Question: Power Struggle

You are team leader on a medical unit of a small community hospital. Your shift is 3 pm to 11 pm. When leaving the report room, John, the day-shift team leader, tells you that Mrs. Jackson, a patient who is terminally ill with cancer, has decided to check herself out of the hospital "against medical advice." John states that he has already contacted Mrs. Jackson's doctor, who expressed his concern that the patient would have inadequate pain control at home and undependable family support. He believes that she will die within a few days if she leaves the hospital. He did, however, leave orders for home prescriptions and a follow-up appointment. You immediately go into Mrs. Jackson's room to assess the situation. She tells you that the doctor has told her she will probably die within 6 weeks and that she wants to spend what time she has left at home with her little dog, who has been her constant companion for many years. In addition, she has many things "to put in order." She states that she is fully aware of her doctor's concerns and that she was already informed by the day-shift nurse that leaving "against medical advice" may result in the insurance company refusing to pay for her current hospitalization. She states that she will be leaving in 15 minutes when her ride home arrives.

When you go to the nurse's station to get a copy of the home prescriptions and follow-up doctor's appointment for the patient, the unit clerk states, "The hospital policy says that patients who leave against medical advice have to contact the physician directly for prescriptions and an appointment, because they are not legally discharged. The hospital has no obligation to provide this service. She made the choice-now let her live with it." She refuses to give a copy of the orders to you and places the patient's chart in her lap. Short of physically removing the chart from the clerk's lap, you clearly have no immediate access to the orders. You confront the charge nurse, who is unsure what to do and who states that the hospital policy does give that responsibility to the patient. The unit director, who has been paged, appears to be out of the hospital temporarily. You are outraged. You believe that the patient has the "right" to her prescriptions because the doctor ordered them, assuming she would receive them before she left. You also know that if the medications are not dispensed by the hospital, there is little likelihood that Mrs. Jackson will have the resources to have the prescriptions filled. Five minutes later, Mrs. Jackson appears at the nurse's station, accompanied by her friend. She states that she is leaving and would like her discharge prescriptions.

ASSIGNMENT: The power struggle in this scenario involves you, the unit clerk, the charge nurse, and organizational politics. Does the unit clerk in this scenario have informal or formal power? What alternatives for action do you have? What are the costs or consequences of each possible alternative? What action would you take?