apparent that the hospital is simply trying to appease and placate an angry physician by filing this Complaint against Ms. Trujillo.
She looks forward to discussing this matter with the Board, if necessary, and hopes to conclude this matter expediently.
SUBMITTED: July 11, 2011
ROBERT CHELLE LAW
Attorney for Amanda Trujillo