[RN-Cardiac]

"You cannot give more, you cannot give less. If the pt want's less, you get up and call the Dr and get the order changed. You do NOT make that decision for the pt. No matter what you think, that's called practicing medicine without a license"

I think the problem with this is that YOU aren't making a decision for the pt. The PT is making the decision. I agree that I can't just decide to cut a med dose in half,..although depending on the med and why I might at 0200 decide to give less and speak with the doc in the am,...for instance if I notice that at 2200 when the pt requested pain meds I gave 10mg of Morphine IV per Q4hr order,...the pt became difficult to arouse, respers dropped from 18 to 12 et became shallow,.O2 sats dropped from 99% ORA to 90%,.now at 0200 pt is fully awake et in pain,..it is in my scope of practice to start with 5mg Morphine et monitor response,.I would of course chart that I gave 5mg and why and then chart the response to the med,..I would then pass this on in report and leave a note to the doc,..I would think calling the doc at 0200 to cut this dose in half would be almost as irresponsible as just giving the 10mg because that's what the doc ordered!
It is my responsibility to monitor pt response to all meds,..it is my responsibilty to understand why the pt is taking the med, what it is for, how it works and what to expect in response to the med,....for instance IV KCL often burns,.I've had pt/family c/o "I'm having an allergic reaction to this IV!!" It is my job to teach the pt the difference between the common side effect of burning and an allergic reaction,.then it is my job to slow down the drip or dilute it so the pt can tolerate it,.if all that fails then I call the doc to come up with a different game plan.
We aren't trained monkeys folks! We are educated professionals and should act as such,.our pt deserve it and our docs expect it!

[canoehead]

I think the key issue is whether the change in dose is nurse initiated or patient initiated. If the nurse just makes a decision they are practicing medicine. If the patient initiates it they are within their rights. In the second case you would notify the MD after the fact. In the first case the nurse should be calling the MD beforehand.

I also think that we can all come up with situations where we would just do something and let the doc know- like giving less morphine. The law is very clear but real life has shades of grey. If you know your doc and what they prefer it may make sense to call later. If the doc complains, or is unwilling to back you up you will be swinging in the wind.

I once gave plain Tylenol for pain instead of T#3 to a healthy postpartum patient at 3am, and the doc filed an incident report. (Crazy) But just because she was a dweeb I won't set the rules in concrete for reasonable docs and patients. It's a judgement call, and we shouldn't be shooting each other down. what flies in one facility won't in another. Some hospitals have ten family docs working 80 hour weeks, and some have a pool of med students and interns to take the calls, and night staff wouldn't recognize the attending if they fell over him. Different situations.

[aussiemags]

Originally Posted by canoehead

I think the key issue is whether the change in dose is nurse initiated or patient initiated. If the nurse just makes a decision they are practicing medicine. If the patient initiates it they are within their rights.

I think this nails it really clearly.

[herring_RN]

I work in acute care and would call the doctor at night if the patient refused all or part of an ordered medication.
I would document exactly what happened.
i have asked an irritated woken up physician to talk to the patient by telephone.
That patient took the medication after her doctor told her she needed the rest of the dose.

A different time a patient refused antihypertensive medications. i notified the doctor who told me, "Just wait. he will ask for it later. this guy likes to report nurses and threatens to sue the hospital over his refusal the take his pills. I expected this call."
And when i told him his doctor was notified he asked for his meds.

The facility should have a policy for such common events as a patient refusing medication.