When you don't agree with the doctor...

meluhn · Jan 30, 2010

Hey nurses- have any of you ever been in a situation where you did not agree with the doctor's plan of care? Or a situation where you were asked to do something/ give a med/ etc that you felt would jeopardize your license harm the patient? If this happens I know you should not perform the task, and you should explain to your superior/ the doctor your reasoning, but what if they don't agree with you and want you to do the procedure anyway? Would you just tell them that they have to do it themself? or get someone else to do it?

The best thing for the pt is for you to have a good enough repore with the dr that you can talk to him about it and ask him the rationale. The days of following orders blindly are over, we have to think critically. However, we also do not know everything. You have to respect the MDs extensive knowledge. As good as we are, we did not go to med school and they do know a few things we dont. We should work as a team, not as rivals.

TigerGalLE, BSN, RN · Jan 30, 2010

I once refused to give Dig to an infant; I felt that the doc had the decimal point in the wrong place, and the dose was 10 times too high. Of course it was night shift, and the night supe 'couldn't remember how to calculate pedi dosages'. This was many years ago, and the supe had to call the attending at home (we staff nurses didn't have that privelege) and she would NOT call. I even showed them how much med would be in the syringe.
I steadfastly refused. The doc gave the med. The baby died. He was extremely ill to begin with, so no one told the family exactly what happened.
About a week or two later, the attending told me that my math was correct.....

Man... that makes me sick. Some people would rather take the chance of hurting another person than hurting their pride. Ugh

nicole109 · Jan 31, 2010

You have to be an advocate for your patient, whether it involves medications or anything else that regards their care. I have refused to give Metop and blood pressure meds on so many occasions when patients blood pressure is 80/40 and pulse is in the 50. Or, demanded an order for a foley when a patient had developed a stage 4 sacral decub (on our watch no less) and they are incontinent of urine, and we have reached a plateau in their wound care bc of their incontinence. You have to advocate for your patients and you also have to protect your license. Go with your gut...if you don't think it's right, chances are it probably isn't, and there isn't going to be anyone there to save you, especially the doctors, when it comes to trial time, if it gets that far (God forbid) they will hang you out to dry.

jemommyRN · Jan 31, 2010

The best thing for the pt is for you to have a good enough repore with the dr that you can talk to him about it and ask him the rationale. The days of following orders blindly are over, we have to think critically. However, we also do not know everything. You have to respect the MDs extensive knowledge. As good as we are, we did not go to med school and they do know a few things we dont. We should work as a team, not as rivals.

I agree with this post totally. Ive called MDs to clarify if thats what they really meant and even sumtimes offer other suggestions. Usually what I get is a rationale as to why they want to use what they ordered and NOT what I was thinking. Its usually something dealing with, like you said, an extent of knowledge that I was not aware of. I find that most MDs are open to approach depending on how its suggested.

Dalzac, LPN, LVN, RN · Jan 31, 2010

I worked in a teaching hospital so 9 times out of 10 I always had an attending to go over the interns and residents head. I have had only one episode where I had to go to a depatment head to save a patient

DogWmn · Jan 31, 2010

I also used to work at a teaching hospital and our FP attending just said slap 'em up side the head;).

One time a baby doc came out of a room and wanted to insert an IUD...I ask him if he'd read her Hx??? and I got a puzzled look. I told him to read it and get back with me...again he comes an sez lets do it and I'm goin' ah nope not gonna happen. (The patient had a history of multiple PID's:eek:.) So I waltzed down the hall and got the attending and told him what was going on and he stormed out and reamed him a new one. Apparently the baby doc had just gone to a seminar on IUD's and wanted to "try it out":uhoh3:. He eventually got canned over other apparent fau paux's...GOK where he is now.

That particular resident would really try to 'lord it over' us LPN's:mad: and would go ask the RN super to take care of 'his' patients...snort, I loved her response - I trust 'my' nurses and they know way more than you do at this point so I'd suggest you use them....LOL

Most of the residents were really good but part of our job was to be that patient's advocate and we were fortunate to have full backing from our RN super and the attending. It was quite a rare environment and one I'll cherish for the rest of my life, we as LPN's we were allowed to work to our full scope of practice and we were valued by most of the Docs RN's and attendings.

I've also worked with some real snots, had one surgeon throw a needle driver at me with the needle in it:mad:.

Scrubby · Jan 31, 2010

The other day a junior surgeon tried sending sending me out the room to get her a standing stool. As I was the only other nurse in the room with a junior anaesthetist and junior scrub nurse I refused to get her one until there was someone else present. I did not want to leave the room in case of an arrest situation and having to explain the delay in pressing the duress alarm because I was off getting a standing stool. She just kept going on and on to me about wanting one and I just ignored her. At the end of the case when the senior consultant left she tried bullying me in front of everyone about this bloody standing stool and I very loudly got in her face and told her if she wanted to say something to say it in private.

