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

[lm8539]

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?

[meluhn]

So what's everyone's take on this situation?

I had been a new lpn for about a year and had just moved to a peds floor. Two weeks on the floor, and we had students that day. The students brought me an ivpb abx to hang on a baby. It was a special mix from pharmacy, one that they had to mix themselves. There were no total mg on the bag, just ml/hr. Students were and I was uncomfortable hanging it because u had no way to tell if the bag held 1mg or 1000mg.

Long story short, after trying to resolve this myself with rx and getting nowhere, brought to charge rn, who cut me off, didn't listen to what was wrong with it, yanked it out of my hand, and screamed at me, well I'll have to go do ur job for you.

I thought I was following the right chain of command, but later in my eval, floor mgr told me I was insuboordinate, and if charge says hang it, then hang it and document circumstances. That wouldn't hold up for the bon, though, would it?

So was I?

I know this is not doc to nurse, but still different levels of authority.

I woud have sent it back to the pharmacy to be relabeled with the dose. I would not hang/give anything that I was not comfortable with. I don't see that as insubordination, just being careful.

[sparketteinok]

I walked it over there, and they said they wouldn't take it from anyone but the charge. I thought I was being careful, too, but apparently protecting yourself is insuboordination. Don't get me wrong, when I approached her and rx both, I was more than polite. Then when she snatched it from my hand, I didn't speak to her the rest of the day because she had been so rude.

[LaceyRN]

I once refused to run an IV piggyback medication at the rate prescribed 1000cc/hr. I researched the med and for this dosage the safest rate was 250cc/hr. I called the pharmacist who confirmed my calculation, then I took it to the charge nurse who replied this doc writes for this "all the time" and "we go ahead and give it." I stood my ground and refused to run the med. The charge nurse did it instead and no harm came to the patient. I would still refuse to run it to this day. It's too risky and I felt it was unsafe to infuse a med more quickly than is safe to do, especially after confirming it with two sources!

[Ruby Vee, BSN]

when you don't agree with the doctor you will be taking your license into your own hands. you have to decide what is more important....following orders no matter what or putting your job on the line. i had that experience many years ago working in a "walk-in" facility. there was a person who showed up, fairly frequently and usually after the regular doctor's office was closed, with migraine headaches. her primary md ordered a narcotic injection that we were supposed to administer but as time went on we noticed that the dose was increasing to alarming levels, well over ordinary levels for pain relief. we began to carefully observe the patients behavior and demeanor as she was complaining of a debilitating condition and it became obvious to us that she was drug seeking. when the dose ordered was way over what is considered normal a few of the nurses refused to give the injection and voiced our concerns. we discussed it with our nurse-manager and the doctor so they were well aware of our concerns but when the situation arose again...and the doctor said she didn't know how to give an im injection..... the two nurses who stood firm were fired. the irony to me was that just a month previous i had been the "employee of the month"!!! it was a shocking and painful lesson to learn after being a nurse for 23 years. we did sue them and they ended up settling with us as the facility was in the process of being bought by a larger company and they wanted to get rid of us. this episode made me feel even more strongly that nurses need a union for so many reasons.

i'd rather lose my job than my license. (this also applies to any situation where you disagree with your manager.)

[DirtyBlackSocks]

More importantly, it's better to lose your job than put some one's life at risk.

Doctor's may have a higher level of knowledge, but they are overworked and make plenty of mistakes.

Once you lose your integrity you can't get it back, there are always other jobs out there.

[imintrouble, BSN, RN]

I am not a pediatric nurse, but I work in a small hospital where every age and illness are lumped together in one place. I had an infant receiving Solu Medrol. The dose was way over anything I was used to seeing. The MD was not a pediatrician. I called the ER nurse as she was more familiar with kids and dosages. The ER doc got involved, and the dose was unusually large. I notified the House Supervisor. All the available material at my disposal confirmed that the dose ordered was too much. Unfortunately, the ER doc had called the attending and the attending was very mad. By the time I called the attending and told him I was not comfortable pushing the drug, the situation was out of control. The pharmacist was called, another staff Md was called, but nobody talked to me, and I was told to push the med by the supe. I refused, and another nurse gave the med. Now the attending says I am too cautious, and dangerous to his pts. He insists I not care for his pts. This could mean my job. Hindsight being 20/20 I can see where the situation went out of control and what I could have done to tone things down. The attending never spoke to me or explained why the dose was necessary. Am I wrong to think the MD could have talked to me and explained his position? I would appreciate any feedback as on Monday I find out if I have a job.

