Can a physician deny an order to transport from LTC?

[anangelsmommy]

I am writing a paper for an ethics class. And I have all my sources and most of the actual paper but I am stuck on one part. I do not work in long term care and do not know much about what goes on there or the actual structure of how things would work in this situation. And after searching every journal I could not locate one source that addressed this topic. So I in order to actually understand how this would work, I wanted to know, if a patient were dying and needed immediate care was of sound mind and wanted to be transported to the hospital from a LTC facility, and you the nurse call for the order and the physician says NO and hangs up, what would you do? Is there a medical director to call, another doctor on call? or would you simply send the patient without the order?

I am taking the position of the patient advocate since he has stated his wishes and you do not have time to actually help him work through another option at this time. The time to cover other options would be at a less critical time. But I do not think it would be ethical to let him die.

[anangelsmommy, ADN, BSN, RN]

I guess documentation is important. And once they get to the hospital, doesnt the hospital have to treat if they receive medicaid under EMTALA? does this standard still apply for the most part? even in an extreme case, if the patient wants the treatment and the staff think it is excessive but it is an emergent situation separate from their chronic disease that will be fatal, do they not have a duty to treat?

[anangelsmommy, ADN, BSN, RN]

I don't and have never worked LTC but I'd view this kind of the same way as calling a code or a rapid response in the hospital. If my assessment of the patient indicates that I should call a code, I call a code. I don't call the MD and request permission to call a code.

As far as going against physician orders go, I think the important question in this scenario is not "what would happen if you went against a physician order?" but, rather, what would happen if you DIDN'T go against the physician's order. As GrnTea says, we don't work for the physician and we are not obligated to follow orders that are not in the patient's best interest. In fact, we have a duty to NOT follow those orders. The patient is of sound mind and wants to be transported, you have them transported.

well I couldn't call a code because the treatment scenario that this patient needs is not something I can provide in the facility. I was hung up on the whole scenario because I could not imagine this happening and was not sure if this thing actually did happen in LTC. If I had an emergency like this, I would never even think to call the physician, I would call 911. In fact, I even have procedures that tell me this type of thing. Not that I need it. I am not allowed to NOT call 911 because in my state if you work for pediatrics you MUST call 911 in an emergency like this no matter what, even if the child has a DNR in place. It is a matter of policy.

[loriangel14, RN]

It will depend also on the code status of the resident. Where I live dying patients aren't necessarily sent to the hospital. Some palliate at the LTC facility.Is the resident in this scenario a full code? If they are wanting to go to the hospital for treatment then you should send them regardless of what the doctor says.

[anangelsmommy, ADN, BSN, RN]

Several parts of the OP's scenario just don't make sense. If a non-hospice resident was literally and clearly dying, no nurse would waste time calling the physician. He would call 911.

And even if he did call the doctor, no doctor I know would refuse the transfer and just hang up. If that did happen, yes, the ethical thing to do would be to send the resident out regardless. But that's a highly implausible scenario.

Like I said this is for a class. I did not write the scenario and I could not imagine a doctor doing this. This is why I posted. I was not sure of the procedures in LTC or if this scenario made sense. I have looked high and low for journal articles that addressed all the key issues in the scenario as we were given and I was unable to find much outside of just basic ethic but we were given multiple scenarios so they all sort of end up working off the same ethics principles. But I really wanted to know first and foremost what would happen in real life so that I am not writing something contrary to what would actually happen.

[anangelsmommy, ADN, BSN, RN]

thank you everyone for all your help! As much as I hate writing papers, I have learned a lot in this class!

[Esme12, ASN, BSN, RN]

Like I said this is for a class. I did not write the scenario and I could not imagine a doctor doing this. This is why I posted. I was not sure of the procedures in LTC or if this scenario made sense. I have looked high and low for journal articles that addressed all the key issues in the scenario as we were given and I was unable to find much outside of just basic ethic but we were given multiple scenarios so they all sort of end up working off the same ethics principles. But I really wanted to know first and foremost what would happen in real life so that I am not writing something contrary to what would actually happen.

