Why physicians should care about Amanda Trujillo

Why physicians should care about Amanda TrujilloFor the past month, the case of Amanda Trujillo has resonated deeply among nurses, triggering an avalanche of postings on Facebook, Twitter and in the nursing blogosphere. Trujillo is the Arizona nurse who was fired in April 2011 after providing education and making a hospice care consult request for an end-stage liver disease patient. This patient was slotted for pre-transplant evaluation and had poor understanding of the disease process and treatment options. Trujillo filled in the gaps for this patient. Trujillo then requested, at the patient’s own wish, a hospice team consult, documented her actions appropriately, and left a note (it was night shift) for the primary physician.

These actions — the education and the hospice team consult — drew the wrath of both the primary physician, who demanded her dismissal and her license, and also her nursing director, who told Trujillo she had “messed up all the doctors’ hard work and planning for the surgery.” The patient-requested hospice care consult was cancelled. Trujillo’s employer subsequently fired her, and reported her to the Arizona State Board of Nursing for exceeding nursing scope of practice, though in fact, nurses previously had ordered a hospice care consult without consequence. In short, many nurses believe Trujillo was fired for educating and advocating for her patient.

These are the bare bones of the story. Further details can be found on WhiteCoat’s Call Room and on Nurse Up for Amanda Trujillo. The debate among nurses — sometimes heated — has common themes around the limits of nursing practice, the meaning of nursing advocacy, and how nurses in trouble are left high and dry by the professional organizations that purport to represent them. Well and good. But why should physicians care?

Before I answer that question, let me tell you about my own practice as a nurse in a busy Toronto emergency department. I work shoulder-to-shoulder with some of the best physicians I have ever known. Our goal is give excellent care and treatment to every patient we see. In order to do this job well and effectively, I need some tools — like the freedom to educate and advocate for my patients — and recognition that my judgement and accountabilities as a nurse are quite separate, if related, to those of physicians.

More importantly, I need the confidence to know I can engage in collaborative practice — and this in not just a one-way street, by the way —with my physician emergency department colleagues. This is not a theoretical proposition, incidentally. If I tell an ED physician, for example, that a patient’s needs are largely social, and I have arranged for social work, and if she discounts or minimizes my concerns, and cancels the referral, then the patient suffers in the end. If I tell her that in my nursing judgement, the patient is crashing, and she ignores me, the patient dies. Being an effective patient advocate and practicing collaboratively with physicians (and patients too, I might add) is good patient care. Yet doing my job well is precisely the same sort of advocacy which got Amanda Trujillo fired and reported to the Arizona State Board of Nursing.

Physicians should be concerned about Amanda Trujillo for this reason: ultimately her case is about providing good patient care.  There are, of course, obvious serious issues about patient autonomy and the ability of hospitals and physicians to override patient decisions about their own care. Many physicians might sympathize with Trujillo’s arbitrary firing, or see in her case a reflection of their own professional concerns about the role of large health corporations in their day-to-day practice.

But for me, as a nurse, the issue boils down to whether the health care industry can tolerate highly educated, vocal, critically-thinking, engaged nurse-collaborators who, in the interest of their patients, will constructively work with — and challenge, if necessary — physicians and established treatment plans. Or does the industry just want robots with limited analytical skills who blindly and unthinkingly collect vital signs and carry out physician orders? More importantly, which model presents the best opportunity for excellent patient care?

For me and most nurses, the answer is obvious. What about physicians?

“J. Doe”  is a nurse who blogs at Those Emergency Blues and is on Twitter @TorontoEmerg.

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  • Anonymous

    Thanks for bringing this interesting story to my attention. Ultimately it is about doctor and nurse not effectively communicating. How could this situation have been averted? Should the nurse have called the doctor that night to discuss her concerns with him, prior to initiating the consult. Certainly it seems that Ms. Trujillo was working as an advocate for her patient. However patient care is most successful when the care team is acting in a coordinated fashion. Was the surgeon receptive to hearing the opinion of other team members? It’s a tragedy that ms Trujillo was fired over this. Hopefully, the end result will be to improve team work on the transplant service of this hospital.

    • http://torontoemerg.wordpress.com/ TorontoEmerg

      A point of clarification: the patient had not seen the transplant surgeon at this point, and the angry physician was, in fact, a internal medicine subspecialist. In the event, calling the primary care physician at midnight (or later) would have drawn the response of “why the hell are you calling me now?” and in any case could have waited till morning.

    • Anonymous

      a NIGHT nurse making a hospice referral??? The role of the night nurse is to maintain stability thru his/her shift, realizing that the vast majority of important decisions happen DURING THE DAY, when patients/families/doctors/social workers/specialists etc. are available and in tip-top shape for medical decision-making, and all appropriate information is readily availabe to everyone.

      And why do nurses frequently assume that doctors don’t give their patients an accurate portrayal of their prognosis?  Nurses see such patients during a brief snapshot of their hospitalization, but don’t they realize that doctors have a relationship with their patient perhaps for YEARS? Also, how does the nurse know what someone’s prognosis is? Is this taught in nursing school? because for cancer diagnoses, it took me med school, 3 yrs of residency, and a year of oncology fellowship, and i STILL have to look up the data when presented with a new clinical scenario.

      I have heard nurses suggesting to me, or even worse, directly to my patient, that they are dying because they have lymphoma, testicular cancer, CHF with LVEF 45%, early-stage breast cancer, and a host of other diagnoses.  This is DEFINITELY beyond the scope of nursing practice, and certainly unreasonable for a night nurse, who maybe is ok to provide some education, but ultimately defer a serious discussion to the day staff, patient & family, primary physician, and oncologist.

      • Anonymous

        Wow.  I occurs to me that physicians just do not understand what nurses do.  Patients can think and reflect at night and that is when most questions are asked and real decisions are made.  Not when there is a lot of noise and a bunch of people with differing opinions throwing data at patients.  It is the time when patients sort out all the information and really set a course of action.  That is why so many patients have epiphanies and change their course of treatments at night.  Night nurses know this and work diligently with patients.  But sometimes, even with reinforcing medical treatment, patients will decide to forgo medical advise and create their own path.  

        I agree that some physicians have great relationships with their patients.  I have seen the great benefits that type of relationship has on patient outcomes.  It truly is a therapeutic healing relationship.

        But in this day and age, that relationship is rare.  Typically a patient sees many many physicians during a hospitalization. Most of them for the first time ever.  There is no relationship.

        Honestly, I think Ms. Trujillo was well within her scope of practice.  The order was entered as a nursing order so hospital policy was followed.  What might have facilitated communication is if the facility would leverage and utilize a hospitalist care delivery system so medical review could be more timely.  Perhaps if the physician would advocate for that instead of targeting the nurse for punishment it would actually address the underlying problem.  Just an idea.

        • Anonymous

          “The order was entered as a nursing order ”

          what does that mean? a telephone order from the physician? since when can nurses independently issue an order? 

          If you’re saying its within her scope to refer a patient going for a liver transplant the next to hospice, that is absurd.  It undermines the relationship between the entire team and the patient, who now views the team as disorganized and divergent.  Sending mixed messages to a patient, who presumably has already been through a long and arduous illness and complex decision-making to undergo surgery.  And as demonstrated above, nurses are NOT as well-equipped to make a judgment on prognosis for a given illness as a physician.

          • Anonymous

            Nurses have been issuing orders since the mid-70s.  A nurse’s order like that is simply asking someone from hospice to stop in and speak with the patient.  It is not placing a patient on hospice.  Nurses order those types of consults all the time.  That’s why the EHR had the option for a nurses order. Nurses orders include interventions for the hospital chaplain, for dietary to speak with the patient. etc.

            Nurses have an independent practice outside the scope of the physician.  Sometimes nurses need a physician order and sometimes not.  That’s why it is called collaborative practice.

            Nurses do not make judgments on prognosis.  For the most part prognosis has little to do with nursing practice.  Nurses assess patients, diagnose and treat patient responses to illness.  That is what nursing practice is and supported by nurse practice acts across the country.  Nurses would be negligent if they did not.  So in this case, the diagnosis was knowledge deficit related to treatment options manifested by patient inquiry.  The intervention was to get the information to the patient by a request that a specialist speak with the patient.  Well within nursing scope of practice.

          • http://twitter.com/MatthewBrowning Matthew Browning

            Wow! KJindal, your ignorance is only matched by your arrogance, misogynism, egotism, classism and stereotypical thinking (or lack of it). Please show your pathetic posts to the nurses you work with so they can teach you the ropes, as they leave your employ, and to your bosses so that they may see your neanderthal-like tendencies in black and white. Your insinuation of kickbacks, hidden in the theoretical, are borderline libelous and completely uncalled for in this discussion. Sorry you couldn’t handle being an oncologist, but to suggest there is some deficiency in night nurses, per-diem nurses, homecare nurses and nurses who choose to not pursue further education speaks more to your lack of understanding than to their capabilities, education or dedication. See, here in the in the good ol’ USA, in the 21st century, nurses are intelligent, respected, and indispensable members of any competent care team. I am not sure what rock, buried in the dark ages, that you crawl out from under to spew this drivel, but you would be laughed of the floor of any real hospital and be fortunate to even continue to earn a living. Any american woman would recognize your innate ability to respect their professionalism simply due to their sex, and any modern man would be embarrassed by your demeaning of these nurses to fuel your unearned, knuckle-dragging, inflated sense of superiority. While your myopism demands you focus solely on the pathology, nurses are trained, licensed and expected to perform assessments of the entire bio-psycho-social spectrum of the human being the are charged with the care of ad, as such, they perform many interventions, procedure and, yes, write orders for their patients. As the primary care givers for the majority of patients, nurses are often more in touch with, have a better understanding of and are better positioned to be the patient’s advocates than the exalted MD. While I do not care for your viewpoint, do not believe in your competence and do not care what happens to you personally or professionally- I shudder to think of all the lives you’ve harmed, the nurses you’ve abused and the patients you’ve compromised with your type of medical practice. Honestly, I’d rather be cared for by a competent nurse than an MD who, like yourself, takes such a regressive stance due to your assumptions. Here in the USA we have a saying that “to assume makes an ass out of u and me” in this case, however, that seems to apply only to you. God help your patients and thank god for nurses, especially for your patients. P.S. The nurse in this case, Amanda, is earning her doctorate in nursing, is intelligent and caring which out classes you in all three areas. Man up doc, your insecurities have overtaken your sensibility. The only statement you’ve made worthy of repeating is “there are just too many unknowns here”, I agree and suggest it would have been better to have people think you were a fool, than to have opened your mouth and removed all doubt. 


            Matthew Browning, MSN, RN, CEO

            P.S. KevinMD and J. Doe thank you for bringing such an important issue to the forefront. Amanda, good luck with your struggles. 

          • Anonymous

            Wow Matt, you are really showing your true colors, and clearly point out your stereotyping of me, and overwhelmingly anti-physician agenda.

            What about anything i said was misogynistic?
            “pathetic?… neanderthal?…”

            let’s talk about YOUR assumptions:

            1- ms trujillo was correct in her actions.  you assume this without hearing the other side, AND with knowing there was some adverse action taking by the nursing board.  You assume that their judgment was wrong, again knowing only one side (as do i)

            2- it seems that you’re assuming that i came from some paternalistic (e.g. far east or middle east) society, and your post even smacks of a little racism (“good ole US of A… Any american woman…”).  This reminds of the dr.roozrokh case where the nurse complained to the medical board that this doctor “with an accent” ordered inappropriate opiate doses to a dying patient. that doctor was born & bred in california. And FYI, not that it matters, i was born & raised in the USA too, and am as American as you.

            3- you assume that i’ve abused nurses & harmed patients??? that is really offensive.  I get along great with my nurses, and patients & families almost universally consider me a great communicator.  You should take notice that the only posts that could be construed as offensive were in response to the attacks, like yours and pattirn’s (since removed, but she called me a ‘f***head’ etc.)

            I have tremendous respect for nurses who truly work at the bedside. Its such  a shame it doesn’t go both ways, and that most doctors are too concerned with political correctness to defend themselves against such attitudes as yours.

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            …At least paint within a color palette of blue (its my favorite color)….no action–formal judgement has been made against me Doctor.   

          • Anonymous

            oops my mistake, i misread the post. i should’ve said “adverse action taken by the hospital…”

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            ahhhhhh….now that feels like a tall drink of fresh orange juice….refreshing. Thank you Doctor, for clarifying. :) 

          • http://twitter.com/MatthewBrowning Matthew Browning

            Mr Jindal,

            I have great respect for physicians, nurses, patients and humans in general. You, sir, simply do not deserve my respect, or that of others, as a result of your behavior on this board.

            1) I discussed and responded to your comments and the nursing profession in general- I have not assumed ANYTHING about Amanda’s case or the AZ BON.2) Maybe nurses in other countries feel differently, so I clarified I was speaking about American nurses. I do not care where you are from, my comments stand, again in response to your denigrating comments on this board alone.3) I’ve seen you verbally (in writing) abuse the nurses here- your bed, lie in it. That attitude directly harms the nurses you interact with and by extension THEIR patients due to fear of your retribution or wrath. Get over yourself, without your nurses and patients, you are just another pompous peon with an outstanding student loan.Finally, you’ve shown zero respect for the nurses posting here and now it does go both ways. It is an unpleasant feeling, isn’t it? You sir, are an over-bloated ego with no agenda but the harassment of the nurse commentators on this blog. I’d prefer to wait for the facts, assume Amanda’s innocence until proven innocent of guilty, and keep the opportunistic obfuscators in check.My appraisal of you, as a direct result of your verbal abuse of the posters here, is that you are a woman-hating, power-tripping, nurse-demeaning bully who has gone far too long without someone pointing out the obvious. As to the use of setting appropriate words like ‘biopsychosocial’, your discomfort with them, together with your poor spelling, vocabulary and grammar, indicates that you are a sub-par intellect that parades as some superior clinical mastermind that doesn’t understand the basis of nursing science nor its practice.Kevin, Amanda and J. Doe please forgive my pointed response to this “doc”  Your blog is important, valued and informative, and I thank you for this post.Sincerely,Matthew Browning MSN, RN, CEO

          • Anonymous

            MY behavior? “pathetic… neanderthal… pompous peon… over bloated ego… harassment of nurses… woman-hating… power-tripping… sub-par intellect”

            my initial point was missed (which others too made), that important decisions are better made during the day. But your gross insecurity interprets that as “night nurses are stupid”.  And i NEVER said anything referencing women. YOU are just determined to portray me as a woman-hater.  

            As an undergraduate (ivy league) I never had issues with vocabulary, spelling, or grammar. I have been published in peer-reviewed scientific journal.  In fact, i remember lecturers saying “if you can think clearly, you can write clearly”. I just don’t feel the need for perfect grammar etc. when writing a blog post- i’ll save that the next time i write a letter to the NY times editor.

            I am again sorry you have such an insecure need to insult me for questioning something that is at least controversial.  You have personally attacked me without shame, and are thus very unprofessional. Read your post back to yourself out loud.  Doesn’t it just sound nuts?  I think you are dangerous, and am surprised you can be a CEO of anything besides maybe a hot dog stand.

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            M….are we nurses supposed to say bad words like….”biopsychosocial?” In recent days I actually got chided for discussing “Root Cause Analysis” with the statement made that nurses arent supposed to be thinking of such things. Maybe we should make a list of words and concepts that nurses are not supposed to know about or discuss….I may make that part of my lesson plan when Im teaching future nurses…….Ill have each student make a list of things they perceive we sould know about and things they perceive are out of our thought process…..Ill give them a big list and ask them to place them in each category…..Im kinda curious about the outcome….hell, maybe Ill even do a quantitative study on that topic. Wanna help???   

          • Anonymous

            and as far as competence, what information do you have that permits you to adequately assess my competence? your tendency make such assumptions make me question YOUR competence, and your need to place lots of letters behind your name makes me think you’re insecure too, a dangerous trait in patient care.

            And the need to use words like ‘biopsychosocial’- i don’t feel the need to flaunt such terms, but FYI i deal with psychologists & social workers every day in the interest of patient management.  I am VERY secure in my ability to take good care of patients (would i be posting so clearly against the grain of PC-ness otherwise?).

            Use your logic, letter-man.

          • Anonymous

            Nurses have been issuing orders since the mid-70s.  A nurse’s order like that is simply asking someone from hospice to stop in and speak with the patient.  It is not placing a patient on hospice.  Nurses order those types of consults all the time.  That’s why the EHR had the option for a nurses order.  Nurses orders include interventions for the hospital chaplain, for dietary to speak with the patient. etc.

            Nurses have an independent practice outside the scope of the physician.  Sometimes nurses need a physician order and sometimes not.  That’s why it is called collaborative practice.

            Nurses do not make judgments on prognosis.  For the most part prognosis has little to do with nursing practice.  Nurses assess patients, diagnose and treat patient responses to illness.  That is what nursing practice is and supported by nurse practice acts across the country.  Nurses would be negligent if they did not.  So in this case, the diagnosis was knowledge deficit related to treatment options manifested by patient inquiry.  The intervention was to get the information to the patient by a request that a specialist speak with the patient.  Well within nursing scope of practice.

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            Since when? Since forever Doctor. There are such things as nursing orders—and those orders are within the scope and process of what nurses do—look it up—”Assessment/Diagnoses/Planning/Intervention/Evaluation”–and before you go tearing about with your hair on fire the word “Diagnosis” is actually standard in ALL nursing texts from day one of nursing school right up to graduate school. Since this IS a teachable moment, here are some examples of nursing “orders”—Dietary education, Diabetic Teaching, Wound Care, Case Management, Social Work, Chaplaincy, pre and post operative teaching for interventions such as incentive spirometry and self care regimen, and Coumadin teaching for patients just being started on anticoagulation therapy. To name a few. I will correct yet another asumption you are making with regards to this case:  “Sending mixed messages to a patient, who presumably has already been through a long and arduous illness and complex decision-making to undergo surgery.”
            1.) No mixed messages were sent because of the use of open ended questioning and the patients requests for more information
            2.) Long and arduous illness is a 100 mile stretch in every sense.
            3.) Complex decision making? No. This person was very clear on what their goals/prioties were and how they viewed their life experience as it pertained to their illness, as well as how they “envisioned” their life being in the time they had left.  
            4.) “And as demonstrated above…” ****SURPRISE!!! (AUDIENCE CHEERING)**** We agree! You are completely right, nurses are not well equipped to make prognosis for a given illness—-ever—-THATS WHY I DID NOT DO THAT NOR HAVE I EVER ATTEMPTED TO DO THAT IN MY PRACTICE!