[imintrouble, BSN, RN]

To army medic, I think you answered my question. It's just so hard to start a new job. I've been at the same hospital for ten years and I love the nurses I work with.

[DirtyBlackSocks]

It seems like most of the nurse/doctor conflicts I hear about have to do with a lack of communication.

No matter how pissy a doctor is - go with your gut. If all documented information you have says it's a bad idea, then it's a bad idea.

Try and open a communication dialogue, I don't care how busy a doctor is - challenge them directly with why they think it's perfectly normal. Demand a concrete explanation instead of "because I say so."

[wooh, BSN, RN]

Now the attending says I am too cautious, and dangerous to his pts. He insists I not care for his pts.

Yes, much better to have nurses care for his patients that don't mind killing them. But I can understand his getting defensive with the way it was handled.

I think you went the wrong direction calling the ER. I'd have called the pharmacist, they're the ultimate resource for drugs, gotten what would be the correct dose for weight (realizing that if it's a pretty full-grown teenager, you're usually ok with whatever the adult dose would be), and called the doctor and simply said, "I got your order for x mg soludedrol, but according to the pharmacist, it would be y mg for the patient's weight of z kg. Is there a reason for the higher dose you ordered?" That way he can tell you why, maybe it actually is appropriate for some reason (there are occasional times when you give high steroid doses, although I'd hoped the patient would be moved to a pediatric hospital if the kid was in that bad of shape), and if he wants to change it, it's just a small thing between the two of you and the pharmacist. Not between 2 different departments and multiple doctors and multiple nurses and the pharmacy. Think about it, if you made an error, would you want the whole hospital knowing about it, especially before you did? And wouldn't you get defensive in that situation, which isn't the best frame of mind for putting the patient first. It's not about having to tiptoe around the doctor's ego, it's about treating the docs the way you'd want to be treated.

Pediatric patients make non-peds people nervous, nurses and doctors. Just go in and explain that it being a peds patient, you got nervous, you realize you handled it badly, and have learned from it for the future. Don't apologize for refusing to give a dose you felt uncomfortable about, you had every right to do that. But for how you went about handling it. Because that could have been done a bit better. (And I speak from experience, I've gotten in trouble for not handling problems I had with a peds patient at a community hospital in the most professional way. :))

[imintrouble, BSN, RN]

I totally agree with you. I wish I could have done it all differently. I did not handle things well. I'm afraid I've made an enemy for as long as I'm a nurse at this hospital. I've worked with this doc for 10 years. You think I just became dangerous overnight?

[DirtyBlackSocks]

I totally agree with you. I wish I could have done it all differently. I did not handle things well. I'm afraid I've made an enemy for as long as I'm a nurse at this hospital. I've worked with this doc for 10 years. You think I just became dangerous overnight?

Easiest way to find out would be to have a talk with the Doctor...

If you think he's your enemy, it's going to manifest that way - if you clear the air at least you'll have a basis for your fears.

[wooh, BSN, RN]

I totally agree with you. I wish I could have done it all differently. I did not handle things well. I'm afraid I've made an enemy for as long as I'm a nurse at this hospital. I've worked with this doc for 10 years. You think I just became dangerous overnight?

You've worked with him for 10 years, one incident shouldn't change things. I'd just go up to him next time I saw him and give him a sincere apology, telling him that since it was a peds patient, you were being extra careful, but handled it badly and will next time go straight to him with your concerns, and that you're sorry for the whirlwind it turned into. I'd hope that 1 incident in 10 years would be forgivable, as if you've made it 10 years then you both must be doing something right.