Can a doctor "order" a nurse to not assess something?

SilleLu · Sep 20, 2015

Thanks KatieMI, good example. I did think of that after the fact...stop the actual "scoring" but put everything I noticed about the patient into a nursing note. Still covering the same ground, and not going against what the doctor said.

Whole situation would have much smoother had the doctor taken 10 seconds to explain the reasoning...

AJJKRN · Sep 20, 2015

The original situation was regarding AWA. Patient day 4 since last drink. Scoring high enough to require IV meds had they been ordered via protocol as usually happens. Some IV meds available (and given) but frequency not enough to keep scoring down. If patient scored much higher, would have to be transferred to ICU per policy.
Now of course it's the doctor's choice on how to treat, I get that. Might have good reasons for it even (would be nice if shared those reasons with nursing, but that's another thread...).
Regardless of doctor's choice of treatment, I just can't wrap my head around being told to "stop it" when it comes to my assessments.
I included other examples only because they are all assessments I thought we as nurses can perform as we see fit, are there assessments that require a doctor's order to perform?

This sounds more like the scoring you were told to stop correlated to Pt and staff safety. No way would I follow MD's orders if Pt was in active ETOH WD! I would be finding a way to go around them. The ONLY orders we get told not to assess on a Pt are ones like not to look under a Pt's fresh post-OP dressing for either 24 hours or MD to do the first dressing change. By no means do they say to not assess the dressing itself though.

sailornurse · Sep 20, 2015

If it came to liability, it would be asked of the nurse, would a "prudent" nurse following the standard of care would have obeyed the doctor's orders to not assess X,Y,Z or using her nursing education/experience & judgement would she have gone ahead with the asessment the situation warranted?

Whispera, MSN, RN · Sep 21, 2015

consider what might happen if you don't assess and something goes south...what then?

PMFB-RN, RN · Sep 21, 2015

See, that's what I wanted...can we as nurses be ordered to not assess?

Yes! Of course a physician can order us not to assess something. They can order and darn thing they like. Doesn't mean WE have to follow that order, and in fact it is our duty to NOT follow and impapropiate orders. I ignore or disreguard stupid orders all the time.

SubSippi · Sep 21, 2015

Was this an actual order, or was the "stop it" more of a suggestion...like the doctor telling you he/she didn't think it was necessary anymore?

I'm curious to know if the doc would feel the same way if there was actual documentation in the medical chart, as opposed to the verbal "don't do that anymore."

KatieMI, BSN, MSN, RN · Sep 21, 2015

Official order: "Dr. Doe (service): please do not call about lab "x" unless patient is symptomatic (a, b, c, d) or "x" is above (certain value)" Dr. Doe, M.D.

Nursing note: received critical value of "x" @time, patient asymptomatic, no a, b, c, d noted, Dr. Doe is not to be informed as per order. M. Doe, R.N.

Curious case of Lasix-induced super-high triglycerides and, correspondingly, serum lipase up to epic numbers with no other symptoms at all. Even nursing staff calmed down after a while, but the lab guys dutifully called every day, first thing in the morning, for a whole month despite of everyone's pleads to please turn on some common sense and stop cover everything under "Imjustdoingmyjob" umbrella

:banghead:

anon456, BSN, RN · Sep 21, 2015

A doc can order something like "BP only while awake", then great. But if you feel the need to take BP at any time at all, given your professional judgement, you are fully within your rights to take it.

If a doc ordered you not to assess something, and you noticed the patient changing but didn't assess anyway, and the patient later dies or becomes very ill, who's going to get sued for that and possibly lose their license? Not the doctor.

Been there,done that, ASN, RN · Sep 21, 2015

No.. the doctor cannot order us.. to not assess and document. We are held to our own regulatory bodies.

I have a feeling you are working in a for profit facility. As a professional nurse, the institution of neurological assessments , seizure precautions ,institution of CIWA protocols are standards WE can and must adhere to.

FurBabyMom, MSN, RN · Sep 21, 2015

When I worked stepdown, I had a patient I felt was too sick to be on our unit. I felt like they should have still been in the ICU. Well, they were extubated and "stable-ish" so we got them. The days nurse I was taking over from for nights, was with me when the patient arrived from ICU and she was kind enough to help me get them settled. Nothing could be done but monitor the patient. The house sup was incredibly not helpful stating as a stepdown unit we should be just fine.