LTC is different than a hospital .....these things do happen and MD's will refuse to transfer the patient to the hospital...for whatever reason including being a jerk. Many facilities have policies about this and the steps to take.

Advance directives is not a DNR. Advanced directives give an outline of your wishes in the event you are no longer to give consent.....and who will dictate your healthcare needs/wishes when you cannot. Not all states recognize a patients living will as legally binding. If the patient needs medical help instead of "calling a code" or Rapid response as you would in the hospital...you call 911 for there is always more than one way to skin a cat. Unfortunately there are facilities out there that will take disciplinary action against these nurses for "going against the MD" or some other remote unethical reason.

Ethics papers are just that...about ethics. Each situation will vary based on the surrounding circumstances. If the patient is alert and requesting care for me it is unethical to refuse them assistance. I'd rather be fired than sued or accused of contributing to a patients death.

As far as EMTALA....ED's treat everyone.....their only concern is the patient a DNR/Comfort care and even then that doesn't mean tha thte patient gets placed in a corner to die. If they are in pain it is treated. If they have an infection they can get antibiotics...if that is their or the families wish.

[KelRN215, BSN, RN]

well I couldn't call a code because the treatment scenario that this patient needs is not something I can provide in the facility. I was hung up on the whole scenario because I could not imagine this happening and was not sure if this thing actually did happen in LTC. If I had an emergency like this, I would never even think to call the physician, I would call 911. In fact, I even have procedures that tell me this type of thing. Not that I need it. I am not allowed to NOT call 911 because in my state if you work for pediatrics you MUST call 911 in an emergency like this no matter what, even if the child has a DNR in place. It is a matter of policy.

I understand my point is it's along the same lines. Just as I wouldn't call the patient's MD to ask permission to call a code in the hospital, I would call them before calling 911 on a crumping resident in LTC either.

In which state must you call 911 for a terminally ill child regardless of DNR status? Terminally ill children are never allowed to die at home? I find that to be a little unbelievable, as a pediatric nurse who has sent many kids home to die.

[DedHedRN]

If the pt wants to go to the ER and the MD refuses to give an order, and I felt that they may be dying, I would just call 911. Then I would document, document, document. Even if I was wrote up for it, I wouldn't give two figs, because my first duty is to the well-being, safety and health of my patients, and being a advocate for them, and that's what I would tell my DON.

[DedHedRN]

Even pts with DNR and comfort care can change their minds in the end and seek treatment, so if they were asking... I would send, even with that in place. But I would sure be documenting that to the hilt. I would even get witnesses in that case. Documentation is the key to almost everything in LTC.

[patriciarrn]

I have to say that the dr is in the wrong. DNR does not mean do not treat. In that case I would call the DON and higher ups. I would also call the dr until I got what the patient requested and I knew as a nurse was right for the patient. I can tell you working in the hospital setting, we have pts who come in as DNR status and we care for them. I can tell you that there are several nurses in LTC that go through this situation. When they call the ED for advice I tell them to call the dr and remind him DNR does not mean do not treat and to call every 10 minutes making sure to document every time called and what the dr stated. When the dr knows that the nurse is doing this they give in. They do not want to look bad on the pts chart and possibly have legal recourse.

[nhelkhound]

I once had a physician refuse to give me an order to transfer his Pt to ER after the Pt had fallen on the floor in the bathroom, had a large hematoma on his head, was complaining of acute abdominal pain, and had diarrhea for 48hours. The Dr yelled at me on the phone. I sent the Pt out anyway. The ER reported he was dehydrated with electrolyte imbalances (duh). The Dr called me later and apologized. I'm sure he was pleased I had "disobeyed" his order.

[motherof3sons]

At our facility it is common to not be able to get ahold of MD's after hours. When that happens I call the family and tell them the situation and it would be in the residents best interest to be seen a the ER and get their permission. I write the order to transfer per family's request. If the MD came in to see the resident and refused to transfer, I would have them call the family with me present and explain why they didn't feel obligated to tx that resident. If it was a phone call and refuse to transfer, then I would be on the phone and get permission from the family.