            Now, can you please—stop painting this picture into some piece of artwork you find stimulating and discussion worthy and stick to painting in the lines of the coloring book. The lines (ie–the facts) are there for a reason. 

            Thank You.

        • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

          I dont think Banner Del Webb knows the first thing about Root Cause Analysis—and yes, us nurses are well educated in Root Cause Analysis in grad school. 

      • Anonymous

        Another Hospice-Hating oncologist.  You DO realize that you are a walking cliche?  There is no cure for cancer,dude, don’t take it so damned personally!

        Also, I am 100& sure that you are young and male, and methinks your cojones feel terribly threatend there, doc.  More’s the pity.  Have you considered dermatology? Hardly ever has a fatal outcome!

        I was lucky to work as a hospice nurse, so the choice was made and idiots like you were out of the picture. (oh, and there are criteria for hospice admission.  We, too, used “data”, not our spidy-sense)  Our interdisciplinary team worked together with one goal ONLY….patient quality of life and family support.  Everyone got to voice their observations, from the CNA to the medical director.  No turf wars, and no denial that life is terminal for everyone.

        Oh, thanks for letting me know that night shift is only for zombies with half-eaten brains.  I forgot that nothing bad or urgent EVER happens when it is dark outside.

        Q:  Why do they nail coffins shut?
        A:   To keep the oncologists from getting in that LAST round of chemo!

        Sorry to be off track on the case in question, but this moron with the world’s worst case of craniorectal inversion needed to be called out for the fuck-head he is.

        • kjindal

          Wow, what a horribly arrogant, misguided, and misinformed personal attack.  I can’t believe that didn’t get censored out. And your ignorance is just astounding. You don’t deserve to speak to patients or families on any level, given your profound gaps in knowledge.

          So since it’s out there, let me educate you, first about your assumptions about me, then about cancer:

          1- I left oncology fellowship because I didn’t come away believing in chemotherapy for solid tumors. I did, however, develop a tremendous appreciation for it for so-called “liquid” tumors.  These are cancers of blood cells and similar histologic types of cells.  For example many leukemias and lymphomas are CURABLE.  Same is true for testicular cancer, and many many early-stage solid cancers like lung, breast, and colon.  Yes that’s right “dude” they are cured with standard treatments in use today every day in any major hospital center.  Maybe this involves surgery, adjuvant and neoadjuvant (look those terms up if you ever feel like speaking from an informed position) chemotherapy and/or radiation. 

          2- now i practice internal medicine with a geriatric population, and discuss advanced directives with real prognostic advice, not just “you have cancer, and hospice would be wonderful for quality of life etc.”.  I do have those discussions too when appropriate.

          3- with standard treatment, do you know what is the 5-year-survival of st.2a breast cancer? 85%. how about st.2b?  70%. how about st.3? 50%.  From uptodate.com “Long-term survival can be obtained in approximately 50 percent of women with locally advanced breast cancer who are treated with a multimodality approach”.  But your compassion would enroll them in hospice and have them die without treatment in 6 months? Unbelievably arrogant and stupid.  What if it’s your sister or mother or daughter with such a disease? immediate hospice referral because “dude” there’s no cure for cancer?

          4- five-year overall survival from Hodgkin’s lymphoma (an agressive blood cancer – but you know that already right? as an experienced hospice nurse?) is between 56 and 89%, that’s at FIVE YEARS! and you want to doom them to the “no cure for cancer dude, don’t listen to your doctor, he just wants to keep filling your body with drugs, come to us so we can set you up to die within 6 months”!

          If you really want to act in the best interest of your patients, you need to get your facts straight, and stop being such an arrogant ass. And if “craniorectal inversion” makes you feel smart imagine how you’d feel with an actual education!

        • http://pulse.yahoo.com/_GXO5UT3MGTPBRYKXHHFG6NCRO4 S

          “There is no cure for cancer,dude, don’t take it so damned personally!”

          Do you have any clue as to what you are talking about? My own child is a cancer survivor. There are almost 10 million cancer survivors in the USA.  Do you know the 5 year survival statistic comparison between say pediatric ALL and metastatic small cell lung cancer? It is greater than 90% and less than 2% respectively. Cancer is not a monolithic disease. 

          As jindal the onc fellow was trying to point out it is important to give the statistics as far as outcomes to the patient. Was this information given? Did the patient understand th information given? The author gives little more than a one liner as to RN “filling in the gaps”. What does this mean? Did the RN quote statistics as far as transplant survival rates? Was long term immunosuppression discussed? What were the comorbidities that would affect long term survival in the patient? Heck, did the RN know the MELD score indicating the chance of getting a transplant? These are all important questions that are more than just “filling in the gaps”.  I am not saying we should know this information, but the RN should have if she was properly educating the patient in his decision making. Did the RN in question contact the doc when she felt the patient was “uninformed”? I don’t know this information and and neither do you. But I do know the “right” way was not by leaving a note from the night before. Frankly, over the years I have met very few RN’s who know specific survival information. Unlike the authors opinion, it does not appear that Ms Trujillo was acting as collaborator of a larger team. She made a unilateral decision. Without knowing anywhere near the whole story this appears to have been a communication issue at multiple levels. Losing a job over it and referral to a nursing board appears over the top, but I wasn’t there. Hopefully an investigation will determine the truth.

          The joke shows that in reality the walking caricature is you.

        • Anonymous

          how unbelievably arrogant, and ignorant.  What a shame that you were allowed to talk to patients and families at all.  FYI, i am not an oncologist – after 1 year of oncology fellowship I left because I didn’t become a big believer in chemorx for solid tumors, and even though it’s lifesaving for liquid tumors (leukemia, lymphoma, testicular cancer) “dude” i found that care too intense, stressful, and depressing.

          And you should really educate yourself on the 5-yr survival rates for st. 2 and st.3 breast cancers, leukemias, and lymphomas.  With standard treatments being given in hospitals all across the country today, these are easily in the 50-95% range.  And you would have them enroll in hospice so you can “compassionately” let them die in 6 months because, as you say”There is no cure for cancer,dude…”

          You sound like an angry child, and shouldn’t be involved in patient care at all.

        • Anonymous

          there is so much fraud in hospice care these days, with big dollars flowing from medicare to hospice agencies, one wonders whether its possible kickbacks could be in play, theoretically, in a case like this

        • Anonymous

          since u think u have me pegged, let me make some guesses about you:

          middle-aged or older, jumped from job to job as a nurse, now working at night and completely stagnant in your dead-end career, becoming increasingly frustrated seeing younger, smarter, and more motivated people achieve the pinnacle of their careers – nurses becoming NPs, interns & residents becoming attending physicians and academicians and researchers.

          have you considered a career as a night nurse? or per diem for a homecare agency? very easy, you might even be able to sleep part of your shift (my residency hospital had union-mandated sleep breaks for night nurses), and spend the rest of your time complaining about staffing ratios, while the day staff has to handle meds, families, calls about abnormal labs, carrying out physician orders, etc.

          More power to ya!!!

          • http://www.thenerdynurse.com/ The Nerdy Nurse

            have you considered a career as a night nurse? or per diem for a homecare agency? very easy, you might even be able to sleep part of your shift (my residency hospital had union-mandated sleep breaks for night nurses), and spend the rest of your time complaining about staffing ratios, while the day staff has to handle meds, families, calls about abnormal labs, carrying out physician orders, etc.”

            Again, you seriously have NO IDEA what nurses do at night. And you know, having a fulfilling and worthwhile career is not about the number of years spent in school or the letters behind your name. And contrary to your opinion, nurses are not wanna be doctors or NPs who are just stuck in a rut. We CHOOSE to be nurses. 

            Also, all those things you say only day-shift nurses deal with, were my daily life as a night shift nurse. Oh and Abnormal labs. They draw those labs at 4am. If it was a critical the MD has the be notified within 30 minutes of the readout. Who do you think was call thing the doctor at 5am? Certainly wasn’t a day shift nurse.

            Your ignorance about what nurses do is becoming increasingly apparent as you continue to post and insult my chosen profession.

          • Anonymous

            you are interpreting my post without the benefit of the Guest post, from ‘pattirn’ that was extremely personal and hateful, which has since been removed.  She stated that “dude you can’t cure cancer, get over it… you are a f***-head” etc., typecasting me as a paternalistic, unilateral unyielding and uncaring woman-hating egomaniac doctor, and i was responding.  I have a lot of respect for nurses, i just wish it was reciprocated, and as this post shows it generally is not.

            And let me add, once again, that the nurses on this thread are blindly supporting their colleague, but with grossly inadequate objective information, and one side of the story

          • http://twitter.com/VanessaObRN VanessaObRN

            ‘And let me add, once again, that the nurses on this thread are blindly supporting their colleague…’

            oh, and the doctors here never circle the wagon when one of their own is attacked on this blog?   How many times is ‘physcian bashing’ the rallying cry to patient complaints?

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            Ahhhh…there’s that artwork again :) “grossly inadequate objective information….” neato.

          • Anonymous

            why is that statement insulting to you? i think you yourself pointed out that lots of information was missing, for privacy and other reasons.  And even if you’re 100% right and the doctor is 100% wrong, we don’t have the benefit of that side of the story.  And don’t you admit that hearing your side only MIGHT be biased a little?

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            There is  nothing biased about denying a patient their  God given right to freedom of choice and self determination. Period.

          • Anonymous

            you are misunderstanding my point: is it possible that, when there is a dispute between two parties, hearing the events from ONE OF THE TWO parties involved, is biased?

      • http://www.thenerdynurse.com/ The Nerdy Nurse

        As a former night shift nurse, I can promise you that I worked just as hard in my 12 hours for my patient as any nurse did on the day-shift.

        You obviously have no idea what nurses do on the night-shift to make a statement like that.

        Your lack of respect for nurses in these comments are really upsetting and sad.

        The rise of hospitalists also means that the doctor who was taking care of the patient may have just met them on that visit. The nurse has spent hours and days with the patient. The doctor may have only spent 15 minutes. 

      • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

        Are you kidding me? I mean who are you? maintain stability through a shift? important decisions happen during the day? what planet do you exist on? tip top shape? Ill have you know doctor that I was a heart transplant nurse and an advanced heart failure nurse who also did a great deal of palliative/end of life care at one of the best heart centers in the country–the mayo clinic–look it up—they are in the elite “heart center 5.” I am a member of the international honor society of nurses, i am also part of the share care program as a volunteer nurse, I have a bachelors, masters, and am currently working on a doctorate of nursing science degree and my nurse practitioner credentials. nurses do not have an on and off switch during night and day, doctor. as a matter of fact, in case you didnt know, patients are admitted at night and I am IN TIP TOP SHAPE when I take on a night shift—to insinuate otherwise is–again, disrespectful and slanderous. If you want to voice an opinion on the situation, your perspective of whether I was right or wrong, or whether you disagree or disagree with my nursing interventions—-fine. But to issue blanket statements like this reflects extremely poor on your medical profession as a whole—your statements are representative of the medical community and I urge caution and careful thought before you further isolate nurses with these mean spirited and biased remarks. and please, dont discuss with me LV EF% because I cared for patients with less than 20% and they are perfectly capable of living at that level. Dont insult my intelligence or experience by suggesting Im going to run into every patients room who has an EF of less that 45% and tell them they are dying. Lastly, your post is largely suggesting that the nursing scope of practice be changed to further divide night nurses from day nurses—at the mayo clinic i was a day shift nurse, but I can tell you the night nurses did the same work we did and in  many instances had it a hell of a lot harder because they had less resources than we did during the day. So, share with us doctor, what would your proposed scope of practice be for  such a lowly, ill educated, less than tip top shape, half asleep nurse be? Oh wait! Let me make a suggestion—how about we just keep nurses on the day shift and employ patient care assistants to work at night—careful to take out those swan ganz catheters and wean down those drips before you sign out for the night to the next provider though….oh yes and make sure to check all those chest tubes for air leaks, your transplant prograf levels, the ultrfiltration output and associated labs to assess for kidney function, your post surgery external pacer settings, your epidural and pca pumps, the heartmate and thoratec bivad flow numbers and total artificial heart settings too–just in case you dont want to be getting hundreds of calls by those patient care technicians who have no clue how to monitor such devices or patients—-THEN…you can leave the patient care assistants (who arent licensed by the way) to care for your patients while you go off to dreamland…..We wouldnt want you to get sued now would we. As for the looking up info? I use an iphone and ipadat all times when I practice to look up information IN FRONT OF the patient and family and for visual aid when teaching about heart failure, copd, or diabetes—I highly recommend PEPID LLC. Good stuff. Lastly. Prognosis? Not my job doc–so again, stop putting words in my mouth. I do, however, take the time to read each one of my patient’s charts from the day they are admitted to present day that I receive them to get the biggest “snapshot” possible of what is going on—including…wait for it…..the doctor’s progress notes. Imagine that!             

        • Anonymous

          do you NOT think that big decisions should preferably happen during the day? after discussion with the whole team?

          and “dreamland”??? who are you kidding. doctors (except hospitalizes) don’t work in shifts. the night is often spent in sub-par sleep being awoken by the ER or office patients or lab or who knows what, after a full day in the office and/or hospital, and before another full day in the office and/or hospital.  I know there is this pervasive mentality among shift-workers that “if i have to be here, then the doc can be awoken with that white count of 11,000 too – after all, he’s making the big bucks”.

          I’m not questioning your competence or education – why do you feel the need to write a dissertation on your background?  

          But i FIRMLY stand by the notion that important decisions are for the whole team to make, during the DAYTIME, unless of course the patient is crashing, and if that’s the case, then of course the nurse should contact the doctor.

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            No, Doctor, big decisions shouldnt just be placed into a nice little box with a lid on it and reopened only during daylight hours to honor your convenience or the convenience of anyone else but the patient. Discussions? Sure. And if youll note thats EXACTLY what this was about—giving the patient the chance to have that discussion prior to being shipped out into a situation they were unclear about. And yes, you were questioning my competence—go back and revisit some of your artwork in previous posts–you were painting me to be some sort of roguish individual who had no clue about much of anything. But…Ive remedied that….and I—-DOCTOR—FIRMLY BELIEVE that important decisions are DEFINED by the following:

            1.) whatever the patient deems important
            2.) whenever the patient deems they need to be made—at 0100 or 1300
            3.) the goals and wishes of the patient
            4.) not dependant upon physician rounds
            5.) not subject to the rules or expectations of a said doctor6.) patient centered
            7.) supported by everyone regardless of when they make their presence known

            If a patient decides “I dont want to do this” or “I need more time to ask questions and get a clearer picture” (which was the case here) it is way out of your jurisdiction and POWER to inform them that “this can wait until me and 50 other people can sit down and allow you to make a decision for yourself.”

            Make up your mind, you either think night shift nurses are competent or you dont–I made the reference to dreamland because of your careless response indicating that night shift nurses are only in said position because there needs to be “maintenence” throughout the night till the “VIP’s” arrive to make the “important decisions” and do the “important work” during the DAY. I can tell you first hand that there is not much difference between what happens on either shift other than sunlight because I have worked both shifts. Its not that complicated, Doctor.

            When a patient puts up the “Proceed with Caution” sign or the “STOP” sign—whether it is day or night–In taught to listen, honor, and abide by that request and to facilitate whatever I can so that patient feels safe, heard, and respected. Regardless of whether that happens when youre sleeping, youre at lunch, or your rounding.

          • Anonymous

            so are you going to be able to contact a social worker, or psychologist in the middle of the night? schedule a family meeting at 3am?

            I don’t understand how my point is not clear, and how it can possibly really be debatable.  It’s not a matter of judging competence, just that it is generally impractical to make big things happen when many many team members are unavailable.  If you refuse to accept that point, fine- let’s just agree to disagree.

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            Well, then, I agree to disagree–and most everything is debate-able in healthcare–its called checks and balances—and the great thing about having a license and an education is the knowledge that I DONT NEED a psychologist or social worker at 0300 to give my patient permission or the green light to make a decision for themselves—-I dont understand how that point is not clear to you or how it can possibly be debated. Patient care, human beings and their decisions and their bodies and their right to a robust end of life experience–one that is fulfilling and healthy is every person’s God given right—Patient care is NOT —nor should it ever be ASSUMED to be about practicality. Again–you take the focus off the patient. There is a reason for both qualitative and quantitative research methods in nursing and medicine and it is for this reason—human beings and their health should not ever be subject what is practical or impractical in your  mind as a physician.

          • Anonymous

            on one hand you’re saying (and others blindly agree) that there was poor communication between the doctor and patient, and that such communication is paramount to patient-centered care (of course i agree).

            then on the other hand you’re saying it’s not important to discuss a potential change in plans to the rest of the team.

            that’s very hypocritical.

            and how do you know this patient was seeking a “robust end of life experience”, or even was near end-of-life at all?

      • Richard Willner

        Hey, so why have a professional Nurse?  Why not have a Nursing Assistant or someone from Housekeeping?

      • http://torontoemerg.wordpress.com/ TorontoEmerg

        To paraphrase Gertrude Stein, an RN is an RN is an RN. I’m not clear about the distinction between “night” and “day” RN. As far as I can tell my duties and professional responsibilities don’t change when the sun goes down.

    • Anonymous

      i was unable to glean real evidence from this post that the physician did not communicate properly.  On the other hand, the post is clear about Ms.Trujillo acting in medical decision-making (dressed up as “patient advocacy”) at night unilaterally, and “leaving a note” for the physician.  So it seems that the ineffective communication was hers, and hers alone.

      • http://www.thenerdynurse.com/ The Nerdy Nurse

        How is case management a medial decision?

      • http://profile.yahoo.com/A3GU3BX2WAGR36CX24CGT7TAPE Mother Jones, RN

        Excuse me, do you think throwing a temper tantrum at the nurses station is a means of proper communication?  Amanda wrote extensive notes, which is how team member communicate with each other.  Why is making a hospice referral out of her scope of practice when she was able to check a menu box that was readily available to her via the hospital’s order set?  Thank God I work with military docs.  They never question my nursing judgement, and they treat nurses with respect.  

      • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

        And for the record, I hate the word GLEAN. It reminds me of the word SPUTUM. And I hate the word SPUTUM.  

    • http://www.thenerdynurse.com/ The Nerdy Nurse

      You tell me what doctor wouldn’t be furious if Amanda had called them in the middle of the night to discuss an hospice and case management.

  • Anonymous

    This situation highlighted one of the many reasons so many nurses are leaving the profession.  We are expected to follow orders and not use our brains.  The absolute fear around providing education is insane. 

    I remember I once took care of a patient with metastatic esophageal cancer, a highly fatal condition.  His MD walked into the room and started discussing more chemotherapy and radiation therapy. Listening to this conversation, I was thinking to myself, “This guy doesn’t know he is almost certainly just around the corner from death.” I carefully asked him the following questions;  “Has your MD talked with you about your prognosis with and without the treatments?  Has he talked with you about the side effects of chemotherapy and so forth.”  

    While I never “educated” the patient, I felt it was my human duty to let this poor man know he needed to ask a whole lot more questions.  His response was “If I am going to die, I want to know!  I’ve lived a good life and I am at peace with my maker but I’d like to be able to say good by to the people I love.”  I responded “then you better talk with your MD” and very embarrassingly told him as a nurse my scope of practice was limited and I couldn’t answer these questions.”  

    My heart goes out to this nurse and good for her for doing the right thing!

  • Anonymous

    Turf wars.  Just ridiculous.  And sad for the patient.
    I practice in adult medicine and have many patients who want to push for that last second of life, and others who want rest and comfort that hospice can bring.  It’s the patient choice, and I stand behind their decisions, no matter how they are made.
    The worst situations are the ones where the patients have made their decisions and family from far away sweeps in at the last second, demanding the mega treatments, placing the physician in an awful position of trying to stand up for the patient’s rights while looking a potential lawsuit in the face.
    Discussion about hospice referrals should never, ever be questioned.

    • Anonymous

      “Discussion about hospice referrals should never, ever be questioned”

      I disagree.  What if a nurse suggests hospice for a 45yo woman with young children and st.II or st.III breast cancer?  lymphoma? NYHA class III CHF?

      I have seen all of these, with nurses saying “come on doc, she has cancer…”

      A little knowledge can be a dangerous thing.

      • Anonymous

        This just emphasizes the fact that patient care in a complicated situation like this should be interdisciplinary. Although not all the facts are there, it really does sound like the doctor just blew past giving the patient any options at all. Having worked geriatrics for 25 years, I have heard “No one told me I could do anything else – I thought I only had one choice” more than not. People are not stupid and doctors are not God. Doctors need to wake up and realize that medicine is way too complicated for one person to manage everything. We are a health care team. My apologies to those doctors (and there are plenty of them) that are already enlightened.

        • Anonymous

          most doctors are not as arrogant and “god-complex” laden as you imply.  But think about this post and this nurse- who was playing God here?

          there was an established treatment plan that probably developed over months or years, whether you agree with it or not – it had progressed to the point where the patient was admitted to the hospital, and Ms.Trujillo, having met the patient for possibly the first time (not clear to me from the post or whitecoat’s site), is ushering in a complete180 degree change in the plan to the patient, WITHOUT EVEN DISCUSSING IT WITH THE PHYSICIAN FIRST.

          That, to me, is the ultimate in arrogance, and if anyone is playing God, it is her.

          • http://www.thenerdynurse.com/ The Nerdy Nurse

            The established treatment plan that a physician feels best, but other options need to presented as well. It’ is about what the patient feels is best for themselves, not what the doctor thinks is the best course of action. 

          • Anonymous

            agreed. but how do you know other options WERENT presented to the patient? we are only hearing one side of the story, then just about every nurse posting on this board is ASSUMING (ie. making an ass out of u and me…) that the doctor DIDN’T do his/her job, and the nurse did nothing wrong.

            your post also reflects an assumption that the doctor acted in his/her own interest rather than the patients’

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            No, doctor, there is no assumption–at least on my part. The patient was DENIED…yes, that’s right, DENIED the right and the request to see a hospice case manager to ask more questions so they could make an informed decision pertaining to their future. The tantrum–who’s interests was that serving? Openly and publicly insisting I be fired and yelling in the charge nurses face—who’s interests was that serving? Because from my viewpoint, it sure wasn’t me, or the patient’s interests. Further evidence that the Patient Right To Self Determination Act means not a thing these days.

          • Anonymous

            such a denial was not made clear in the original post, and seems particularly relevant to this discussion. 

            and yes i agree, a tantrum is unacceptable under any circumstances, from any member of the team

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            Doctor. This post is bordering on slanderous. While I respect everyone’s views, I dont feel it necessary to be insulting or disrespectful within an already emotionally and ethically charged and controversial discussion that is relevant to each one of our disciplines and patients alike. Ive not one single time insulted a physician in open forum throughout this entire experience and I dont deem it necessary now as it accomplishes nothing but furthering the rift between medicine and nursing—ultimately hurting quality of patient care. I ask that you refrain from using such terms as the ones you are using to illustrate your point.     

          • Anonymous

            i am sorry you feel insulted, and that certainly is not my intent.  I am simply responding to the multiple posters who seem to have a blatantly anti-physician agenda, and would love to paint physicians as male egomaniac woman-haters who make decisions on patient care against the will of patients, families, nurses, etc.

            Even pushing a patient into surgery for money (talk about libel & slander!)That is a tired and insulting stereotype.  I’ll also add that some posters even sound racist, like I’m not from America and my viewpoints are as if i was trained in an ultra-paternalistic society like the middle-east (“in America we do it this way” etc.)  Not that it’s anyones business, but I was born & raised in the US and my nurses regard me very highly, particularly for my communication with patients and families.

          • Richard Willner

            You really think that Amanda is playing God?

            She did her job as a Nurse.  She provided education to a patient. 

            OMG!!  She needs a formal complaint to the State Nursing Board and a 11 month investigation and the loss of her career.

            What a message to Nurses.

            What a message to STUDENT NURSES !!

            When this one case filters down to every Nursing School, I would be shocked if hundreds if not a thousand drops out.

            It just takes one person to post these posts to every student Nurse forum.

          • Anonymous

            geez did you even read what i was responding to? Krumkage is saying that the doctor was playing god by withholding options from the patient!

            you are blinded by your anti-physician agenda.

      • Anonymous

        And I disagree with you.  Discussions are not final.  The doctor still needs to give the order.  I have no problem with discussions.  I have my own with the patient as well.

      • http://www.thenerdynurse.com/ The Nerdy Nurse

        A little knowledge can be a dangerous thing.” this statement is insulting.

        I may not have gone to medical school, but I am not dangerous. 

        • Anonymous

          this is not meant to be literally interpreted (have you never heard this phrase?)

          this is a phrase often echoed to residents & interns from residents, when presenting a case and making management decisions with incomplete information. it doesn’t mean that, as you seem to think, nurses are less educated so are dangerous!

      • http://profile.yahoo.com/A3GU3BX2WAGR36CX24CGT7TAPE Mother Jones, RN

        You just insulted patients.  They have the RIGHT to learn about anything that crosses their mind.  

        • Anonymous

          yes i agree, and their education should be in the context of full and accurate information, with the entire care team, not just one nurse in the middle of the night.

          i am sorry you have interpreted my post so defensively.

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            Reinforcement reinforcement reinforcement……………this whole issue centers on the very fact the patient needed more time to TALK TO THE DOCTOR and OTHER HEALTHCARE PROFESSIONALS before making a DECISION. Let me put that in plain non medical terms ok? I bought the patient more time to talk to their doctor and other people on the healthcare team before being sent out into a situation they were unsure about. Thats it. Thats all. They had crucial questions, and i facilitated more time for them to ask those questions of the appropriate people so that they could make the best decision for themselves. Refer back to my posting about giving the patient paper, pens, highlighters and instructions to write down any and all questions/concerns for the Doctor and the hospice case manager. 

  • Anonymous

    There are just too many unknowns here. 

    Reviewing whitecoat’s blog posts, it seems that the patient maybe is still alive (Ms.Trujillo states she could easily have the patient advocate for her), however this all started in April 2011.  So doesn’t that itself bring into question the judgment that a hospice referral was appropriate?  Did the patient have a transplant?

    Usually transplants aren’t done for patients that are fated to die within 6 months, but rather may be curative.

  • http://twitter.com/moving4wellness Bobby Fernandez

    Isn’t it in the first year of med school that doctors are taught the role of the healthcare provider is to educate, explain all options then carry out the option chosen by the patient?

    • http://www.thenerdynurse.com/ The Nerdy Nurse

      Nurses are taught the very same thing. We also spend more time with the patient and have more opportunities to educate.

      • http://www.facebook.com/brianpcurry Brian Curry

         I think that was the point of Bobby’s post.

  • http://twitter.com/Chakrabs S.C.

    This entry and the blogs linked in the article seem to show only one account – that from Ms. Trujillo herself. There doesnt seem to be anything from the hospital, the patient, or the physicians involved. It seems to me, as if the patient was waiting for a pre-transplant evaluation – It doesnt seem as if they were awaiting surgery the next day or something – and Ms. Trujillo took it upon herself to page a consult for hospice, a completely different treatment plan. Something like that should definitely be discussed with the physician overseeing the patient’s care. Surely it wasnt necessary to do all this overnight and could have waited until the morning when she, the patient, and the physician could have all discussed this. 

    Instead, the physician comes in and is blindsided by a patient questioning his treatment plan and a nurse going over his head to involve another team. Certainly he should not have thrown a tantrum, but I’d understand why he would be upset. I doubt going over a physician’s head like that are against hospital policy, which is why she was canned.

    I am also disturbed by the tenor of the discussion in the two linked blogs. With only one account of the incident – Ms. Trujillo’s – the general consensus seems to be decidedly against the “greedy surgeons” who “coerced” the patient without “adequately informed consent” into an “unnecessary procedure”. By most accounts, the surgeon wasnt even involved yet, and the aggrieved physician was on the primary team that working up possible transplant. I submit that Ms. Trujillo unnecessarily went above and beyond her duties as a night nurse, which in many ways is commendable, but certainly should have elicited the rest of the treatment team’s participation especially the physician before proceeding to educate the patient and implementing a hospice consult. The hospital’s subsequent actions may be extreme, but I do believe that Ms. Trujillo is not entirely in the clear on this matter.

    • http://www.facebook.com/profile.php?id=536906816 Kim McAllister

      Do you believe this required demanding her firing and that she be reported to the nursing board? Seriously? Because the physician also did exactly that.

      Do you believe this action requires an entire YEAR of investigation, after the initial nurse investigator told the AZBoN that Trujillo was not a danger to the public?

      Do you believe this action requires investigation into Trujillo’s entire career, AND a psychological evaluation?

      Either she operated out of her scope of practice or she didn’t.

      This is ridiculous.

      Neither Banner, nor the Arizona Board of Nursing, (or the physician, for that matter) is saying a word, other than to say they can’t say a word.

      Maybe they can talk in the depositions in the lawsuits when this is all over.

      • Not Nurse Ratched

        I agree with what S.C. wrote—as everyone knows by now. Kim, S.C. did say those reactions were extreme. I wish we (“we” being the entire healthcare field) could separate the issues of patient advocacy and Amanda Trujillo advocacy, because the original post makes some extremely good points that are exemplified by Amanda’s case, yet her case has too many deal-breakers for everyone to get on board, which is a simple fact. I would argue at an extreme that Amanda has even made it more difficult to support patient advocacy by tying the issue so closely to her own personal case. Most of the comments are like yours, in defense of Amanda and in opposition to what happened to Amanda, and not about the profession at large. It has become difficult to discuss the issues at all without being perceived as an Amanda-hater. 

        • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

          Well hello Ratched. Its been a while hasn’t it? It’s really nice to see you. As you can see, Ive come out to play for a while.  

        • http://www.facebook.com/profile.php?id=536906816 Kim McAllister

          Hi NNR!

          I did not call S.C. an Amanda hater, and you know that I most certainly have never referred to you as that! : )

          It is difficult to separate the two, at least for me, because a registered nurse (in this case, by the name of “Amanda Trujillo” is having her life torn apart because of the act of patient advocacy.

          It’s so appalling.

          So, at least for me, it’s what is happening to a nurse for doing exactly what she was supposed to be doing. It just happens to be be Amanda right now. I’d be just as outraged if it were you (or me!).

          My reason for pointing out the even more extreme responses of the Arizona Board of Nursing was to show exactly how far this has been taken.

          If it seemed that I was referring to SC as an sort of an Amanda hater, I certainly apologize, it wasn’t the intent. 

          • Not Nurse Ratched

            No…I was just generalizing. To disagree with an issue has become anti-Amanda rather than anti-issue by and large in the blogosphere. I have always found you to be fair and open-minded, Kim.

    • Richard Willner


      The physician and the Hospital and the State Nursing Board have spoken by their actions.

      Surgeons think they are bullet proof.  Trust me, they are certainly not.  There is something called Sham Peer Review that affects them.  In 30 days, they are Data Banked and that could very well destroy one’s career.

      The Hospital has immunity and so do the attacking doctors.

      Richard Willner
      The Center for Peer Review Justice

      • http://twitter.com/Chakrabs S.C.

        If you read one of the blog posts linked in the above article and in Ms. Trujillo’s comments, this was a dispute between her and the patient’s “primary” medical team. This was a pre-surgical case and at no point was a surgeon ever involved. I’d encourage you to curb your biases and not jump to besmirch surgeons. 

      • Anonymous

        again there is just such an inherent anti-MD bias in this post and the responses

    • http://twitter.com/Mtl4u2 Les Zouazo

       “Ms. Trujillo took it upon herself to page a consult for hospice”

      Re-read nurse Trujillo reply to one of…your posts above! It was NOT a consult for hospice, but a case management one.

      • http://twitter.com/Chakrabs S.C.

        Just going by what was said in the article. Ms. Trujillo did helpfully clear it up. Above, she also mentioned the importance of interdisciplinary care. She unilaterally called case management when she easily could have discussed the patient’s concerns with the physician in the morning together.

  • Anonymous

    Juliet is right! This issue is not about whether nurses or doctors are better patient advocates, or even about who is the better communicator. The problem here seems to be the failure to establish a unified message among well meaning professionals. The most disturbing situation is for a patient to hear divergent messages from different, trusted members of the healthcare team.
    While the balanced story is not presented here, and I don’t know whether the physicians fully disclosed all option, even if Amanda was correct in her clinical assessment she should have discussed her concerns with the attending physician before addressing alternative approach which appeared to undermine the patient’s trust in his physician. In any case, I agree the punitive actions against Ms. Trajillo seem excessive.

  • Anonymous

    As a primary care MD, I am glad if someone provides perspective and education for a patient.However,at the end of shift, there is no reason why the nurse could not have called the MD, to  at least discuss.
    This case pivots  on whether the nurse knew the patient for a period of time other than that night, whether she was providing information that the patient had been given but didn’t understand, and whether the nurse understood transplants.  What a patient look like  hospital and on  discharge may be a whole lot different than 6 months later- I get this a lot when patients are transiently confused on the wards- there is a nihilist feeling that all of them should be DNR.  I have almost all of my patients sign POLST forms long before they get ill, so they have thought about it, and are making their decisions when I am not tired, grumpy or frustrated. I also work hard to keep my patients OUT of the hospital , 
    The patient wouldn’t be accepted for transplant if she were not viable.  If the patient didn’t want this, that is different. However, Ms Trujillo may or may not have known the patient enough to know if she were depressed from illness  or encephalopathic .Effectively, a DNR order was generated.
    Of note, I regularly have patients on Hospice, suggest it , and the hospice nurses have my personal cell number
    Collaborative care is just that-collaboration. if  a nurse calls me and tells me that this is what happened, I will round on that patient first.I will bring the family in. They  need education, too.I take advice from nurses very seriously. If I ask a few more questions, and they can’t be answered, ( when was the last dose of morphine. what are the vital signs, ) then I listen with reserve.I have signed orders for Lasix I didn’t give gratefully  for patients that needed it urgently, orders for PT/OT , social services, suggestions all the time.
    But this wasn’t collaboration- it was unilateral. It’s not the issue of education, which perhaps was needed,  not the advocacy- it was not talking to the physician who has known the patient longer and in a different context. He or she may have needed the heads up that he/she had provided insufficient information.
    However reading the report from WhiteCoat call room give one pause as to the physician, and his maturity,
    Ms Trujillo’s specialty was palliative care, which also suggests she had her own biases
    Did this warrant referral to the nursing Board- not if this is the only issue.
    Did it warrant some kind of joint Grand Rounds on collaberative care, Yes

  • http://www.facebook.com/profile.php?id=100002934866034 PJ Dew

    I’m a nurse working in long term care and most of our members are able to make their own decisions.  However, we have an attending who is rather, well, old, and stubborn.  He’s 75.  He won’t listen to anything we nurses say, even to the detriment of the patient.  We had a guy who was very small, on 60 of lasix daily, 25 of aldactone BID, and coreg 3.125 BID.  His B/P was continuously 70 something over 30-40 something b/c of all of this.  He would D/C coreg and add lisinopril.  HELLO!?  Systolic B/P is 70!  Don’t need a B/P med!!   The patient could not get out of bed, b/c he was so weak.  We finally had to go to the medical director and got all of those unnecessary meds D/C’d (after the doc put him on hospice).  Now, the patient is motoring all over the place and having a great time, b/c his B/P is in a normal range. He is no longer on hospice.  When you have physicians like that, it makes it hard to be a nurse advocating for your patient.  Some physicians have the God complex and very ignorant of the patients that they care for.  But, I agree, the consult could have waited and she should have discussed it with the doctor first and the patient’s family, and just documented what she had talked to the patient about.  She should certainly not be fired or lose her license!!

    • http://twitter.com/Mtl4u2 Les Zouazo

       “But, I agree, the consult could have waited ”
      The patient was due to be transferred first thing in the morning as Nurse Trujillo made patently clear in an above entry right here on this blog.

      • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

        Les…that brings back memories of a physician/mentor Im still very fond of –learned so much from him–he used to call me “Nurse Trujillo” all the time. ;) Thanks for the moment….

