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

tewdles, RN · Jan 31, 2010

It is our job to question physician orders on behalf of the patient when it is appropriate. If we do not, and carry out an inappropriate order, we can and will be held accountable in a court of law.

As Ruby Vee aptly described, most attendings in a teaching hospital recognize the relationship and appreciate that nature and professional capacity of the nurse. Outside of that setting, some docs forget that, but it does not change the nature of the relationship.

I find that in traditional medicine, many doctors are comfortable with the format of them directing the course of the care. In hospice, the patient and family direct the course of care which is communicated (most times) by the case nurse to the doc...this is troubling for some docs, but a skillful nurse gets them past it or the medical care gets transferred to a hospice medical director.

It is not always easy, but I advocate for my patient. This means that over a 30+ year career I have been screamed at by intensivists, hospitalists, have been in the office of the CMO, the nursing director, etc. I have never lost a job because I was advocating for a patient, but I was nervous a couple of times.

My experience says that a nurse who can verbalize what the concern is in clear and factual terms can safely advocate for his/her patient without fear of repercussion.

DogWmn · Jan 31, 2010

That is assault.

Yup, but this took place in the late '70's and many nurses consider Doc's "gods" or what ever and they were allowed to get away with just about anything then. But not to worry I had a really big stick to wield, my husband at that time was HIS boss . His 'tude was adjusted there after:lol2:

OldnurseRN · Jan 31, 2010

Many many years ago I had an elderly unresponsive patient. Along comes a family practice physician with his troop of residents, who decide that they need to do an invasive procedure. Mind you, the procedure would not alter the outcome of her condition nor change the course of treatment, it was only to give the residents a patient to practice on. I told the attending that there was no family, the patient was unresponsive and there was no way to get an informed consent and the procedure could not be done. He argued and I stood my ground. I contacted my manager who advised I contact the the House Supervisor who passed me along to the Officer of the Day. In the meantime, the team had found a pastor who agreed to sign their informed consent! I still refused to participate and my hospital actually stood behind me on this. I informed the team that while they may certainly perform their procedure, (it was a lumbar puncture) they would have to do so without any assistance from my staff. I remember the head doctor snidely asking if I would at least get him the LP tray. I showed him the supply room where he could look for himself.

I did my best to advocate for that poor woman but, in the end the docotr and his residents won. My satisfaction is that I was not required to participate. The LP made no difference in the woman's diagnosis, prognosis, or treatment and she died the next day.

911fltrn · Feb 10, 2010

I have definately refused orders from physicians. 2 that stick out are

Working ICU I had a a patient with an intracranial bleed. I had an MD tell me to hang heparin over the phone. I said excuse me doctor are you sure you want to do that. Yes hang heparin (he gave bolus and infusion doses i dont recall) I said one second please doctor, I would like you to repeat that order to another nurse. He did!!!! I wrote the telephone order and didnt start drip. Called director of ICU who agreed with me. Original MD called me back to discuss his order and asked me to stop heparin.

Working ER had a massive GI bleed patient who had become hypovolemic, GI doc shows up and tells me to start Dopamine!

I actually said to him "Doc, your out of your mind, Im not going to press a hypovolemic patient." He complained to the ER doctor. The ER doctor laughed at the GI doctor and explained to him why i wouldnt.

inava · Feb 10, 2010

The primary concern is patient safety.

You are, after all, the last line of defense.

And you are the patient's advocate.

You are also,expected to do what a "prudent" nurse would do.

And diplomacy is paramount.

That said, sometimes you have to be ready to lay your badge down and walk away from the job. I know I have been several times. Didn't have to, but I was ready.

HazeKomp, BSN, RN · Feb 10, 2010

I read through many but not all of the replies.

One phrase stuck out: "Generally if I ask in a non-accusatory tone..."

I am an old nurse, doing this for 35 years.

I tend to want to shout "are you out of your mind?"....

but I have found ASKING WHY in a non-accusatory tone, with the implication that I want to learn and understand the rationale has gotten me so much further with the docs!

Many times, we can discuss the order and resolve our differences, with one of us changing our opinion about the order. (yes, sometimes it is me understanding better)

Sometimes I still disagree, and have to say, "I'm sorry, Sir, I am not comfortable with your plan of care and I am going to initiate The Chain of Command to discuss it further with my managers." Usually this stops the Doc in question in his tracks and makes him take another look at what he ordered.... sometimes it doesn't and I have to go up the ranks for resolution.