I got home and there was a voicemail on my phone with her apologising. The next day I thanked her for the apology but she said it was only because she should have spoken to me in private. Appearantly I made her feel devalued because I didn't rush to do her bidding. I told her that as I am the senior nurse in the OR you need to respect my judgement. If I find it is unsafe to leave the room I have a bloody good reason not to leave. I left her there with her mouth open. She has been on her best behaviour ever since.

LVAD RN · Jan 31, 2010

A doc asked me to give a med and I stated, "Doc so & so I don't think it is safe for the patient and if you want to give the med then do so but I won't" he was upset and all the nurses on the unit agreed with me and he had to change the order. You should be assertive, calm and have a good rationale for why you disagree and be able to argue it if it came to that.

The nurses where I work are AWESOME & for the most part supportive of each other :)

LDBRN · Jan 31, 2010

i agree with post that went something like this - i wouldn't argue over a suboptimal treatment but i would absolutely refuse to do something that i knew would cause harm.

meluhn · Jan 31, 2010

I've also worked with some real snots, had one surgeon throw a needle driver at me with the needle in it:mad:.

That is assault.

wooh, BSN, RN · Jan 31, 2010

I often do things that I don't think are optimal, and when I get a chance talk to the doctors about it. I've never had to flat out refuse. Generally if I ask in a non-accusatory tone, "Shouldn't it be this dose?" or "Why are you ordering x instead of y?" then I'll get their rationale, sometimes learn something, or they'll think about it and decide to go in a different direction. They want to do the right thing, we want to do the right thing. And if I ask in a respectful manner, wanting to gain from their knowledge and experience, they're usually more than willing to work it out so we both feel comfortable with the plan.

Ruby Vee, BSN · Jan 31, 2010

I've spent most of my career in teaching hospitals, and part of my job is to educate the house staff or, as one preceptor decades ago put it, "to keep the residents from killing the patients." I have kept a few residents (and a manager) from killing patients . . . . but usually, it doesn't come to that. if I disagree, I ask for the physician's rationale and if it makes sense, we do it his/her way. if it doesn't make sense or he won't explain it to me -- which happens rarely -- I won't do it. there have been a few times that things turned into a nasty confrontation, but those times are rare and far between.

years ago, I had a little old lady admitted for a "work-up." in the 70s and 80s, that used to be a common diagnosis. they're admitted "for tests" and the residents get to practice doing procedures on them. the best patient was someone with vague complaints, because you could milk it for several procedures. this particular woman was about 90 and tiny. her veins were tiny, too, and all we could get was a 22 gauge butterfly. (angiocaths were rare in those days.) her k+ was 3.8. intern decided that her k+ was too low and we needed to replace it immediately. I disagreed. nevertheless, I was only the charge nurse and there was a cute new grad taking car of the patient. (did I mention that the intern was considered to be very attractive?)

the intern wrote an order for kcl 40 meq IV. since this was med/surg and not the ICU, we couldn't do that. our policy said we could put 20 meq in 500cc or 40meq in a liter and run it no faster than xcc/hour. (I don't remember the exact policy, but you catch my drift.) nancy the new nurse told him that "our policy says blah blah blah, but if you want to push it, you can give it as fast as you like. and she proceded to draw up 40 meq of kcl and handed it to the intern to push.

I told the intern he couldn't do that, and explained why. he replied that "the other nurse told me I could do it." (worst combination in the world -- a new intern who thinks he knows everything and a new nurse who believes it.) I repeated my explanation. he insisted. I called his resident who thought I was joking. (I have only myself to blame for that -- I did do a lot of joking.) I paged the attending who didn't answer his page. I flung myself in front of the patient and told him he'd push potassium over my dead body -- and he insisted. (you'd think by this time he'd have done a little double checking, but no.) what finally saved the day was the pharmacist, who had just read the order, called the unit to question it, and when no one answered the phone came running up to see if we were really going to do something so stupid. the pharmacist really laid it out for the intern, chapter and verse. he believed the pharmacist, but never apologized to me...

and then there was the intern who wanted me to do something so stupid I refused. just flat out told him no. the next morning he complained to my manager that I had refused to follow orders and he wanted me fired. it was tense for awhile. I nearly lost my job, but I'd rather lose my job than my license. years later and 3000 miles away, he came to the hospital where I was then an experienced ICU nurse and accepted a position as head of cardiology. I dreaded working with him from the moment I heard his name and knew we were getting him. and when he came, I sincerely hoped he wouldn't remember me. turns out he did.

on July 1, he came around with a flock of brand new residents fresh out of medical school. "this is ruby," he said. "we go way back. she's an experienced ICU nurse and if you let her, she'll keep you from doing something really stupid. when I was an intern, she kept me from making a really big mistake. when she asks you "are you sure you really want to do that, doctor?" what she means is "you really don't want to do that you freaking idiot." if that happens, stop what ever stupid thing you were about to do and call your resident for guidance. or she'll be calling me."