    • hampter320

      Patients with CHF have been shown to have decreased mortality and fewer cardiac events when on a diuretic, ACEI, B-blocker, and Aldactone (if Stage III/IV).  It has nothing to do with blood pressure.  This is why cardiologists sometimes tolerate a BP in the low 90′s or even high 80′s with CHF patients.  With all due respect, physicians go to college for 4 years, medical school for 4 years, residency for 3-5 years, then fellowship for 1-3 years so they can know this stuff, not to mention spending hours upon hours of their “free time” reading literature and journals.

  • http://www.facebook.com/people/Michael-Richmond/100001691617490 Michael Richmond

    Ultimately the blame falls on family who will spend hours researching the best TV but can’t be bothered to research a major medical decision on their loved ones behalf. Even the average internet user can easily see how thin mayoclicic.com is and will keep looking until they find a page, big on medical jargon and sparse on graphics.

  • http://www.facebook.com/robolivermd Rob Oliver

    It would seems (whatever the validity of her concerns) that the nurse significantly overstepped her role in this instance. The context and manner of the discussion she had with the patient was inappropriate in the extreme. There are proper channel she could have brought up her concerns with in systems like this that make whatever urgency or self-righteousness she possessed to be better addressed.

    Patient care is nominally a team effort, but the patient’s attending physicians are the captain of the team and her behavior significantly disrupted the doctor-patient relationship.

    • Richard Willner


      I strongly disagree.  I appreciate smart women.  Hey, I heard that women got the right to vote and they even drive now!!

      A Smart Board of Directors would hire a woman like Amanda as their CEO as she shows leadership skills and character.

      Richard Willner
      The Center for Peer Review Justice
      PeerReview (dot) org

      • Anonymous

        why are you assuming a role for gender discrimination here?

        i have seen such disputes even between female nurses & female doctors, and male nurses and male doctors etc.

        I don’t understand the quickness that you and other posters here paint the situation in that light.

    • http://twitter.com/Mtl4u2 Les Zouazo

       ” attending physicians are the captain of the team”

      You said it; “captain’ not “caudillo”. As a reminder,  teamwork is not a lot of people doing what I/you/someone say!

      Furthermore, I am particularly incensed by your willingness to judge A.T. with incomplete information and innuendos. ” inappropriate in the extreme.” Really? Why is that? Because the patient changed his mind? Must we infer from that that you view this as an offense against the physician’s will?

      If you haven’t done so already, read Nurse Trujillo’s entries on this blog for more context.

    • http://torontoemerg.wordpress.com/ TorontoEmerg

      So what happens if the captain of the team fumbles the ball?

      J. Doe RN

      • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

        The RN picks up the ball and carries for a touchdown? Or the Ref throws a flag? Or there is one of those slow motion replays and everyone talks about it for 10 minutes or so? Thoughts?

  • http://profile.yahoo.com/WWS2J6FVVCP2743CIRB5AFAE6M Todd

    I’m a patient who is alive today because a nurse looked out for my best interests and ignored a doctor’s orders. 

    Several years ago, I had a mild heart attack and underwent a catheterization and had several sents installed in my coronary arteries. At the end of the procedure, things started to go wrong, and my femoral artery tore at the point where the catheters had been inserted and I began to bleed internally.  The cardiac surgeon was not aware of what had really happened and thought everything wold be fine and had me moved to the CCU and ordered that pressure be kept on the point of the incision, as is normally done, to halt the bleeding.  He wanted to wait 24-48 hours before taking further action.

    Meanwhile, I had already lost most of my blood and my blood pressure was down to around 50/0.  A CCU nurse argued with the doctor and then called a cardiothoracic surgeon without the cardiac surgeon’s permission.  The cardiothoracic surgeon rushed me to the O.R. and repaired the artery.  Afterwards, he told me that had lost so much blood that I was just a couple of minutes away from being dead.  I received 19 units of blood and blood products during the repair procedure.

    I thank my lucky stars for that nurse and the fact that she looked out for me and didn’t think or care about going over a doctor’s head.

    Doctors and nurses should be working as a team to do what is best for their patients, not arguing over who is responsible for what and whether one or the other has crossed a line.

    Had my nurse toed the line, I would be have died and you can bet that the doctor would have been hit with a malpractice lawsuit.  My nurse not only saved my life, but she saved that doctor’s ass as well.  Maybe that’s why she wasn’t disciplined.

    • http://www.thenerdynurse.com/ The Nerdy Nurse


      The sad part is that even after saving your life, it’s likely she still was disciplined.

      • Richard Willner


        We don’t know if that Nurse was disciplined or not.  We don’t know if a Complaint was sent into the Nursing Board.  I doubt it.   Not every male Surgeon or physician is a schmuck !!

  • http://bit.ly/gwalter gwalter

    This was my question in my previous and current profession - 

    “the issue boils down to whether the ___________ industry can tolerate highly educated, vocal, critically-thinking, engaged collaborators”

    Apparently, the answer is no.

    • http://www.facebook.com/nursefriendly Andrew Lopez

       Gwalter, it is similar to the question of whether the Healthcare Industry can tolerate better educated consumers as patients.

      On the one hand they state, patients need to be self-advocates and learn as much as they can about their conditions.

      On the other, doctors complain that patients are “taking up too much time” at office visits with their questions that they have after researching their conditions.

      Again, apparently, the answer is no.

      • http://bit.ly/gwalter gwalter

        As we continue to consolidate agencies, and each organization joins to a larger corporation, the amoral, protocol driven methods replace free – and creative thinking.  

        Seth Godin said it best when he wrote about how our society is continually risk averse.  Managers want status quo, not creativity or insightful solutions.  Tried and true solutions are favored over anything that might get anyone in trouble.

  • http://twitter.com/Jahmai11 Renee Hernandez

    I am a former RN that tired of situations such as these and the stress & workload plus disagreeing with drugging people .Good health is not obtained with pharmaceuticals. Sorry to hear of Ms. Trujillo’s plight but more than likely the hospital & MD will prevail nursing boards do not support nurses.

    • http://www.facebook.com/nursefriendly Andrew Lopez

       Hello Renee, we’ve been examining the records from state board proceedings in Arizona, and you’re exactly right.  Think then, it is time to put the Arizona Board of Nursing on trial.  Put them in the public eye, perhaps have the governor of Arizona kick a few of not all off the board and start from scratch.

      • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

         Andrew I am curious–how many complaints have been filed against RN’s in the state of Arizona and of the total number filed, how many nurses were sanctioned?

  • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

    ….There are many *many* details that I have been unable to disclose out of respect to the patient privacy act that would change the perspectives of many a doc who weighs in here.  What I will disclose is that the patient had been in the hospital for a week. No previous history with any doctor–primary or otherwise. I did not establish an order for hospice care, rather, a case management consult per the patient request to come in and answer questions. Standard practice in AZ, per hospice organizations here, all that is required for a patient to speak with a hospice case manager is the patient calling from their hospital room, a family or friend calling for them at their request, or a nurse/doctor calling on the patients behalf. That being said, the patient requested to ask some questions so that they could make a decision about what they wanted to do with the remaining time they had—while there are very sensitive and relevant details i am not at liberty to discuss–the foundation of this issue revolves around the fact that the patient expressed a wish for more education—no permission is required by a nurse to provide access to education, especially when it comes to end of life options. A physician’s involvement, however, is required to order hospice care, to certify a patient’s life expectancy, and to discharge a patient on hospice. Neither of these were the issue in my case. No hospice agency was called in, or contacted by myself.  A case management consult is just that–a case management consult to further elicit information from the patient and to fill in the gaps where the patient is experiencing a knowledge deficit–to be that bridge between members of the healthcare team and the patient. I provided extensive documentation in the chart, I discussed my concerns with my manager that night, who approved of my nursing care plan and nursing interventions and supported them. I relayed my concerns about the ethics of the situation and requested that the doctor be paged immediately upon shift change in the morning so that the connection between physician and patient could be made at the earliest opportunity. There were no policies in place that prohibited me garnering a case management consult at this hospital–in fact, when I was hired i printed them all out for easy reference. The patient was provided not just hospital approved patient education material by myself, but was also provided paper/pens/highlighters and instructions–by me–to write down any and all questions/concerns for the doctor and that I would facilitate an urgent call be placed by the dayshift RN so the doc could come and see the patient. I used SBAR at report, relayed the urgency of the sitation at report, I had a care plan in place, I consulted with my management, I followed policy, I abided by the patients request to be connected with expert education I could not provide, and gave the patient all the tools necessary to educate themselves and to write down questions that were out of my scope to answer. The easy thing to do here, as far as Im concerned, that would prevent this from every happening again, would be to rid hospitals of nurses altogether and use CNA’s instead. Nurses can be nurses outside of the hospital and be just as successful with the added plus of being able to practice what they learned and were licensed to do in school. We obviously, in present day and within the current healthcare system, do not belong in hospitals any longer. To realize that—pretty sad stuff for me, that nurses are now realizing we do not have a place in the care of patients within the walls of hospitals–is a reality, and a troubling one at that. This situation, in which no drugs were involved, no medical order being entered by myself, or sentinel event occuring–rather a simple case management consult—illustrates just how far nurses are being pushed away from the holistic care and advocacy of patient centered care. CNA’s can easily be used to start IV’s, hang piggybacks, take vitals, clean patients, take vital signs, and not ask questions. It would be much easier on everyone to do this, because CNA’s are task oriented, which is what is desired these days. This–would solve the problem between nurses and doctors. Doctors could have their place in the hospitals, and nurses could take over outside the hospitals and do what nurses are taught and licensed to do–without having their lives and their professional ethics and practice torn apart in such a demeaning and destructive manner.   

    • http://twitter.com/Chakrabs S.C.

      I just don’t understand why this patient’s education could not have waited until later so in the day the physician and the rest of the care team – and possibly the rest of the patient’s family – could have been present. The patient had been in the hospital all week and then all of a sudden late at night they want more information? This doesnt make much sense to me.

      I think nurses play an absolutely valuable role in our hospitals one that the training you mention is vital to. Indeed, I wish more nurses were curious about their patients’ disease processes and got more involved. At many hospitals I have worked at nurses hang out in the periphery and rarely get involved in the decision-making process. At other places, the nurses do ask questions and offer feedback. I LOVE this. Nurses are the “boots on the ground” so to speak of the medical team. The physicians are taking care of numerous patients throughout the hospital and it would very nice if the nurse with relatively fewer patients is able to observe and interact with the patient and offer real-time and accurate feedback on the patient.
      I currently work in the Acute Care for the Elderly unit at a hospital in NYC – a place likely similar to where the patient in question was located.Here, there are daily multidisciplinary rounds involving physicians, nurses, social workers, and managers so everyone is on the same page. I do believe this system is spreading to many hospitals throughout the country and I do believe it as a good one and has a positive impact on the patient and the rest of the healthcare team. The incident that landed Ms. Trujillo could have easily waited until the next day and brought up and discussed during the rounds. I would hope that this multidisciplinary team-based approach is adopted throughout the country to avoid such issues in the future. No need for nurses to flee our hospitals – good RNs are desperately needed there!

      • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

        The patient was due to be transferred out first thing in the morning SC. There was no extended family. Never in my nursing career have I been expected to put off patient education until a physician arrived to approve my methods and materials…..it is an unrealistic expectation in the hospital setting to have every member of the healthcare team in the same room at the same time with the patient so the nurse can go about her education of the patient. This is why we go to school for years and get licensed. There was no interdisciplinary model of care in place at this facility as there was at the mayo clinic–which is what i was accustomed to. For those not familiar with the Interdisciplinary Model of Care, IMOC for short, please visit the American Association of Critical Care Nurses for a complete run down on it….In fact, I, as well as other nurses, made numerous complaints to administration about abusive behavior on the part of physicians toward nurses—we were often cursed at, insulted, yelled at, and hung up on–especially at night. Our calls for rescue were also often ignored when patients were crashing. I had to report those too. That…..doesnt make much sense to me. There was no program in place or in this hospitals culture that encouraged physician and nurses rounding or participating in care coordination meetings with other disciplines. Patients. They are unpredictable people. They change their minds at any hour of day or night. It is my moral and ethical and professional duty to the patient to hear,  honor, and support their needs and their “story” so that their goals and wishes remain center to everything. When the word “patient” is uttered, the phrase “all of a sudden” is synonymous with that. Ive had patients change their minds about an LVAD implantation the very morning of their surgery—and no, before you ask, it had nothing to do with me—-in fact I had to make the difficult call to awaken a physician and bring them in from home to explore further and meet with the family—–but this was at the mayo clinic. Physicians there do those kinds of things. That was not an option here, as the majority of calls we made in the middle of the night were responded to with verbal abuse or not answered at all.

        • Anonymous

          I appreciate your input, Amanda.
          This really confirms what I was thinking.
          Hope you have been able to find a fulfilling place in health care once again.  We need people like you.

  • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

    ….And before anyone freaks out and takes out a hit on me (there are plenty in AZ who are already considering that) by take over I meant, nurses could assume their rightful role in patient centered care and advocacy—ie: home health, public health, independant nurse advocates, independant nursing businesses. The idea being that doctors could control/dominate what they wish to within the walls of a hospital, while nurses could—without fear–be who and what nurses are supposed to be in the community. So call off the headhunters please, i have a deep appreciation for physicians–in fact my mentors are physicians from the mayo clinic, many of whom (surgeons included) wrote wonderful letters of recommendation for me and also wrote to universities recommending me for the programs I have participated in. These physicians I worked closely with for multiple years and continue to keep in contact with—they were my teachers and they were the ones who taught me what it meant to have truly professional regard between physicians and nurses. Everyone should take this example that is so clearly at the foundation of patient care within the mayo clinic healthcare system—my mistake, my fatal error, was trying to exist outside of that model of care….we are in the midst of losing nurses at the bedside and are facing another shortage in 2014. Nearly 25% of new graduate nurses leave their positions at the bedside before the end of their first year. Experienced nurses have grown tired of situations such as this and have left the bedside for careers outside of nursing, others are retiring early….which leaves, you guessed it, new graduate nurses taking care of your increasingly ill, complex and older patients with less mentors to help them navigate……you want to know why nurses dont stay and why we cant seem to keep them at the bedside? This. Situations like mine. Who would want to stay. At the end of the day—its the patients who will suffer more sentinel events and injury and prolonged hospitalizations because nurses just dont want to go through these scenarios time and time again. This—–is why we leave. The bedside. The profession.

  • http://www.thenerdynurse.com/ The Nerdy Nurse

    This is a GREAT read and I am so glad to see it on KevinMD. This will allow a larger audience to see Amanda’s case and form their own opinions. 

  • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

    So far—I’ve seen: “self-righteous, God complex, disruptive, boldly independent, extreme, dangerous, arrogant, ‘medical decision making dressed as patient advocacy,’ and ill equipped.”

    And yall wonder why we flee from the bedside? Here’s the deal everyone, this nursing shortage is undergoing an exacerbation right now that will be a full blown epidemic again in 2014–as it has been predicted. Regardless of what you think of the situation–which I will remind everyone—had nothing to do with a drug error, sentinel event, the ordering of anything medical like a lab test or ultrasound, rather——a case management consult to answer patient questions—-this is representative of why there is not enough nurses now, nor will there be enough nurses in the next couple of years to help with YOUR PATIENTS. This is why you should care about my case. In the next couple of years, if enough nurses aren’t willing to step foot in a hospital after my oh so public show and tell—guess who will be playing in the sandbox with you in the care of YOUR PATIENTS? Unlicensed personnel–that’s right, patient care assistants, who are taught the mechanical aspects of patient care. Why you ask? Because, they are less expensive to pay for than nurses, require less training and recruitment cost, and they can easily fill in the gap when there isn’t enough staff on the floor. Keep in mind patient care assistants are not taught anything above and beyond tasks—taking vital signs, daily care, feeding, room upkeep…..and these will be the very same people who will be (already are) trained to start IV’s etc.

    You cannot have it both ways. You either want complete control over the hospital care of the patient, to be the captain of the ship–or as Banner Health puts it—”the focal point of patient care” or you want the patient to get safe quality care. That involves registered nurses who can do the mechanical stuff and more. My situation is a warning sign. Nurses have written me from all over telling me their stories of how and why they left nursing in just this past year alone, and nursing students who have decided not to work in a hospital after watching all of this play out in social media. Tragic don’t you think? The upswing of this is that nurses are now realizing they can be nurses, and damn good ones, outside the hospital systems and in the community.

    Nursing students are exploring other options now after seeing all of this–so this means we may actually retain some nurses in the profession even though they choose to stay out of the hospital and out of the reach of corporations who seek to twist and mold the profession into something they deem appropriate rather than respect the time honored scope and tenets of our body of knowledge. So, bummer for doctors, who will have less nurses to care for their patients, —bummer for patients who will have less attention from nurses because the nurse to patient ratios will rise….but hopefully this will be a plus for the newer generations of nurses because they are realizing hospital nursing is not AT ALL a safe route to take for one’s career or well-being.

    This should concern every physician who works in a hospital, and there is still time to do something about it….if you choose not to—well then, I’d be purchasing a lot more liability insurance because there are going to be some very big problems in the next couple of years in every hospital throughout the United States….with the exception of the Mayo Clinic of course—because they actually “get” that in order for patients to get good care that is “centered” on them—nurses and doctors must work in tandem with one another in a healthy and productive and respectful manner

  • http://twitter.com/pav1991 Suresh Pavuluri

    Amanda, I am extremely saddened at the fact you were fired for merely educating your patients. 

    This article really intrigued me. So, I wanted to take the time to present my perspective.

    You, as the patient’s nurse, have the responsibility to appropriately educate your patients. You have the responsibility to present your take on the patient’s disease and prognosis. It is then up to the patient to make the necessary decisions based on the information provided to he/she by his or her medical care team (all of this assuming that the patient is mentally competent). Now, let’s take a step back here. From my understanding, the real conflict came-in when you presented a different side of the story to the patient than the physician. If the physician had thought that your advice was not in the best interest of the patient, he or she should have presented his or her take to THE PATIENT. Then, the physician should have consulted with you to discuss your perspective on the patient, and come to a mutual understanding. However, it’s important to remember that the patient was presented with both sides of the story, and ultimately the patient MADE the decision to ask you to consult hospice care. In essence, the physician is at fault for not acknowledging that nurses play an equal and an important role on the medical care team. 

