Going toe-to-toe with a physician.

[ceecel.dee, MSN, RN]

Read this in the NSO Risk Advisor, Vol 12, No. 1, Spring 2003.

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GOING TOE-TO-TOE WITH A PHYSICIAN

How do you tell a doctor that the dosage of a drug he ordered falls outside the normal limits, or that a patient is in serious danger of aspirating if she's fed as ordered? "Very tactfully," advises Jonathan Cooperman, JD, an attorney based in Akron, Ohio.

Approached without rancor, many physicians will adjust the dosage or defer to your judgment. Others will confirm that the order is correct, believing that's all that's necessaary. And an occasional doctor may angrily insist that you do as you're told or fill the order as is, no questions asked. If you express further doubts, Cooperman adds, a physician may go so far as to vouch for the patient's safety. "I'm willing to take full responsibility for this," he or she might say.

Then what?

Don't ever agree to such an arrangement. It may be the doctor's order, but if you carry it out despite serious doubts, it's your license at risk. The only exception: life-threatening emergencies, where "Act now, question later" prevails.

WHEN IN DOUBT, SPEAK UP

The American Nurses Association code makes it clear that RNs have a duty to advocate what's best for their patients. Fulfilling that duty requires that you question any order you believe to be below the standard of care, in violation of a hospital or employer policy or procedure or contrary to a patient's best interests. That extends to any order for a drug or treatment whose safety and efficacy you have reason to doubt, as well as to unclear or illegible orders.

Facilities should have prohibitions against dispensing or following ambiguous orders, consistent with state practice acts. Gayle H. Sullivan, JD, RN, an attorney based in Fairfield, Conn., boils it down to three simple words: "Appropriate. Legible. Complete." Additionally, any time you have a question that a conversation with the doctor does not address to your satisfaction, you have a professional duty to refuse to carry out the order until your question has been answered or the issue has been clarified. Notify your supervisor as well.

Unwise as it is to accept a doctor's word without question, however, it's equally important to realize that there will likely be times when the physician has a solid rationale for an order or action that strikes you as unacceptable. The key is to approach the doctor with an open mind but to insist on more than reassurance before you acquiesce.

If you ask, "Doctor, that is four times the normal adult dose. Is that what you meant to order?" for instance, and she says Yes, request further clarification: "That dosage is contraindicated according to the manufacturer's directions," you might say. "Do you have any evidence of its safety and efficacy?"

Even if the physician provides a published study or other written material as back-up, however, do not administer the drug until you have conferred with - and received confirmation from - your facility's pharmacist. Be sure to document your conversations with both providers.

STICK YOU YOUR CONVICTIONS

There are times, too, when you will need to confront a physician not with a request for more information, a clarification or a discussion about the particulars of an order, but to make it clear that you cannot - or will not - carry it out. When your're convinced that complaince would jeopardize patient safety, failure to stick to your convictions can have diastrous results.

A lawsuit in which a hospital was found liable for the actions of a nurse who caved in under pressure is a case in point. The RN was with a patient who had just come out of the OR when a doctor asked her to accompany him to another patient's bedside. She said No, explaining that she had not yet completed the post-op monitoring that hospital policy required. When the doctor persisted, however, the nurse relented and left the room. The post-op patient arrested and was left permanently paralyzed and semi-comatose.

CHALLENGE A FAILURE TO ACT

As a nurse, you also have a duty to speak up and to follow through when you believe a doctor's inaction is endangering a patient - if he fails to provide adequate pain relief or to order antibiotics for what appears to be a massive bacterial infection, for example. In one such case, an RN asked a physician to order morpine IV push for a patient in severe pain because the PCA on order was not available. But the doctor said the patient could wait and reprimanded the nurse for "insisting on an order."

Although the RN did not persist, she should have, according to Sullivan. "Any time you believe a patient's pain is not being adequately addressed, you have an obligation to take your concerns up the chain of command," she says.