Bottom line: PATIENT SAFETY FIRST

(yes, the caps were because I was shouting it...hehehehe)

Haze

soupnurse56 · Feb 10, 2010

when a doctor ask you to do something that is within the policies of your hospital and follow the recommended guidlines of the product or medication we are supported in doing what the doctor ask. If it isn't policy we have an obligation to stop the process until we have documentation that proves it effectiveness and administration has an obligation to approve or disapprove what we are ask to do. If it is not approved then we do not have to do it. The key here is that we must protect the pateint and that means we do not hand over the medication to a doctor until it is allowed by administrative approval, or covered by policy of the facility we are working within. If we do without this process and there is a bad outcome we are also held responsible.

egomaniacal1 · Feb 11, 2010

ruby vee said:

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."

absolutely one of the best comments I have ever read. kudos x 1000!

tewdles, RN · Feb 11, 2010

Just a point of interest, as we speak of disagreeing with physicians...

I invite all of you who are not already doing so to check out the twitter on the Texas Whistleblower Nurse Trial. It is a frightening case of a nurse being prosecuted in a criminal case because she reported his medical misconduct to the proper authorities!

Mustangsal · Feb 11, 2010

1.You are first & foremost the patient advocate;not the Physicians.

2.You are every Physicians colleague, and never forget that. You're their equal.

3. If ever, and I mean ever, you don't feel comfortable giving the medication dosage or medication; it's simple, don't do it.

4. YOU CANNOT be fired for being safe. The hospital would be in great trouble, and so would the Physician, if you were fired for refusing to administer medication for patient SAFETY. That is number one. Patient safety. If they did try to fire you for this call your union, You are entitled to 30 min free time to discuss this with an Attorney. Also, your Union Representative would love this one.

5. After you discuss this issue with the attending physician, and your nurse manager, fill out an incident report immediately. Their are no repercussions for this action. Make sure to make a copy for your records. the nurse manager/supervisor may not tell you to do this. The incident report is given to your nurse manager/supervisor. This protects you greatly. One of the first questions an attorney or Union Representative will ask is, "did you fill out an incident report?"

6. You must have, and keep integrity. If you can't do that you aren't an advocate for the patient, you're an advocate for yourself and the physician. What was the oath you took when you graduated from nursing school? Remember it, and stay true to it. You will be able to stay in peace, knowing you have taken care of your patient with the utmost care. That my friend is what our initials should represent. If they don't we need to get out of this profession.

Hope this helps.

fdesjardins · Feb 11, 2010

Yes, I have had similar situations. I have even been the "final straw" for having a resident removed from her ED program because of her "emphatic requests." I must say it is a little bit easier in an academic facility, especially in an Emergency Department as the Staff Doc is always there. When working the floors in an academic organization (usually nights and weekends) it was more difficult to find the "back-up" for your opinion. However, I have found that a simple, "...if you can wait just a moment while I chart your requests and my concerns based on..." the individual usually will take a moment to think; and usually does not "give it themselves."

Incidents like this have been rare for me in the non-teaching setting, but still occur. Then it is nice to have the Risk Management Director's phone number on speed dial. It can be rough, and I know as new nurses come on-board it can be intimidating. However, I did not take up patient care to make friends with all the doctors. I became a nurse to care for and protect my patients. Which means I sometimes have to stand up for what is right! I haven't been fired yet!

BluegrassRN · Feb 11, 2010

Yes, I've refused to peform a physician's order twice.

Once was to reinsert a foley in a man who had just ripped one out. He had a several centimeter tear at his meatus, was still actively bleeding, and was unable to pass any urine. I work nights. I just told the doc "I'm sorry, I'm really uncomfortable doing this, but I would be happy to assist you if *you* want to come up and do it." He just laughed and gave me some different orders.

The other was a medication issue. I can't remember the details now, but I do remember it was out of the parameters of what we are allowed to do on our unit (medical floor, not ICU or stepdown). In that case, I told the doc he could come up and do it, or I could see if an ICU nurse was available to come and give the med. He still wanted to med given. I called the nursing supervisor, who came over with an ICU nurse, hooked the guy up to a portable monitor, gave the med, monitored him for half an hour, and then I took over again.

It wasn't that I thought the treatments were suboptimal. It's that I thought they were flat out inappropriate, and also that *I* was not qualified to perform them. In each case, the doc was a bit frustrated, but not really at me, just at the entire situation.