    Amanda, I am personally sorry that you lost your job for such a trivial and inconsequential reason. In the long run, it might be better for you not to work at a hospital that does not value the vital role nurses play on the team. At the same you could have done things differently. If you thought that the patient did not quite understand his or her disease, it might have better to consult with the patient’s physician first and come to a mutual understanding before both of you present completely different takes on the patient’s diagnosis. 

    Many physicians underestimate the importance of effectively collaborating with other members of the team. It’s a shame, but thankfully, it’s changing. As a pre-medical student, I see a lot more students that acknowledge the importance of effective communication and the important role other healthcare-professionals play in patient care. We are drastically moving away from paternalistic way of doing medicine (physicians occupy the hierarchy) into a more team-based one. Thank god for that.

    I am a junior in college, so I might not be the most knowledgeable on these issues. So, take my perspective with a grain of salt. :-) 

  • Richard Willner

    I know Amanda Trujillo’s case.  In fact, I have interviewed her and she rings quite truthful.  She is educated and competent.  She worked within her scope of practice.

    She  is an excellent Nurse and that is the bottom line.   She did nothing wrong.  To think that she got a Complaint to the State Board of Nursing to the extent that they have spent almost a year “investigating” her shows beyond a doubt that there is another agenda.

    As the CEO of the 12 year old Center for Peer Review Justice, I have seen hundreds of cases like this.  This is “Medical Mobbing” and it occurs to Nurses and to Physician and Surgeons. 

    With Surgeons and Physicians we call it  “Sham Peer Review” or “Physician Peer Review Fraud”.  It is the misuse of the Health Care Quality Improvement Act of 1986 where the Hospital and doctors all enjoy immunity where the doctor only has procedural due process and NOT “due process” rights.

    Amanda, unlike almost all other posters here, uses her own name.  The fact that others do not use their names means that they are afraid.     Afraid of what?  Being the educated and talented professionals that they are and they are afraid to speak up?

    Amanda, your support is more powerful than you think….

    Richard Willner, CEO
    The Center for Peer Review Justice

  • Richard Willner


    Yes, Amanda lost her job.   But, in reality, because of the nature of the Complaint and “whispers”, she probably lost her career.

    Richard Willner

    • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

      No, Richard, it sucks to be a nurse. and i for one, am glad as heck that im never stepping back into a hospital again–and I intend on making the message of “why” loud and clear in the book im writing, and guest speaking at every nursing school or nursing conference I am able to reach. my message? “never again.”  “not one nurse, not one more patient–ever again.” I am strongly encouraging every nursing student who has been writing me to stay away from that setting and focus on public health roles, home health roles, patient advocate roles, or nurse entrepeneur options so that they dont expose themselves to burnout, ptsd, career devastation, and injury (back issues) and they experience a better career than most of us have thus far. The future nurses deserve a fulfilling career, they deserve to walk into a profession that affords them the opportunity to contribute, make change, be innovative, and transformational. They deserve to accomplish their goals and dreams of improving healthcare for people and improving their profession—they cannot do that in a hospital—and Im glad they are seeing what really happens.

      • Anonymous

        You are inspirational Amanda!

      • http://profile.yahoo.com/L5E5IDEGD4GSXI4J7GMLNM4XQQ Brett

         Are you kidding me?  I am an Acute Care Nurse Practitioner and would never say things like what you just did.  What do you think would happen if every nurse just decided they would never work in a hospital again?  You are a patient advocate?  That is not advocating for patients.  In case you have forgotten due to the circumstances in which you found yourself, patients in the hospital are the MOST vulnerable.  Educate students regarding what happened to you and how to best avoid those kind of situations.  THAT is leadership.  Bitter ranting is beneath being a professional in any position.  Maybe you should encourage nurses to eventually become hospital administrators.  In that role, they CAN change the way hospitals function.  Let’s face it, you consulted hospice in your case.  Consulting is only in the scope of practice for NPs, PAs, and physicians.  You surely did not deserve to be fired, but you did not go by your own nursing scope of practice.  In the future, you should encourage nurses and nursing students to go work in their dream jobs and settings.  You should then push them to move up to management and provide a better future for nurses and nursing as a profession.

        • http://profile.yahoo.com/L5E5IDEGD4GSXI4J7GMLNM4XQQ Brett

           I just found one of your other posts explaining you had consulted for a case management discussion with the patient.  Your explanation of scope of practice for Arizona in regards to this situation seem to make perfect sense and back your decision making.  What happened to you was not right.  However, what I said about pushing nurses away from hospitals still stands.  Please consider all consequences of what you tell nurses and students in the future.

          • http://www.facebook.com/seungk5 Seung Oh

            I stand with Brett here… I am a new grad RN and although I am going into public health/ health education (due to the job market mainly), I do love acute care. It is true that it is stressful, injury prone, and everything else you said.  I am very sorry for what happened and I don’t think it was right.  However, as Brett said, that’s all the more reason we as nurses should stand up for our patients in acute care and act as patient advocate.  We cannot as nurses retreat from acute care and hospitals and just focus on public health.  Patient advocacy is fought in the hospital and if we retreat from that, we are simply giving up. 

  • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

    This sort of railroading happens to MD’s all the time by hospital boards. One of the main reasons why hospice evals are so underutilized, if you happen to be the nurse/MD in charge of a patient when they are at death’s door these days it is as if you are the cause of the death. What she did is out of line, a nurse should not set up hospice, she should suggest it to the physician and its up to the doc to do it. Nurses can be very convincing, she was definitely wrong in what she did but her intentions were good. She did not deserve such treatment but the public outcry and what not will probably score her a sweet book deal and she’ll land on her feet just fine. 

  • Anonymous

    After reading your post, I feel the utmost of empathy for the abuse of this educated professional.  I have been in similar circumstances. I have been an R.N. for 40 years , with a backround in Critical Care management & hospital supervision and for the last 11 years, in Long Term Care as a Director of Nursing. I was with a large University-based Long Term Care facility for 4 years as D.O.N., and brought them to their first deficiency-free Department of Health survey in over a decade. I never received a “thank you” for all the hard work, but rather, 5 weeks later, I was walked out of the building. Even someone from our covering Survey office, couldn’t understand it.  Now, 4 years later, they still haven’t had a long-term D.O.N. at the facility. The worst of it is when applying for other positions, trying to explain an involuntary exit. This has haunted me for years. I am a nurse to my soul…it’s who I am, not what I do. Once you are “black-balled” it’s very difficult to recover.  

  • http://www.facebook.com/nursefriendly Andrew Lopez

    Dear Vikas, Amanda educated the patient after consulting with her nurse
    manager and other staff.  She used hospital approved educational
    materials and put the consult (coded under nursing orders in the
    hospital information system) in at the patients request.  She left
    detailed notes, documentation for the physician. Most nurses will not,
    wake a doctor up in the middle of the night for an “education deficit”

    How was she out of line?

    • http://www.facebook.com/profile.php?id=558041620 Vikas Desai

      initiating hospice should not be done by the RN, but if this thing was approved by the nurse manager then i guess thats not so bad. In the end even if she went over the head of the MD to initiate hospice, that at the most should have been a slap on the wrist not license losing stuff. I feel for this nurse but when you are talking about the “hospital” you are actually talking about hosptial adminstration a group of people with questionable goals. 

      • http://www.facebook.com/brianpcurry Brian Curry

         She didn’t initiate hospice.

  • http://twitter.com/cilburke Thea Burke

    This isn’t a conversation about who was right as much as it’s about ‘one more time’ nurses have to deal with an abusive physician.  Her job and her license?  Come on.

  • http://www.facebook.com/people/Ricky-Martin/10705992 Ricky Martin

    Lots of mistakes made from all parties. Sad story. Amanda Trujilo sounds like an excellent nurse and patient advocate; a smart engaged nurse, who unfortunately, despite her talents and abilities, acted in a fashion that led to confusing and disorganized team based care. Appropriate communication is so crucial to effective patient care, and it’s frustrating to hear about this situation, in which a nurse gathered valuable information, developed a perfectly acceptable and patient oriented plan, but then failed to communicate this plan with the rest of the team in the appropriate manner. Though, misguided, her actions certainly were not worthy of what sounds like an extreme over-reaction from the physician. As a physician, I’m sure I would be frustrated in the heat of the moment, but ultimately, Amanda sounds like a nurse I would want on my team. Rather than ask for her license, I would want to meet with her to game plan how she could communicate more effectively and better incorporate her talents into the team, so that she doesn’t feel like she has to choose between the two extremes of being a passive robot, or a solo super-nurse who writes orders for patients.

    • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

      1.) i used SBAR at report.
      2.) i engaged my nursing management and got approval of my care plan and interventions
      3.) i asked the night manager to pass the situation on to the dayshift manager so that she would speak with the physician and patient
      4.) i asked the dayshift nurse at report to page the doc asap, show him my note, and meet with the patient and her together.
      5.) I had a complete care plan as well as a thorough progress note addressed to the physician–which I asked the dayshift nurse to review with him–the doctor
      6.) short of staying until morning rounds, or calling this doctor and asking his permission to teach my patient in the middle of the night, or ignoring the knowledge deficit and leaving it for the next person Im not sure what else I could have done
      7.) I was never given the opportunity to sit down and be interviewed by an ethics committee or an opportunity to meet with the doctor to arrive at consensus. I was swiftly terminated. 
      8.) I did not act alone.

  • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

    What is appalling to me is how no one in this forum even mentions nursing management, or the fact that I took measure to engage nursing management when I discovered a potentially harmful situation involving my patient. As Ricky Martin points out—my actions “led to” disorganized team based care. Really? There was no concept of team based care at Del Webb. We werent oriented on it, we werent inserviced on it, and there were no initiatives to promote it. In fact, when our management asked for nurses to submit projects to improve patient satisfaction scores on the unit i submitted–along with a new grad nurse I was mentoring–a huge multi-pronged project that incorporated an interdisciplinary model of care within the Robert Woods Johnson Foundation initiative “Transforming Care At the Bedside.” I was actually PROMOTING team based patient centered care. Wanna know what Del Webb’s response to my submission was? SILENCE. Neither myself or the new grad I was working with ever received a single acknowledgement of our submission after weeks of thoughtful hard work that would have promoted better teamwork between all healthcare disciplines. We emailed all the management and the CNO to ask for feedback and were ignored. So, with all due respect, please don’t insinuate or suggest I am not able to incorporate my talents or education to the “team” when there is no “team” based care at that facility—nor the desire to incorporate one. I saw the need, experienced physician to nurse abuse, tried to remedy the communication issues–and was ignored, and eventually fired.

  • http://twitter.com/AtulJainMD Atul Jain, MD

    Unfortunately, from the legal perspective it doesn’t matter if what she did was within the scope of her capabilities of nursing practice. If the hospital bylaws or her employment contract specifically state that such consultation requests must be made only by the patient’s attending physician, then this alone may be cause for dismissal .

    The author of this blog post makes a good point about how important it is to be an active collaborator in patient-focused care. However she fails to make a convincing argument that Amanda Trujillo attempted to act as a “collaborator.” She apparently did not inform the primary physician of her discussion with the patient or notify him/her of the patient’s request for a hospice consult. How is keeping the patient’s primary physician “out of the loop” an example of collaboration?

    Atul Jain, MD

    twitter: @AtulJainMD

    • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

      Great argument…had I not printed out all the policies of the hospital as a reference when I was hired….Im a bit type A like that. 

    • http://torontoemerg.wordpress.com/ TorontoEmerg

      I point out that Trujillo documented — voluminously, as it happens — and additionally left a detailed note for the primary care physician. I am not sure, given the fact the physician was not there, and short of paging her/him late at night, to act more collaboratively. In the event, if the consensus of the team was that Trujillo’s actions were unwise, they were easily undone.

  • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

    Here is another very important reason you should care about my case. The discipline of Nursing has been twisted and molded into something  that suits the interests of a corporation at any given moment in time. Nurses. We are taught, trained, its drilled into our heads what the profession is and what Nurses “do.” Awesome. Neato. Totally inspirational stuff, really. But! The moment you walk into the doors of a hospital–these days, within the current healthcare economy–all that goes out the window. Nursing is no longer what you were taught about and learned to do—Nursing is now defined by whatever hospital you work at. Corporations have literally redefined who we are and what we do within the walls of their organizations. You think this cant happen to Doctors too? If you say no–I implore you to think on that one again because as powerful as the American Medical Association is—the power of money and the big hospital corporations is  much greater. 

         The hard facts are that the financial bottom line of hospitals all over the country is suffering. Medicare is tightening up and adding to their “never events” list, they are reconsidering what they will and will not reimburse for, and the amount of money our country spends on acute care continues to drive up the cost of healthcare which is increasing the financial burden on a hospital’s ability to keep running at status quo. Now, here is where you Doctors come in–it doesn’t matter if you have an MD or an RN after your  name, if a hospital is losing money and there is the threat of shutting down, a corporation is going to do what a corporation needs to do in order to continue to generate revenue. Whether that means redefining “who and what Doctors are” or “telling you” what you “will and will not do” —the possibilities are endless right now in this aggressive patient care industry. They started with nurses because we don’t have a seat at the major healthcare policy making table in Washington–and nurses are afraid to talk so as not to rock the boat and lose their jobs, we were an easy win, really. But to think you wont be subject to the same behaviors and treatments by these major corporations? Id think twice on that. 

         It would be prudent to watch for signs, keep an ear out for that familiar language that would signal one to think whether a hospital its trying to play God not just with your patients–but with your license and ability to practice to your fullest extent as an MD. Because–at the end of the day, MD or RN, when you walk through those hospital doors–its not you that is the priority—its all financial and its largely about profit—and not about patients. It really is just a matter of time…..a good example of a potential outcome—I’m sure you all have monitored how often OB’s get sued, their lives and careers ruined—I read somewhere that now less Doctors are wanting to go into that specialty. Same sort of thing here—-what I’m hoping will happen is that a few doctors will get mistreated like this and the AMA will wield its giant sword at big business and say “I think not!” …Because the ANA sure isn’t.

    • Anonymous

      Amanda, thank you for going public with your story and helping to get some important facts out there.  As a physician who has been scapegoated by a hospital/medical board as a pawn in a much larger power play (someone else mentions this issue below as well), I can assure you that this type of thing DOES happen to physicians as well.  However, I don’t even think it’s worth pretending that the AMA or any specialty society is going to bat for physicians over hospitals — the ones that would need to get involved lack the power to do it, and for the most part, these organizations are run by people who have interests very much aligned with hospitals (essentially, academia = hospital in clinical medicine).  I think it is widely known how powerful the managed care lobbies are, I think it’s less well known that hospital lobbies are in the same league.  God help the health care professional who dares to question the maximize-billing assembly line of the modern hospital.  It’s not about bad individuals for the most part, I firmly believe that most physicians, nurses, and allied health professionals have the best interests of their patients at heart, but it’s usually easier to fall into your appointed role than to question the goals of care or the best interests of the patient.  To work in a hospital, one needs to conform to a given role.  Most of the time, it works OK that way, but not every time, not when the financial rewards of a complicated, well-reimbursed (maybe even high-profile) surgery, or a lucrative Phase I drug study cloud the minds  of the providers involved.  I think it’s very important to call attention to cases where the best interests of a given patient clash with the organizational goals of a hospital, and what happens to the professionals who dare to point that out and take action.  Medical training is a very long road, one which is completely dominated by hospital-based care, so this lesson often waits a decade or more, and comes to quite a few as it did to me, as a very rude and career-threatening awakening.

  • http://twitter.com/AtulJainMD Atul Jain, MD

    Amanda, thanks for providing more details of what took place and your attempts at engaging all involved parties. This appears, in the end, to be a situation where care/communication protocols were ineffective and somehow led to a backlash against you. This is unfortunate and should be seen by administration as an opportunity to improve whatever policies are in place and to act as a mediator for involved parties, not to undercut valuable and conscientious employees. I wish you luck in hopefully turning this into opportunity for you to become an engaged advocate.
    FYI- Someone I know whom works at that hospital sent me a local news report of this incident and it failed to provide the details that you did. It changes the situation, in my perspective!

    • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

      Thank you Doctor, I wonder if it was the individual who threw the party and forgot to invite the guest of honor….

  • Anonymous

    Amanda, I just had a long talk with one of our amazing ICU nurses.  The crap that they have been put through because they are at a higher pay scale have them fearful of termination at the next silence of a call bell. In fact, one has been fired for not having their BLS up to date,(although ACLS was).  I was appalled at that, and that other nurses have no where to go to report unfair treatment. Their “superiors” turn a blind eye, and promote new nurses indicating to the seasoned ones “don’t correct them, we don’t want them to feel bad about themselves”  What a crock!!!
    Anyway, YOU are our eyes and ears at the bedside ALL day with our patients. We have to trust you, and your judgement.  Could it be that the doctor was mad because you took away a potential transplant case (even if it wasn’t the right thing for the patient)? Revenue driven? Hospital quotas for transplants??
    I have found recently through personal experience that many doctors are clueless with hospice and end of life care.  It is as if we are trained to do EVERYTHING no matter what.  We need to realize that our patients deserve quality care, and if that means going home to enjoy their family for a little while IS ok. 
    I really wish you still did nursing, I am sorry that one really jerky person ruined your chance to advocate for patients.  They really need someone like you.  Best of luck…


    • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

      Thank you Dr. Meese, I think what concerns me most is that slowly but surely large corporations are inserting themselves in to bodies of knowledge in a “back door” fashion and they have no business doing so. Unless all hospital CEO’s and associated executives are put through both nursing and medical school–they have no business redesigning the profession of nursing or the medical profession to suit their own needs within the walls of any institution—medicine is medicine and nursing is nursing—remolding those disciplines or attempting to limit scope of an established, licensed discipline is careless and dangerous…..refer to the argument people make about pro life: “get your hands out of my uterus.” That is what I am trying to illustrate here—its when people outside of those disciplines and training start to insert their hands into our bodies of knowledge and training that situations like mine occur and places Doctors at the very same risk. As Ive said before—my situation will be one of the last warnings before someone actually gets hurt next time—we, both medicine and nursing, have the ability to stop this NOW. It will just get worse if the AMA and the ANA dont put a stop to corporate america’s hands in our practice with patients. I miss nursing terribly Doctor, there are no words for it—but now that I know what is expected from the “Corporate RN” I refuse to participate and allow my profession to be demeaned and reduced.  