I reviewed the orders for the patient including qshift full assessment, with q4 vitals and neuro checks. Something told me I should be doing the vitals and neuro checks q2 and not q4. Even though there was no documented change from the patient's post op (patient was post op from a crani for decompression of subdural) at any time so far. You just get a gut feeling sometimes. Wouldn't you know, but at 0210 when I did my q2 neuro check/vitals, the patient had a significant change in LOC and was not following commands as appropriate (even as they had been doing at 1230).

After rapid-responsing the patient and getting orders for a stat CT head, a coworker and I packed the patient up on the travel monitor, with code drugs and an ambu bag for the trip to the ED (standard procedure for transporting patients with similar situations). It's probably 0225 or 0230 at this time. As we're standing there and scanning the patient, the on call neurosurgeon arrives in the CT control room. He's watching the images load on the screen...and asks which of us was the one who decided to re-assess the patient q2. I was afraid to admit it was me (he was super hard to work with). My coworker sold me out, the surgeon just says "Lucky for the patient you did."

We packed the patient up, transported the patient to PACU where anesthesia took over care of them for their (second) surgery. We arrived in PACU around 0245. The patient had their second surgery, spent several days in ICU and came back to our floor. I took care of the patient every night I worked between their second arrival on our unit and their discharge to inpatient rehab.

I don't want to think about what might have happened had I waited until 0400 or 0430 to re-assess my patient.

luv2 · Sep 21, 2015

Doctor's order specific nursing assessments all the time...vital signs q4h, neuro checks q2h, orthostatic BPs, AWA and opiate withdrawal scoring, etc.
They can't order us "NOT" to do these things, right? I mean, if I feel a neuro check,or AWA score, or any of the above is called for, they can't tell me not to do it (and chart it), right?

Tell the MD to discontinue it NEVER take word of mouth if you are not able to write down v.o or if your facility does not allow the order make a note where the order is d/c. Ensure whoever is in charge is aware of the ordered being d/c.T o cover yourself write a note that dr...... state and order to d/c. pt not to continue basically SBAR. Reassess and writ a note.

anon456, BSN, RN · Sep 21, 2015

When I worked stepdown, I had a patient I felt was too sick to be on our unit. I felt like they should have still been in the ICU. Well, they were extubated and "stable-ish" so we got them. The days nurse I was taking over from for nights, was with me when the patient arrived from ICU and she was kind enough to help me get them settled. Nothing could be done but monitor the patient. The house sup was incredibly not helpful stating as a stepdown unit we should be just fine.
I reviewed the orders for the patient including qshift full assessment, with q4 vitals and neuro checks. Something told me I should be doing the vitals and neuro checks q2 and not q4. Even though there was no documented change from the patient's post op (patient was post op from a crani for decompression of subdural) at any time so far. You just get a gut feeling sometimes. Wouldn't you know, but at 0210 when I did my q2 neuro check/vitals, the patient had a significant change in LOC and was not following commands as appropriate (even as they had been doing at 1230).
After rapid-responsing the patient and getting orders for a stat CT head, a coworker and I packed the patient up on the travel monitor, with code drugs and an ambu bag for the trip to the ED (standard procedure for transporting patients with similar situations). It's probably 0225 or 0230 at this time. As we're standing there and scanning the patient, the on call neurosurgeon arrives in the CT control room. He's watching the images load on the screen...and asks which of us was the one who decided to re-assess the patient q2. I was afraid to admit it was me (he was super hard to work with). My coworker sold me out, the surgeon just says "Lucky for the patient you did."
We packed the patient up, transported the patient to PACU where anesthesia took over care of them for their (second) surgery. We arrived in PACU around 0245. The patient had their second surgery, spent several days in ICU and came back to our floor. I took care of the patient every night I worked between their second arrival on our unit and their discharge to inpatient rehab.
I don't want to think about what might have happened had I waited until 0400 or 0430 to re-assess my patient.

What a great example of nurses following their gut feeling! You don't know how many times I've relied on that and it's been right!