Nurses must comply with Joint Commission on Accreditation of Healthcare Organizations pain management standards. These standards recognize patients' right to appropriate assessment and management, require that accredited institutions ensure staff competency in pain management and require facilities to establish policies and procedures that support the appropriate use of pain medications.

Whenevery you find yourself requesting that a doctor take action (or, for that matter, find yourself questioning a physician's order or refusing to carry one out), keep in mind that thorough documentation is a must. Remember: Not documented, not done.

(http://www.nso.com)

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This article speaks directly to some recent events at our facility regarding conscious sedation. Thought some of you might find it re-empowering in your units too.:)

[teeituptom, BSN, RN]

Howdy Ya'll

Sometimes you have to stick to your guns. Especially if you feel the MD is in error. Notify your supervisor, document your concerns. And if need be refuse to do so. And document why you refuse. I have come up with situations infrequently. Maybe once a year where I felt certain meds were ordered wrongly. I have persisted in my beliefs and have never gotten into trouble once for acting in what I thought the pts best interest was. One time I was in error to my beliefs of a certain order. But my concern and refusal were correctly placed in for the pts best interests. No Harm No Foul.

If you do something you feel is unsafe and something happens then you are accountable. 100% so.

Never hurts to stick to your guns when you need to.

[KRVRN, BSN, RN]

Yeah. If all avenues of questioning it have been exhausted, and they really want the med given the doctor is just going to have to give it him/herself.

[MandyInMS]

"When in doubt...DON'T"

Sounds so simple..but so true :)

[rileygrl11, BSN, RN]

Thanks for sharing a most useful article with us!

[colleen10]

I had drug calc. this summer and my instructor advised that if an order is ever over or under a recommended dosage just ask the doctor in a kind way to educate you on why the drug was prescribed the way it was (either over or under). She said usually they say "oh, I that's not the right amount" and quickly change it to the correct dosage. The doc. doesn't get mad because you didn't come across accusing him of being wrong (even though they were).

[Tweety, BSN, RN]

Fortunately the MD's I've talked to are fairly receptive. Just last night I called an md to correct a dose. He was very open to the idea. Usually, I involve pharmacy, ask them and present it to the MD "it's the pharmacy's recommendation that you do this."

As a sometimes house supervisor I have been involved in a pain control issue. The nurses felt the md wasn't adequately controlling a patient's pain. I called the md myself, and got some orders changed, but then he said the patient can find another doctor if they are unhappy. But I also felt he realized that pain control can be serious.

Bottom line, it's our license if the MD makes a mistake and doesn't treat appropriate.

Thanks for the great article.

[jnette, ASN, EMT-I]

Thank you ! Good read. Need to keep reminding ourselves of this.. especially the new nurses, like me !

[snoogans]

In long term care the doc visits are few and far between, often they only ask how the pt is doing and only take a quick look at them from the doorway. The vast majority of problems are taken care of over the phone, more often then updating the md office nurse and they talk to the doc. One doc will call us back and listen to what we suggest and his fav line is "Make it so" when some one is dying and I call for orders. the doc need reminders about tapering psycotropic meds and other meds. Some will actully yell over the phone with any type of suggestion. From experience I know who they are.

I will certainly question a doctor if I think he is wrong. After five years I've learned to do it tactfully. "Are you sure", "wouldn't you like to taper that medication"

It's my license, my career and my future.

[Nurse89]

great article, thank you

I have run into this issue a few times

I was taught to never hesitate to ask about an order I found questionable, and I have done it several times.

The doc will usually say, something like, oh what was I thinking, etc.

[ceecel.dee, MSN, RN]

Most of our enjoy the "team" approach and will often thank us for input that protects or makes the patient more comfortable. We have quite a few new nurses who have not yet reached the comfort zone with one doc in particular that likes to push the P&P limits of our hospital. A really good read for them in particular.

[mother/babyRN, RN]

Yep...Many times my blood pressure has been elevated beyond belief and my heart racing when I have had to tell a doc something he or she doesn't want to hear....Mostly now a days, I mention that since he or she has a license he or she can feel free to compromise or endanger theirs, but I worked too hard for mine to lay it on the line for anyone......