      • Anonymous

         Most Physicians don’t know how to be team players and don’t want their imagined authority questioned.  The patient is the customer and the one in charge of their care.  The Dr. and ancillary personnel work for them.  I’ve fired two of my Physicians in my lifetime for not having my best interest in mind.  One was the surgeon I was referred too and the other a referring physician.  I was divorced by a dentist for missing an appointment because of an emergency issue in the blood bank! Even though they are the team leaders, they don’t always no how to lead or decide what’s best for the customer.  I’m surprised that I was never fired for advocating cannabis to chemo and aids patients in misery due to ineffectual supportive measures.

  • Anonymous

    RN Trujillo needed to be working at a facility that had a union. In fact every nurse should belong  to a union even if they work at a facility that does not have a union as I do. The “healthcare” system in our country (There is actually no healthcare system in our country. It’s supply and demand.) uses nurses and doctors as mechanisms and until we create a healthcare system (like medicare for all) that treatment will continue. However, a union does offer representation that can be followed up with a lawsuit for an inappropriate loss of job like this nurse’s situation. 

    • http://profile.yahoo.com/L5E5IDEGD4GSXI4J7GMLNM4XQQ Brett

       Unions destroy the workplaces in this country.  They do not stop at providing protection for wrongful termination and safe workplaces.  They provide for such benefits as those seen in California.  Every nurse receives time and a half after their first 8 hours, no matter whether they are in overtime or not.  They receive double time for hours after 12, again, even if not in overtime.  The lavish benefits unions negotiate for in this country virtually destroyed Detroit.  They shut the doors of numerous California hospitals over the last 10-15 years.  Do you think that benefited the local patients?  Or, how about the fact that advancement in union facilities is based on longevity of work at the facility as opposed to skill and ability?  There are some nurses who have been working for 30 years whom I would not trust anywhere near a budget.  They get management positions in union facilities just because they exist.  Give me a break.  Unions had a great purpose when people were working in factories without oversight.  They were getting limbs chopped off, lost their jobs, no worker’s compensation, and no social security.  Yes, unions were a godsend then.  Now, we have social security, worker’s compensation, agencies like OSHA, and numerous other built-in protections.  Unions simply go for the more fancy stuff that shuts down businesses.  They take the dues they enforce on their members, and they send them to candidates running for office who will support what should be illegal practices.  These candidacy donations are not spread out evenly either.  Last report, 96% of donations went to the democratic party.  Sounds like nothing more than a system of kickbacks to me.  Either you are a socialist, or you are simply uneducated.  I am hoping for uneducated.  At least then, you still have a chance.  Good luck!

      • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

        Actually  I worked in Europe where there were communist labor unions. We could only hope to have as many rights as workers have in Europe. With that said it is not a perfect system because I saw workers go on strike two to three times a week. The factory ended up closing because there was no productivity. In Europe women get time off to nurse their babies thanks to the unions. That would be a nice perk for moms and their babies but it will never ever happen in our country.

        • Anonymous

           I don’t believe the unions in europe are communist -you need to look up the definition.  Communists purport to be socialists but are in fact totalitarians giving the people no power

      • Anonymous

         I’ll bet you have no trouble with holding your employer to the wage and hour laws the UNION fought to get passed, you have a double standard like most anti-unionists-you want benefits without responsibility and are obviously not a team player.

    • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

      I agree, we need unions to protect our interests. We cannot serve three masters-ourselves, our employers and our patients. We can take our interests out of the equation by having a union to represent us.  As far as the competing and conflicting interests that exist between a hospital’s needs and a patient’s needs, it seems ludicrous that a patient’s needs can conflict with the organization that is there to serve them.

  • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

    Hi Hampter! Totally agree on that one :) Ive had patients with blood pressures in the 70′s who were operating just fine. They had grown accustomed to those BP’s with the Carvedilol etc and I agree with the cardioprotective benefits of maintaining blood pressures in the 70′s and 80′s as much of anything greater often precipitates arrhythmia issues, as well as recurrences of decompensation and renal issues…they walk such a fine line when their blood pressures are even slightly out of “their” norm. I used to be scared in the beginning to see such blood pressures but the more questions I asked from my mentor (a heart failure/transplant doc) the more I learned how good this is for them and if the patient is properly monitored for signs and symptoms they are not tolerating the blood pressure they are at, then its back to the drawing board for the doc and the team to figure out. Whenever my patients had a dose change I would just monitor more frequently and look at their urine output and neuro exam to clue me in to potential problems and then call the doc if i picked up on anything new.

  • Anonymous

    Has anyone mentioned the money involved?  There is far more money to be made from a transplant than hospice care!  Perhaps the physicians involved were more interested in the money than in the patient’s care!  It seems to be an excessively severe reaction to the “offense” committed (which doesn’t really seem to be an offense at all)  Clearly the patient’s wishes were being ignored and any caring physician would comply with what the patient wants.  They didn’t really inform the patient of all of his options for his care in the first place perhaps so they could perform the transplant for the money they would make even if the transplant failed or had complications.  The follow up care would bring in money which could also be a factor.  Many MD’s do have a “God” complex and feel the patient has no right to decide their own health care.  This was far more common in the 50′s but certainly out of place in this time and place.  Patients have more rights at this time than they have in the past and rightfully so.  Doctors now need to take ALL the information available to them and the patients to ASSIST the patient to make their own decisions about their health care and that includes the information provided by the nurse who is a QUALIFIED member of the health care team.

    • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

      Ahhhh….and the special part of all this is—-the Doctor was cleared of the complaint I filed against his license—neat huh? Just found that out this past week.

      • Anonymous

        I’m sorry to hear that Amanda. Having been hopitalized on a couple of occasions,I can say that caring, proactive nurses such as yourself should be supported, not treated the way you were. Good luck and keep on doing good things for your patients.

  • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

    I believe Amanda made the doc look bad in the eyes of the entire team and could have handled it differently.  If it was that important to her, she should have waited around for the doc to come in and discussed her concerns with him personally. I thought the golden rule was never to chart anything that would open the organization nor another colleague open to liability? This isn’t such a black and white issue. Furthermore you can achieve the same result in different ways. Initially I supported Amanda but have to withdraw my support because she is very defensive and does not seem respectful of anyone who disagrees with her.  It seems that whenever someone disagrees with her position, she responds defensively and with a long dissertation about why she is right and they are wrong. Why would you even be defensive about your level of education? It’s as if to say, I have credibility because I am working on my doctorate in nursing. I have known MD’s who ere very smart but who had little or no common sense. In the meantime I will wait to hear both sides of the full story.

    • http://profile.yahoo.com/L5E5IDEGD4GSXI4J7GMLNM4XQQ Brett

      As an Acute Care Nurse Practitioner, I have to say that Amanda did work outside her scope of practice.  I do, however, think the firing was extreme.  A transfer of departments and a probationary period assigned by the board to her license would have been more suitable for the situation.  You have to understand (because it has taken myself a while to understand this as well) that many nurses walk around with chips on their shoulders because they either believe their education is being belittled, or it has been belittled in the past.  I could care less because my scope of practice says all it needs to about my education.  Unfortunately, that is not the case with most nurses, and this is why you see the reactions that you do. 

      If the patient did not understand the full extent of the treatment plan, Amanda should have given general facts about how liver transplant patients do and said she would contact the doctor about further discussion.  She is not a transplant surgeon and does not know the individual patient’s prognosis.  However, she was right to push furthering the patient’s knowledge about what was to come.  The hospice consult should have been pitched to the physician to decide.  Even still, palliative care (as opposed to hospice) would have been more appropriate. 

      On a separate note, respect is a two-way street.  I have seen more instances than I ever care to admit in which physicians cover up their screw ups because of fear of losing their licenses.  It is wrong, I agree.  However, I can at least understand that in today’s world where many patients are trying to make a buck off their health care provider, the initial reaction may be to cover up errors.  Also, let’s be realistic about this.  How many people (in any profession) are going to put something out there that is surely going to mean they lose their income because it is the “right” thing to do?  The right thing to do depends what perspective you take.  Is it right by the patient?  Yes.  Does losing my income mean I lose my house, my ability to put food on the table for my children, my ability to ever practice again?  If the answer is yes to these questions, then you are correct.  Everything is not so black and white.

      • http://profile.yahoo.com/L5E5IDEGD4GSXI4J7GMLNM4XQQ Brett

         I have to correct myself.  I found a post very far down explaining Amanda simply consulted case management to speak with the patient.  She went on to explain how the scope of Arizona nursing practice backs her decision, and I stand behind what she did.  She did not work outside of her scope given her explanation of her state’s practice.  A nearly year-long investigation by her board is political at best.  It gets more and more difficult to work in health care in this country.

        • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

           Brett you are right. It IS difficult to work in health care. I am surprised many more nurses and doctors are not choosing a career in politics so they can be the ones to drive the changes needed in our health care system.

      • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

        Thanks for you thoughtful response.

        You are correct. Many docs cover up wrong doing and we need reforms in that area as well. If they injured a patient they also need to start doing the right thing by apologizing and compensating those injured instead of giving lawyers money to prove a guilty person innocent.  That is costly. I know what the reality is but this is something we should work on as a profession because it benefits everyone involved including the one accused of malpractice. Although their malpractice premiums will still go up, they will be less than what they would be currently since their legal costs won’t be as high. 

        If a nurse currently works in a state where there are whistle blower protections and they do not report fraud or harm to a patient, then they enabled the system and do not have a right to keep that card in their pocket only to use it later when they are about to be fired for some unrelated reason. That is self serving. I agree to disagree. There are other instances where things are black and white like child abuse in any shape or form. The FACTS leading up to the conclusion can be black white and shades of grey but if you believe with firm conviction that someone has been harmed, you have to err on the side of caution and you have to stand for something.

        I agree with you and many others that the punishment was harsh but we are not yet privy to all of the
        facts. The psych consult (as well as sham peer review) is also an abuse
        of power and has been used against doctors for many years.

        It seems like we are dealing with a lot of Amanda’s emotions and we do not yet
        have all of the facts. Amanda seems to be firing off a lot of comments when she is emotionally upset.
        For example when she recently learned that her complaint against the
        doctor was dismissed. It wouldn’t be fair to Amanda if Banner went online and only presented their side of the story. We have a legal process where we follow a fair and balanced set of rules while investigating the facts.  Amanda could have been
        more professional about this by going through the legal process instead of  turning this into a street fight.  If Amanda went through the proper legal channels her point would have still been publicly made because once all of the facts and opinions were in, the legal process would leave a paper trail of
        the FACTS for all the world to see. Yes we all have the right to free speech but with every right comes a

        In terms of the State Board, the current system is not perfect but we need a system to protect the public. On the one hand it seems unfair that the state board uses licensing fees to prosecute nurses for a perceived wrong doing but on the other hand,  the Board uses the same fees to acquit nurses who are innocent. And I believe that out of all the complaints filed, a majority of nurses are acquitted? Does  anyone know?  I know one thing…I am appalled when I read about nurses who sexually abuse patients, or those who steal drugs from their patients or those who are committed of murder in their spare time. So what is the answer? Do we need a triage system for state board complaints? Do you separate and have a different process for complaints that involve technicalities, misunderstandings, procedural issues, cat fights, and competence versus those that involve sexual abuse, stealing drugs etc? I don’t know what the answer is but I believe you absolutely positively cannot serve two masters.

        As a fellow nurse I truly wish Amanda the best

      • http://pulse.yahoo.com/_6336Q77Q7X6ZX6HYZVC4DEIG34 Choobs

        How is that outside the scope of practice? She requested a consult with hospice/palliative care; she did not officially order it. I don’t know how each and every hospital works, but anybody can call an ethics committee consult if they feel something is not right for the patient, whether it be nursing or physician care, can be ordered by a nurse. AND it was the patient’s request. 

        • http://www.facebook.com/profile.php?id=536906816 Kim McAllister

           Amanda requested an ethics committee consult. It never happened. She was fired the same day.

          The case management hospice consult she placed in the computer had “nurse order” option. She had placed this same order before without any ramifications.

          All actions were done in consultation with the nurse manager on her shift. This was not the action of an APRN, she is not an APRN. Any staff nurse could have done this (or as noted above, a patient or family can self refer).

          The order was cancelled before the patient was able to speak to anyone, Amanda found out later.

          Amanda was told she had ruined “all the hard work” of the doctor.

          And lost in all of this? A patient, now educated about what was being planned FOR them, not WITH them, was kept from a requested a requested referral for information. Just to speak with a nurse. This would have put off a transfer to another hospital for pre-transplant testing, due first thing in the morning.

          Who knows, perhaps the patient might have chosen to go through with it after having a chance to speak to the hospice consult. I wonder what happened to the patient.

    • Anonymous

      I am so disappointed in your response. Our healthcare system is disintegrating because of money driven policies instead of social justice imperatives. Your understanding of the profit agendas driving this debacle seems very short-sighted and possibly uninformed. It is amoral of our country to send dividend checks to people living on Park Avenue who never touch a patient at the expense of what nurses and patients need for the delivery of good healthcare. The World Health Organization (WHO) and United Nations International Children’s Emergency Fund (UNICEF) held a joint conference in 1978 declaring that health and health care were fundamental human rights. Amanda’s case is only a symptom of the negative forces that will truly ruin our health care delivery system in the U.S. You question Amanda’s ethics when nurses are voted by the American public every year since 1999 (except 2001) as the most ethical profession in our country. Amanda was doing what nurses do, advocate and collaborate with patients to achieve their optimal health care outcome. It is the patient’s decision, not the doctors, regarding how their health care plan will proceed. Let us never forget that and put aside the profit agendas. 
      D. Paxson Barker, PhD, MS, RN

      • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

        Dr. Barker
        Where did I state that I question Amanda’s ethics?  I believe I said I question the ethics of any nurse who witnesses harm done to a patient but who does not report it.  Amanda was one who did the right thing and who reported it. Assuming all of the statement made by her to date are true, she did the right thing but I disagree with the way she went about it.

        The fact is we do not have all of the facts in this case. I will reserve further judgment when I have all of the facts in front of me. Yes, I absolutely agree with you that our health care system is disintegrating because of money driven policies but it is also disintegrating for many other reasons.  And yes I agree with you that health care is an absolute fundamental human right but believe that is a separate argument.

  • Anonymous

    I think it is ridiculous that she was fired for looking out for the patients best interests. That doctor needs a severe ego-ectomy.

  • Tafara Mugwangi

    This was a very unfortunate situation. I work in a british system and the last paragraph of this article describes exactly what transpires here too. You’re a living threat to humanity (in management’s eyes) if you’re proactive, forward thinking, strategic in your thinking and critically manage all affairs regarding patient care. To me this was a win win, you provided great patient care, at the same time you saved the institutions budget by avoiding the surgery. They should be thanking you. Besides, ethically we know patient consent should be informed. That would have been an unrecoverable cost with great impact to the service. Physicians, clinical managers or executive managers should not be seen as god’s who supposedly know it all. If they really want to improve operational capability, value creation and building capacity then they have to stimulate and accomodate critical thinking and process improvements as seen by operational staff, i.e nurses and healthcare assistants. There is a great deal to be gained from listening to those voices, not trying to shut them. How can a CEO evaluate and design strategy without sound informed knowledge of operational conditions at the lo level of their organisations. 
    I know exactly how you feel, only i wasn’t fired. 
    I salute you. 

    • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

       Tafara I coudln’t agree with you more that there is a great deal to be gained from listening to those voices, not trying to shut them.

    • josie boyle

      The US systems not on a “national health” model.  If procedures don’t happen, hospitals and physicians do not get paid.  This is one of the road blocks to advocating for patients in the US. Is the inverse true where you are?  Treatments are not offered in order to save money?  That would be a tough position to be in as well.  

      Patient’s look to their physicians for advice and treatment plans.  I often see one or two solutions offered, most resulting in expensive procedures or prolonging end of life care even when it is not in the best interest of the patient.  I feel as though it is my job to interpret the medical jargon and offer the solutions not presented by the physician.  

      I am not implying all physicians function this way, but enough for me to feel it necessary to stick my neck out and advocate.  I haven’t had the experience of punitive action and feel for my fellow nurse.  

  • http://www.facebook.com/cheri.turner60 Cheri Turner Black

    Collaboration with an MD means discussing the patient and determining an appropriate treatment plan directed by the MD prior to directing the care.  In this case, the RN directed patient care prior to collaborating with the MD. 

    • http://www.facebook.com/profile.php?id=744472187 Vicki Roberts

      Everything should have been documented in the patient’s chart and this includes the plan of care. There should not have been any guess work on the part of the nurse. If the physicians did not document that there was an impending liver transplant how would the nurse have known? She is only going on information that is documented. This mistake could have happened to any nurse who was advocating for their patient. Arizona is such a backwards state. I use to live there and the best thing I did for my career was leave and move to California.

      • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

        Vicki we are so screwed up on many levels. im being persecuted for this while we have a governor who points her finger in the face of the president and scolds him, turns down a dinner invitation from the president, openly calls him names via the media—and oh lets not forget the sheriff who decided to use our tax dollars and resources to aim an investigation at the president of the united states trying to prove obama is a fraud. all m trying to do is protect the jobs of nurses and the rights of patients by getting legislation passed in my state—and I AM THE TROUBLEMAKER. Neat right?

    • Richard Willner


      This Nurse lost her job.  She was also reported to the AZ Board of Nursing and they have been “investigating” this for 11 months.  She can no longer work as a Licensed Nurse..  I would guess that her license will be terminated eventually.    In fact, I would bet on this.Do you think that this is the proper punishment?

      Richard Willner
      The Center for Peer Review Justice
      PeerReview (dot) org

      • Anonymous

        No and the way she is being treated is outrageous. She was her patient’s advocate and that is part of her job.

        • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

          Is she being treated more outrageously than other nurses who are reported to the state Board? Don’t get me wrong.  I have a tremendous amount of sympathy for Amanda.  Being reported to the State Board has to be a nightmare in and of itself. I would imagine that whenever a nurse receives a letter from the State Board it has to make their skin crawl.

          The State Board of Nursing has a tremendous amount of power over our ability to earn a living. And because our field is so specialized it is harder for us to get a job if our nursing license is taken away. In that case you would have to start your education all over again. I decided against an MSN for that reason.

