The story of Amanda Trujillo is a horrifying one. Briefly, she is a single mom who fought to get off welfare and fulfilled her dream of becoming a nurse. Not only did she become a nurse, she earned a masters and doctorate degree in nursing. One night while working a Banner Health in Arizona, she took care of a patient who was being asked to undergo a liver transplant. In talking to the patient, Amanda learned that the patient did not fully understand what was going to occur. Amanda educated the patient. She explained the option of hospice instead. The patient decided against the transplant. Then the physician came in, had a well- witnessed tantrum at the hospital when he found out his patient had decided against surgery, and Amanda was fired by the hospital. Her case came up for review by the Arizona Board of Nursing. The summary of her case written by the attorney representing her is below. Amanda has been devastated in terms of her career and her finances. She is back on welfare, her dream of being a nurse shattered.
Read more about the details of what happened here, including Amanda’s description of the events.
Amanda Trujillo was guilty of doing what nurses are trained to do – to be a patient advocate. We are required according to our ethical codes to speak up on behalf of patients. The physician was obligated to explain the risks and benefits and alternatives of the surgery. Somewhere along the way this process got derailed, and the patient was left not understanding the impact of what she was facing. Shame on the doctor for not seeing his patient as a person instead of a case, and shame on Banner Health for bowing to the pressure to terminate Amanda for doing her job. Shame on everyone for labeling Amanda as being in need of a psychiatric evaluation.
I have been reviewing medical and nursing malpractice cases as a legal nurse consultant for 23 years. I am a past president of the American Association of Legal Nurse Consultants, a national organization of people who practice in this field. When nurses do NOT speak up to question doctor’s orders, to advocate for their patients, to report changes in condition because they are intimidated, BAD outcomes can result. All of us are patients; all of us need advocates to help us make decisions. Amanda fulfilled that role. The nightmare that has descended on her head is horrifying.
Read more about Amanda below and at this link: http://www.nursefriendly.com/amanda/
Here is my letter to the Arizona Board of Nursing
Arizona State Board of Nursing
4747 North 7th Street, Suite 200
Phoenix, AZ 85014-3655
To whom it may concern,
In the case of Amanda Trujillo, RN, as I understand the details of her case, she was doing her job. She was upholding her obligation to be a patient advocate. I have been a legal nurse consultant for 23 years, a past president of the American Association of Legal Nurse Consultants, and editor of Nursing Malpractice, Fourth Edition, 2011, published by Lawyers and Judges Publishing Company. I have seen cases in which patients have been injured by incompetent physicians.
Amanda’s case needs to be looked at in the bigger issue of patient care. Yes, she educated her patient to help her decide on the best option for her. But what happens to other Arizona nurses who need to educate their patients if that education results in incurring the wrath of a physician? When the nurse is silenced, afraid to speak up, afraid to advocate for the patient, some very bad results can occur. Your disciplinary action against Amanda would send a message to nurses that they should not speak up. Your failure to support her would undermine the very necessary safety net that nurses provide.
Ten years ago, five years ago, the Arizona Board of Nursing could have taken action against Amanda with very little notice from the world outside your borders. Now, through social media, you have a spotlight on your actions. We watched the case of the nurses in Texas and rallied behind them. You can’t hide. Do the right thing and drop the complaint against Amanda. Allow her to resume her life.
Patricia Iyer MSN RN LNCC
Past president of AALNC
Here is the report prepared by the attorney representing Amanda.
BEFORE THE Arizona STATE BOARD OF NURSING
In the Matter of Registered Nurse License No. RN137552 issued to:
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 (date omitted) with the Arizona State Board of Nursing (“Board”) by (“facility”).
Description of Relevant Events
The allegations contained in the complaint arise from events that occurred on (omitted), when Ms. Trujillo was caring for a patient with end stage liver disease in the (unit at facility). Ms. Trujillo had been a registered nurse with (facility) 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 (facility) 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, and was eventually terminated by (facility).
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 facility’s website that addressed those areas. Additionally, she printed out education materials from facility’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, (omitted), 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 (facility) 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 (facility), Ms. Trujillo self-educated in order to work within facility’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 (facility) 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 (facility) 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, 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 (facility) 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
Donate to Amanda Trujillo. Use this link.
Sign up on this site for your own monthly copy of Avoid Medical Errors Magazine – no charge to you. See the sign up box in the upper right corner. Join us today.