          Our education and  finances are an investment and in that sense, it is safer to diversify than it is to put all of our eggs into one basket. Sometimes an advanced degree in nursing can limit a nurses opportunities…that is in the absence of any other degrees.

      • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

        Kudos on your Center for Peer Review Justice!!

        I don’t think it is a fair statement to say Amanda can no longer work as a Licensed Nurse. They haven’t taken her license away. Furthermore there are many area of nursing where she can obtain a very good position given this experience. We also do not know at this point and time  if her license will be terminated.

        I am concerned about something I read on another blog regarding Amanda’s alleged  misuse of credentials. The AZ Board of Nursing in a February 8, 2012, letter to Amanda is alleging that she improperly used DACNP-S credentials. Amanda has written that she used the (S) to indicate she was a student however the state Board alleges she used these credentials during a period of time when she wasn’t even enrolled in a DACN program.  If true, this will truly hurt her credibility. The letter posted on another bloggers website in part reads, ” …Our office also received a copy of your November 8, 2010 resignation letter to Mountain Vista Medical Center in which you used the credentials “MSN, RN, DACNP-S.” We have been unable to verify, however, that you held a “DACNP” degree in November 2010 and/or were enrolled as a student in a doctoral progri.,m or nurse practitioner program in November 2010…”

        Keep up the good work with peer justice

  • http://profile.yahoo.com/SSOXXRADYDRRIPQFDSCG7PKKIA Pepcice2

    Nurses need to engage in and be encourage to use cirtical thinking.  This facility and the doctor who demanded her dismissal should be ashamed.  Patient advocacy is role #1 for nurses and anyone who believes otherwise should not be involved in healthcare.

  • http://pulse.yahoo.com/_6336Q77Q7X6ZX6HYZVC4DEIG34 Choobs

    Ahh, sorry, I saw that you wrote another reply. 

  • Anonymous

    The persecution of Amanda Trujillo by the AZBN is especially troubling to me.  Me and my son Zachary (deceased) where victims of a cruel and abusive OB Nurse that had several formal complaints in her personnel file at Scottsdale Shea Hospital over the course of 2 years.  The AZBN determined that this nurse’s actions led to the death of my son.  She is currently on probation, but still able to work and potentially harm others.  I have asked the AZBN to explain how an abusive and grossly negligent nurse that killed a patient is able to continue working while another nurse (Amanda) that fully advocated for her patient’s needs all within the scope of her employer is being crucified.  It seems like the AZBN bases their decision on whom will benefit politically or financially.  Attached is my letter to the AZBN:  

    February 24, 2012


                    Re:         Amanda Trujillo (RN137552) and Dawn
    Copeland (RN120149)


    To whom it may concern,
    Please read my letter to the AZBN asking for honest answers as to why AZ citizens are not protected from abusive and grossly negligent nurses while Amanda Trujillo is being crucified for advocating on behalf of her patient’s needs all within the scope of her employement:

    To whom it may concern,
    My name is Shawn Soumilas and both my son (Zachary) and I
    are victims of an RN (Dawn Michelle Copeland) that violated numerous sections
    of the Nurse Practices Act set forth by the Arizona Board of Nursing.  Ms. Copeland’s cruel and negligent actions
    led to my son’s death and almost ended my life, leaving me with permanent
    health issues.  The emotional scars left
    by Ms. Copeland’s abuse will never heal.
    The charges against Amanda Trujillo have recently come to my
    attention.  I am horrified and sickened
    by the AZBN’s relentless crucifixion of an RN that advocated for the needs of
    her patient all within the policies and procedures set forth by her employer
    Banner Health.  Isn’t patient advocacy
    the foundation of the nursing profession? 
    Isn’t one of the main roles of the AZBN to ensure that nurses are
    advocating for their patients?  At this
    point it looks like the AZBN bases their decisions on whom it will benefit
    politically and financially.
    On 1/26/11 I spoke in front of your board detailing the vile
    abuse that my son and I received at the hands of Ms.  Copeland. 
    At that time I pleaded with the board to protect other Arizona citizens
    from being harmed by Ms. Copeland.  The
    AZBN did not listen to my plea and Ms. Copeland is still able to work after her
    actions led to the death of a patient. 
    If my son would have been 5 years old and not a healthy full term baby,
    would that have made a difference in removing Ms. Copeland from the nursing profession?
    The Amanda Trujillo investigation is blatant hyprocisy and
    demonstrates a fundamental breakdown within the AZBN.  The zest in which the AZBN is pursuing Amanda
    reminds me of a spoiled child that is not getting its way and throwing a big
    temper tantrum to get attention.  I would
    like each member of your board to ask yourselves this question:
    If you were at the end of your life due to debilitating
    illness and had to make a decision on how you wanted to end your life, would
    you want to be in the hands of a caring and compassionate health care
    professional that educated you about all your decisions and the outcomes OR  would you want to be in the hands of a health
    care professional that doesn’t see you as a human being, but rather a vehicle
    to feed their own ego and pursuance of the all mighty dollar? 
    When I was preparing for my appearance in front of the board
    on 1/26/11, I was told by investigator Judy Pendergast not to show anger and
    not to make demands of the board.  Well,
    I am angry and I demand answers.  As the
    mother of a dead child, explain to me why the person  responsible for my son’s death is still in a
    position to harm others while Amanda Trujillo is being persecuted for actually
    caring for her patients’ needs all within the scope of her practice?  How will the AZBN explain to the next victim
    (or victim’s family) of Ms. Copeland that the AZBN could’ve prevented any
    further trauma inflicted by Ms. Copeland if the right thing would have been
    done by the AZBN on behalf of Arizona citizens at the board meeting on
    1/26/11?  Having firsthand experience as
    to the type of person Ms. Copeland is, it is not a matter of “if” she harms
    another patient, but when.  The Consent
    Agreement facilitated by the AZBN and signed by Ms. Copeland  says it all and proves that Ms. Copeland’s
    actions  killed my child.  Not only was she negligent, but the abuse was
    over the top.  What type of individual
    screams at a dying mother whose baby has crashed:
    “Where have you been,
    didn’t anyone tell you that your baby isn’t breathing?”                       

    As a reminder, Ms.
    Copeland left me sitting in a hallway for 20 minutes after she knew my son’s heart rate had gone to 50 than ultimately

     Also to refresh the
    AZBN’s memory here are all the Acts that Ms. Copeland violated including lying
    to the investigator about previous complaints she had received in her 11 years
    of nursing.  Ms. Copeland had 3 formal
    complaints in her personnel file at Scottsdale Shea alone:
    I wholeheartedly support Amanda Trujillo as does many
    Arizona citizens.  If Ms. Copeland had
    exhibited half of the compassion and professionalism that Amanda Trujillo
    embodies I have no doubt that my son would be alive today.
    I fully expect clear and honest answers from the Arizona
    Board of Nursing  as to why this gross
    injustice is happening.  Platitudes will
    not be accepted.



                                                                                                    Shawn Soumilas

    • Anonymous

      I am so sorry for your loss. I lost my dad because of the actions of an incompetent physician and the care his nurses failed to provide. I desparately tried advocating on his behalf, but no one listened to me because they felt I did not know what was going on with him. I was in nursing school at the time of his death, and the professors “preached” advocacy. However, I feel that his nurses didn’t stand up to the doctor because they were afraid of losing their jobs. It is a shame that anyone has to go through that.

      • Anonymous

        I’m so very sorry for your loss.  I can’t imagine the pain that you feel. Please keep fighting as that is the only way to make a difference.

    • Jenny Holstein

      I am sorry for your loss. And what you’re saying, I think is right.

      But I worry though that you might find yourself in breach of the law i.e. libel/slander with the full name of that nurse + her licence number written on here. Just saying.

      • Anonymous

        Hi Jenny, thank you for your condolences and concerns.  Please be assured that discussion of our situation has been given the “green light” by legal counsel and validated by the simple fact that all facts are backed up by public record.  Myself and my family truly appreciate your concern. In loving memory of Zach, The Soumilas Family 

  • http://profile.yahoo.com/XJALXLDUQUPIOP4JJ7JWACJRC4 Missy

    Any patient can SELF-REFER themselves for a hospice “consult”.  A nurse who informs her patient of this right is not working outside her scope of practice.  This is general public knowledge, or should be.  The surgeon should inform the pt of this option, but many don’t.  The surgeon is responsible for evaluating the pt for eligibility for surgery and for informing the pt of the risks/benefits of having the surgery and the possible outcomes.  The hospice care provider is responsible for explaining hospice services.  The only time a physician’s order is needed is if the pt actually elects to choose hospice care, and then an order is required along with certification of hospice eligibilty from both the pt’s attending physician and the hospice physician.  Whether or not hospital case management staff is involved is beside the point.  This nurse informed her pt of the option of hospice care and requested that case management assist the pt in following up on the option when the pt requested it.  That is not an “order.”  It is a request for assistance from another member of the interdisciplinary care team.  She then appropriately left a note for the attending physician.  (She could have phoned and awakened the doctor in the middle of the night to speak personally, but decided it was not an emergency and could wait until morning.  I would think the doctor would apprecaite this.)  I am speaking from the perspective of an experienced hospice nurse (RN) who has responded to many requests for hospice “consults”.  I provide information, and if the pt is interested in hospice care, my agency collaborates with the pt and the attending physician to come to an appropriate decision.  If the pt is indeed eligible for hospice care, it is ultimately the pt’s decision whether to accept hospice care or to pursue further life-saving treatment.

    • Anonymous

      It sounds as if the doctor was threatened by the care this nurse provided her patient. All too often some physicians get ticked off when questioned about the level of care they are giving their patients. This not only happens with nurses but with family members as well…ask the MD a ? and get treated as if you have no right questioning anything…some physicians suffer from the “God” complex. However, there are also as many physicians out there who do welcome questions and accept the fact that they are indeed human and can make mistakes. It is unfortunate for those patients/nurses/family members who get the MD who doesn’t care what anyone else thinks.

  • Anonymous

    I know I don’t have all the facts here, but I fail to see wrongdoing. Proactive nurses have improved patient care and enhanced my treatment plans at every turn in my career. I would rather work with a nurse that thinks for herself and the patient any day of the week than with one who is just clocking in the time. I hope this case does not throw cold water on the enthusiasm of bright nurses in this country.

    -Palliative Care Doc

  • Anonymous

    Look ,
    Behind our smiles lies a lot of animosity.
    It’s all about the money people.

  • Anonymous

    For the record, my Discus account was hacked, and earlier comments under my name were NOT authored by me, ladies and gents.

    • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

       What was the outcome? Did you get it all worked out?

      • Anonymous

        Yes, thank you, but I cannot get rid of the hackers trail of hate all over the ‘net, except where his/her work was deleted due to content already.

        • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

           That’s a nightmare. Did the website owner cooperate and help you to get all of this worked out or were you on your own?

  • Anonymous

    If she can get her license back, she should work for the VA hospital. The amount of incompetence in those facilities is so mind-boggling, she would look like a superstar. AND, you never get fired!

  • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

     There was something about this situation that wasn’t and isn’t making sense to me.  Amanda has written that she used the “S” to designate she was and is a student but this complaint (taken from medbloggers time line) tells a different story.

    Feb 8 2012 BON letter listed in your timeline
    “…Of note, you do not presently hold a valid and current certificate as a registered nurse practitioner in the State of Arizona. In addition, according to the Associate Dean for Academic Affairs at the Arizona State University (ASU) College of Nursing & Health Innovation, you have not graduated
    from ASU with a Doctorate in Nursing Science (“DNSc”) and are not presently studying for a “DNSc” at ASU.

    The Associate Dean advised our office that you enrolled in the BS-DNP Adult Health Nurse Practitioner Program in Fall, 2011 and are presently taking non-clinical courses.

    Our office also received a copy of your November 8, 2010 resignation letter to Mountain Vista Medical Center in which you used the credentials “MSN, RN, DACNP-S.” We have been unable to verify, however, that you held a “DACNP” degree in November 2010 and/or were enrolled as
    a student in a doctoral program or nurse practitioner program in November 2010…”

    Furthermore the information taken from the Feb 16 2012 entry (medbloggers timeline)  addresses more than the hospice referral,  namely “multiple practice errors” which Amanda has not addressed and  “”failure to maintain professional boundaries while employed at THREE DIFFERENT facilities and not just Banner and not during the one night shift in question.

     “…As a failure to maintain professional boundaries, multiple practice errors, and scope of practice violations while employed at EITHER Banner Del E Webb Hospital, Mayo Clinic Hospital, Valley Home Care, AND/OR Mountain Vista Hospital, the board issues this interim order:…”

    Can Amanda shed some light on these issues so we can better understand the facts.   I know that as an RN I am not very happy when a Medical Assistant tries to pass themselves off as an RN and then tarnishes my professional reputation . I believe the Boards of Nursing is not doing enough to put a stop to this practice. If Amanda is trying to give others the impression that she is a DACNP or even a DACNP student when they are saying they have evidence that she was not, then that is a clear violation and would be deceitful.

    • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

      1.) I underwent interrogation about my entire work history–their wording is a genius way of  making me look just how you are perceiving it–If I had anything to be ashamed of I wouldnt have allowed that to be published. The word they used was “either” between all the facilities to make it appear i am a troublesome being EVERYWHERE while taking the focus off the situation at Del Webb. 
      2.) I have been enrolled as a student and am currently a student. I have since submitted evidence to that fact to the nurse investigator as well as my dismay that they did not properly investigate my enrollments. I utilize student credentials when commnicating with my mentors, for scholarship apps, and with other nurses or nursing organizations. Whoever they talked to or supposedly talked to at my school misinformed them. 
      3.) I allowed the letter to be published to illustrate the lengths to which certain agencies are going through to discredit me and make me look awful. 
      4.) I never misrepresent myself as being something i am not nor do I misrepresent myself to pass off as anything more than who and what I am. I hope that clears things up.        
      I approved all documents published by Whitecoat–i submitted them to him myself.

      • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

         Thanks for the clarification Amanda. It makes a lot more sense now. Are you able to elaborate on the interrogation process you went through with the SBON personnel and do you have any advice for other nurses going through that process?

        • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

          Is there a way I can contact you or connect with you on the first question? I dont want to step too far out on what i say in this forum pertaining to the process…as far as my advisement to other nurses….we all make mistakes in our careers—own up to it, answer truthfully, dont be defensive, and remember what you were thinking clinically at the time so that whoever is asking you questions can get the closest they can to what you were thinking at that time. I didnt feel an interrogation for my entire six years as a nurse was necessary for a case management consult at a facility Id never been disciplined at–however–that being said, I felt transparency was an important piece and I knew what was in my work history and that they wouldnt find anything like sentinel events, or patient injury etc–rather–mistakes any nurse would make or could make along the way so I just went in and did the best I could—remembering youre a human being is a big part of it and no human is perfect–none of us can be perfect practitioners…I take this approach—i make a mistake, i learn from it, I give thanks for it, and I move forward trying to be better for it. 

          • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

            John..I am on facebook and twitter. Find me there, and perhaps we can work out a conversation over the phone? Or email??   

          • http://profile.yahoo.com/7M7TPTWIZVMLOGAE4PKFRQUDYI John

             I will connect with you on one of those. Thanks

    • Anonymous

      I think the “DACNP-S” designation is misleading.  As a medical student, the chart designation is “MS-III”or MS-IV” depending on the year of school in which one is enrolled.  The urge to display a cacophony of letters reflects a need to prove one’s worth, to me.

      • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

        I never document anything but RN in my charting…..

  • Michal Haran

    The health care system is meant for patients (even though this is sometimes forgotten).
    Patients clearly need (and do better with) wise, caring and dedicated nurses and physicians. 
    No one is error proof and that is why it is great for a physician to work with a highly educated, vocal, critically-thinking, engaged nurse. The opposite is also true-It is great for a nurse to work with an open-minded, critically thinking engaged physician. 
    Even in a perfect team miss understandings and lack of communication may occur. 
    Many times patients feel more comfortable discussing their concerns with nurses than with physicians. There are many reasons for that-nurses are more at their bed-side. also, patients are some times afraid to dissapoint their physician or be seen as non-compliant in their eyes.  

    I had a patient who would smile and appear very optimistic when talking to me, but the nurse taking care of him made me aware of the fact, that he is not so happy when I am not around. This led to a discussion about his fears and concerns that I would have never initiated otherwise. 

    Another patient had difficulty understanding my explanations regarding his treatment regimen, but felt uncomfortable telling this to me. The nurse was the one that brought this to my attention, and together we explained it again in a way he could better understand. 

    And those are just two examples of many, in which the excellent nurses I work with significantly influenced my patient’s care.    

  • Anonymous

    Given the currently available evidence, Amanda’s punishment does seem to be excessively harsh.  However, I am very surprised to see so many comments supporting Amanda’s action.  Liver failure patients awaiting transplant are exceptionally difficult to manage, and the evaluation prior to transplant is detailed, time consuming, and complicated.  To assume that Amanda had a complete understanding of the patients eligibility and health as an RN is, to me, unrealistic. The average wait time for liver transplant is 12-36 months (depending on region) and the 1 year survival is between 20-80% (depending on MELD score) for patients with liver failure.  Lets say that this patient Amanda was trying to “advocate” for was given misinformation by Amanda (again, RN’s are not trained to may complicated decisions directing the overall care of patients).  The patient in his confusion may have then elected to be placed on hospice.  If a liver match had become available, he would have been off the transplant candidate list ultimately leading to premature death of this patient.  This is the exact situation that should be avoided by ensuring that nurses are advocates for their patients WITH the direction of the physician.  Nurses are not trained like physicians, this is not a critical statement meant to belittle nurses, but a fact that health care teams need to remember when using a team based approach to health care delivery.  

    • Michal Haran

      I agree with much of what you say, but have one comment-when there is a good physician-patient relationship based on mutual trust and respect, interference of this sort can not mess things up to the extent that someone who is fully prepared for a certain procedure or treatment will abruptly change his/her mind. 

      I think every physician experienced having someone give “advice” and mostly disinformation to his/her patient. I have had this happen with nurses, residents, GPs and even well meaning relatives and friends. (who had a neighbor that received much better treatment and did well with no side effects etc.)

      I am not familiar with the details of this specific case, but in general I would think that a patient who has full confidence in his physicians and has reached such a hard decision (like you say it is a long process) after being given all the information, may become fearful the night before, but will still go ahead with what he decided to do. Or at least insist on raising his concerns with his physician. That being said, I agree that people (nurses, physicians or relatives and friends) should be very cautious in giving advice which is against the advice of their physicians. As this is many times counter-productive and can lead to needless confusion. Medicine is not an exact science and most times there is more than one way to go, each with its pros and cons.  Once a patient has reached a hard decision he/she is overall content with, it adds nothing to make him/her repeatedly question it. I think that even if Amanda has made a serious judgement error, the punishment is excessively harsh. No doubt that she meant well, and like every physician, nurse (and person) may have made a mistake. I don’t think that one error should destroy the life and career of a person, who overall has a good record. We all learn from our mistakes, gradually doing better.  “The road to wisdom? Well, it’s plain and simple to express: Err and err again but less and less and less”. – Piet Hein 

  • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

    “If only life were a dress rehearsal….and there was time for do overs…If only we could practice and practice every moment until we got it right. Unfortunately every day of our lives is its own unique
    performance…It seems like even when we get the chance to rehearse and practice and prepare…we’re still never quite ready for life’s grand moments….”

    • Anonymous

      Amanda, that’s like saying you’ve spent your life practicing and practicing to be a stagehand and then trying to perform as a ballerina.  You have watched the ballerina but you lack the perspective and gravity of what it takes to fill that role.

    • Anonymous

      what does that mean exactly? how is that relevant to this discussion? are you saying you made a mistake? if so, that is a complete 180-degree-turn from your earlier comments and tone.

    • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

      People. it was a quote from greys anatomy. and seems to be taken out of context. the quote itself can be interpreted from a multitude of standpoints and was meant to spur discussion–not criticism between disciplines. One could take this quote to reflect that no matter how much we are trained to act in specific ways in specific situations that no amount of cllincal rotations or practicing on eachother or care plans can ever prepare you for the reality that is out there. And no–I did not make a mistake.  

      • Anonymous

        Since when is trying to get a patient off the transplant list and jeopardizing their life not a mistake? If that was my father that would be considered a grave mistake robbing my loved one of potentially years of quality life provided by a liver transplantation.  

    • Anonymous

           I am not an RN,but in Healthcare. I also live in a Right to work state and was fired after 20+yrs ,no problems and above average yearly reviews. You are so right about the if you could re-do some.  There is no way that everything would be the same as it was at that moment. The past is just that, you must correct a problem now and get clarification of a policy{ Just Culture does not always apply} or a term such as ZERO Tolerance.  
          Patients do have rights and we must respect that. We must report inconsistency within the system especially when staff are rotated to different campus within the healthcare system where Patient Safety is concern. I think all of us experience inattentional blindess at one time or another.  We must also support our co-workers when they are being bullied and other information is distorted.
      An example of this is “not always properly checking Patient ID”, if placing patient in bathroom and you are waiting outside the door you must recheck their ID Bracelet if they have one and have them restate their Name and DOB.

  • Anonymous

    I haven’t researched this case much, but I think it boils down to MD trumps RN.  And as a RN, I have been on the side of a MD full of ego and malice….it’s a losing battle.
    I hope this case will promote more collaboration and communication in the medical world; not only with MDs and staff, but to include more patient education and advocacy.
    Sounds like Amanda would make a great liason for nurses and healthcare laws/mandates/etc.  Best of luck, Amanda!

    • Anonymous

      I’m disappointed this comment continues to perpetuate the stereotype of the egocentric physician that makes decisions on the patients behalf with malicious intent.  As a nurse, I would expect you to appreciate the sacrifice and dedication that MD’s make for the sake of their patients.  Please stop portraying nurses as the sole patient advocate who must struggle against a physician.  While Amanda may be a wonderful nurse and caring person, she made a mistake in judgement.  It is troubling to see so many other nurses support her actions as appropriate.  Ordering or directing care decisions without the guidance and collaboration of a physician is NOT appropriate for a nurse to do.  This isn’t about an egomaniacal MD (which the Dr. in Amanda’s story may be) its about making a decision that affects the health of a patient in the most informed way possible.  Nurses are not trained to make decisions about transplant candidacy in liver failure patients.  

      • Anonymous

        I did not mean to make MDs all out to be full of malicious intent, but I was in a situation with a MD that disliked the fact that I was the advocate for my patients.  He hated the fact that parents were scared to call him so they would show up at the ED with their child instead.  I should have been more direct with my comment.
        I have worked with some wonderful physicians that are true patient advocates; but I have seen the other side.  I’m sure MDs can say the same for nursing staff.  I wish a collaborative environment would be pursued by all….guess I’m a dreamer~!

      • Anonymous

        I agree about the general tone of nurse commenters here. Some posters (see earlier, e.g. Matt Browning) are even viscious, bordering on a sociopathic insecurity, again which goes along with the childlike need to put lots of letters behind one’s name.

      • Anonymous

         Actually, it IS about an egomaniacal MD and the subsequent inappropriate response to a totally legit NURSING action.  There are these things called nursing orders that we can actually do all on our own, imagine that, and usually, they equate to simple consults or screens without any actual medical interventions being initiated.  It is troubling that you see this utilization as inappropriate; it demonstrates a lack of the ability to critically think without being told what to think, and as a result, I would not want you as my nurse.  It’s 2012 and we can do more than fetch their coffee and duck when they throw tantrums.  Get with it or retire, please. 
        Now just like the rest of us (I’m sure), I’ve worked with some fantastic physicians as well…but we’re not talking about them…we’re talking about this guy…and his actions were appalling…please stop defending this gross abuse of your fellow nurse, it’s disgusting.

      • http://www.facebook.com/profile.php?id=1612418256 Cindy Maughan

        I have had  3 special needs children that see more Dr.’s in 1 year than most people see in 10 years. I know for a FACT that MOST Dr.’s are egocentric and have a “God complex” and that nurses and parents are rarely given any credit for their knowledge of the patient. It is VERY VERY RARE to find a Dr. that really cares about his patients. Most Dr.’s do not value anything the nurse has to say and I know many nurses like yourself feel it is NOT your place to make any comments or observations to the Dr. about a patient unless you are asked and then many times your answers are vague and not accurate because you also look to the Dr. like he is a God. I find it really disturbing that the thoughts and opinions of the nurses are not valued.
        Nurses spend a lot more time with the patient then any of the Dr.’s and so I think it is important they they feel free to discuss the patient like a professional without fear of retaliation from egocentric Dr.’s. It is very clear to me that most nurses do fear discussing a patient with the Dr. because many have said as much!
        I feel it is very appropriate for a nurse to have the ability to answer her patient honestly when they are asked a direct question concerning their health that might be information the Dr. “neglected” to make them aware of.  Many times I value the opinion of a nurse practitioner much more than a Dr.’s opinion. I have noticed that most Nurse practitioners put more thought and care into what they do then most of the Dr.’s. And many times they know as much as the Dr. does they just don’t have the M.D. behind their name.

  • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

    New video that surfaced on youtube this week—sent to me via email. same hospital involved. 

  • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

    So…after a week of discussion, reflecting on the multitude of postings–I come to the same conclusion. The rift is deep between the two disciplines. While I do not condone criticizing my physician colleagues (again–something I learned at the mayo clinic from my physician mentors—the  mutual respect thing)–it comes down to one thing…..doctors cannot do this alone. nurses cannot do this alone. research shows that the two disciplines overlap in scope throughout the continuum of patient care. It would behoove us all to come together in a meeting of the minds to figure out how to make it work so more people do not get hurt or–like my patient–get their rights to self determination denied. my patient was denied their request to see a case manager for hospice to get more expert teaching so they could make the best decision for themselves. the physician refused to let the consult happen. In the end—harm reached the patient. 

         Jockeying for who can teach the patient what and when hurts the patient and hurts nurse and physician relations. I respect each and every physician for the incredible sacrfices they make to get their education and balance their family lives with the work they do to care for the lives of strangers…..at the same token, please appreciate that  we have a unique, tried and true,  scientific, theoretical, and holistic body of knowledge and we go to school for a great deal of time as well. Im about to start two more years of clinical rotations for my NP–Ive been in school since 2001, with the exception of 18 months I had to take off for a devastating illness/surgery. That is a long time to dedicate to my studies in order to be the best practitioner I can be. Im sure both camps—nursing and medicine can go back and forth for the next 10 years on this issue alone–what happened in my case. my intent was to open up a dialogue to prevent this from happening again. 

         Another nursing shortage is coming to a head, and that directly affects both patients and physicians—as well as the large amount of new grads who will be left in the hospitals without proper access to skilled veteran nurses to teach them the ropes. Conflict or not, right or wrong, experienced nurses are burning out and tiring of being caught up in situations like these and they are fleeing the bedside. New grads–nearly 25% leave their positions in hospitals, or the profession at the end of their first year or shortly thereafter. This story is more than about perfections or imperfections, who is wrong or who is right, or who stepped on who’s toes or who violated who’s turf. Its about one of the last chances we have to take that “pause” and learn how to come up with a plan to work together before things get really bad and doctors lose the resources of the veteran nurses who are supposed to be teaching the new nurses how to care for your patients properly.The research is out there….this patient, this human being, who was denied their fundamental right to self determination–is a symptom of a problem that continues to swell. If you want nurses to stay at the bedside, something has to change–and soon. 

       Nurses……..We (or our scopes) are not to be divided by day or night, or the areas we practice in, or the level of practice we are at—a nurse is a nurse, and we all do the same thing—were at the bedside 24/7 monitoring labs, heart rhythms, pain control, hemodynamic status, and even parking our portable computers next to the patient who is alone and dying in the middle of the night. We do the things that help you to provide good care. Because you cannot be at the bedside at all hours of the day, or sitting in a  room teaching a patient and their family about CHF for an hour, or doing preoperative teaching the night before a CABG. We are well aware of the importance of physician leadership—but in many ways we lead as well, and most of us would do well just knowing that we are considered your partners in care, rather than subservient workers who must ask permission to do the very things we were educated and licensed to do within the nursing process. Common respect and collegial relations between medicine and nursing is central to improved patient care outcomes and nurse recruitment and retention both in hospitals and the profession itself.   

  • http://www.facebook.com/profile.php?id=27701254 Amanda Trujillo

    Please see youtube “Arizona Right To Fire” —this was a video sent to me this week by a cnn health reporter, it surfaced on the net this week. the same hospital is involved. 

  • http://profile.yahoo.com/3Q5HDZPZHN3TJCOYTA63V7KFL4 Dr. T. E. Huber

    deleted – points are moot at this point

  • Anonymous

    What has been glaringly absent in this discussion, which has become Nurse v. Doctor apparently, is the PATIENT’S WISHES.  I have silently read about this case on more than one blog and it has ASTOUNDED me how everyone has glossed over this teensy detail.   Amanda was right not because of anything other than she was carrying out, WITHIN her scope of submitting a NURSING ORDER, of what the PATIENT wanted.  It is through no fault of her own that the doctor never informed the patient as to his/her right to hospice care, and it was completely inappropriate for the doctor to cancel the order.  This, after all, was not something the nurse had insisted upon, it was something the PATIENT insisted upon after being further educated by his/ her nurse.  WHY were the patient’s wishes not followed? Because they hurt the surgeon’s feelings? Because it was a nurse’s idea and not a doctor’s? Because the nurse “ruined all the surgeon’s hard work and planning”? Again, lacking in all of these suppositions is the stance of the PATIENT.
    At the end of the day, not only did the nurse get bullied out of her job, the patient got bullied into a surgery. Seeing as how “patient-centered care” is the new buzzword, this is such a disappointing juxtaposition of that concept.
    Back to basics people.  Docs, stop worrying so hard about whether we as RNs are stepping out of scope if you’re not covering YOUR full scope of what YOU should be doing (INFORMING the who? You guessed it — PATIENT). Maybe if  this doctor had been more thorough in his explanation of options and prognoses, the nurse wouldn’t have been forced to pick up the slack.  
    Nurses, just another example of why you document, document, document, and ALWAYS follow your facility’s policies – Lord willing Amanda will win this case because (hopefully) she did that.  We all know that at the end of the day, we will ALWAYS be the ones hung out to dry.

    • Anonymous

      H’m, “always” hung out to dry?  I believe it is the physician who is liable and who will be primarily sued should something go wrong in this patient’s care not the nurse.   

      Of course healthcare is about patient choice.  Going through a liver transplant is a big deal with multiple outpatient appointments and visits to which Amanda was not privy to.  Talking to a patient in the middle of the night regarding a life ending decision such as hospice is not what would generally be regarded as an appropriate time to initiate this decision.  I agree that physicians should thoroughly inform patients about the risks and benefits of all medical decisions but giving a one sided inpatient view from the nurse standpoint can be not only confusing to a sleep deprived patient but short sighted since this is a one dimensional view.  I don’t understand how the inpatient nurse believes they can possibly understand all factors that go into that decision given their limited knowledge.  It is poor patient care to take it upon yourself to taint a patients opinion with an unknowingly ignorant perspective.  Correct me if I’m wrong but NICU nurses don’t run clinic, right?

      • Anonymous

        Yes, in instances of multiple parties being involved, I believe the nurse will “always” be the scapegoat, in my oh so humble opinion. We’re disposable, dispensable, replaceable, and have no surgical or medical billing privileges with which to generate income. Let’s be realistic, not idealistic.
        Now, you begin your paragraph saying “Of course healthcare is about patient choice” and then proceed to write a paragraph of “BUTS” explaining why THIS patient choice should not have been honored.
        Despite the rhetoric surrounding this situation, the issue at hand is not the tact with which Ms. Trujillo may or may not have exercised her disclosure of hospice care, the issue is whether this was outside of her scope and deserving of not only termination, but loss of professional licensure. So now, from your response, apparently, nurses are not supposed to talk to their patients about their health at all, because we couldn’t possibly know nearly as much as the physician about anything. Maybe, maybe not. The point is that Ms. Trujillo, while perhaps not exercising the best discretion in timing or professional communication, did not step out of her scope. Apparently, she did not provide prognosis (as per her statement) but a worst case scenario alternative. Honestly, if a patient asked me, ‘If I choose to not treat this cancer, what are my alternatives?,’ I would probably mention hospice/palliative care as well. It is our job to educate our patients just as much as it is the physician’s. Now, I probably would have told the patient to discuss this with the physician, however, I’m not going to lie to my patient or play dumb and withhold information just to sooth a surgeon’s ego. The other underlying issue is the general attitude towards hospice. Traditionally, surgery and hospice care have been basically opposite ends of the spectrum. We cannot expect practitioners of one end of this spectrum to readily release their patients to the other end, especially when these ends are most basically viewed as “life” or “death.” It is unfortunate that Ms. Trujillo is a pawn caught this subliminal prejudice as well. But hey, like I said, it’s easiest to just “hang the nurse out to dry” and pacify the physician.
        Correct me if I’m wrong, but policy is policy and if policy enabled her to enter a nursing hospice consult, and she did that, I fail to see where she deserves to lose her license, period.

  • http://www.facebook.com/people/Greg-Mercer/100001786695804 Greg Mercer


    We just created a petition calling for a boycott of Arizona tourism and other business, as well as on Nurses seeking education or employment there, until the abuse of Nurses and pressing defects in Nursing regulation are addressed, because we care deeply about these very important issues. 

    To start, we are trying to collect 100 signatures and spread the word absolutely everywhere and ASAP, and I could really use your help.  We anticipate much greater numbers soon, as we are only just today beginning to reach out for this campaign.

    Regardless of outcome, our message will be heard by every news outlet and business and civic group in Arizona very soon, as well as every venue for conventions, tourism, and entertainment, and every patient and Nursing group nationwide.   Some national politicians and journalists have expressed interest, as have multiple groups in Arizona: those in favor of your recall, immigration activists, and so one.  To think, we only started a few days ago, and only started spreading the word in earnest today.  We’re well on our way to the next Komen: exciting times indeed!

    To read more about what I’m trying to do and to sign my petition, click here:


    It’ll just take a minute! 

    Once you’re done, please ask your friends to sign the petition as well. Grassroots movements succeed because people like you are willing to spread the word! 

    Thanks for your consideration, 


  • Anonymous

    This is the silliest thing I have ever heard of.   She can fight her own battle that she caused. You are on every blog that has her name in it.  Don’t you work??

    • Anonymous

      i agree it’s very silly to take such a one-sided stance with only half the information presented here.

  • Anonymous

    I agree that it at least isn’t clear that Amanda’s in the clear.  I am curious to see the outcome of this case either way. If the investigation results in some disciplinary action against her licensure status, I wonder if the nurses on this board supporting her and villainizing the MD will openly acknowledge an error in judgment, or will they claim the deck is stacked against nurses?

    I, for one, will continue to have an open mind and not judge either party with only one side of the story.

  • http://profile.yahoo.com/YORQDMDPMGV6MPZWVFSCS7EADA jinc

    what happened to the ‘multidisciplinary team’?

    as a surgeon in training myself i’d hate to think that if this had been my patient, I would have paintstakingly pursued investigations, consults, the cost to hospital of admission etc etc all of which would be overridden by another member of the medical team without consulting me first.

    regardless of seniority at my training institution, whenever a colleague does something for, or in regard to my patient,regardless of seniority and experience, as drs we all respect that exchange. the dr would get  hold of me and ensure a running dialogue to institute a change in a patient’s care

    in this nurse’s situtation, why on earth wouldnt the same hold true?

    wouldn’t telling the primary physician be in the patient’s best interests too? 

    surely if the patient’s life was threatened, wouldn’t she have called the physician urgently to attend to the patient? why would this request be treated any different?

    i personally and professionally feel that the nurse in discussion should
    have pursued her concerns with the primary physician before embarking
    on what
    she thought was best for the patient.

    it seems she did it simply because the patient wished
    it – whether or not that would have been in the patient’s best interests remains to be seen

    perhaps what the public may not know is that a medical team – like any other team – needs a leader and that individual is generally recognised as the attending physicain. the rest of the team then comprises of other drs as well as professionals from the allied medical disciplines and so forth

    I sympathize with the patient as, ultimately it is she/he who lost out.

    they lost out both on education and the opportunity to generate a wholesome relationship with his/her medical staff.

    this whole scenario became an elaborate and unnecessarily public drama stemming from an oversight on both the nurse’s and dr’s sides that speaks to an actual lack of communication more than anything else

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