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

jadelpn, LPN, EMT-B · Sep 21, 2015

Yes, a doctor told me to "stop it" referring to one of the above assessments. My nursing judgement led me to believe that assessments were called for and my fellow, more experienced, nurses agreed. I discussed with the doctor asking for the assessments to be ordered, but did mention that myself and previous nurses had been doing them even though not ordered. At that point I was told to "stop it." I did not stop it. And I don't think the nurse that followed me "stopped it" either.

And I am sure that there is a policy that backs that up. So even if it is not ordered, it needs to be done per policy. However, if the score needs medication, then that could be an issue if the MD declines to order the necessary intervention.

A "stop waking my patient to assess" can also be a factor. And yes, withdrawal protocol aside, patients can actively withdraw while sleeping.

I would take this to your charge nurse to discuss with the MD an adherence to the policy. And to obtain orders to cover. And this will mean this MD will NOT get phonecalls in the middle of the night to medicate or not medicate. Which I am sure is the crux of this issue.

CryssyD · Sep 21, 2015

Just a gut feeling here, but were you addressing your concern that the patient needed additional treatment for his/her withdrawal symptoms in any other way--by asking the doctor directly, for example? Merely charting that the patient should be "getting IV meds...via protocol" could be perceived by the MD as a rather passive-aggressive way to imply that he is prescribing inadequate care--and rightly so, if I may be so bold. If you have a concern about patient care you should be advocating for your patient directly, and, if you get no satisfactory response, go up the chain of command to your supervisor or nurse manager; the doctor has a right to be a bit miffed if you continue to chart an assessment that is apparently quite different from his (perhaps he simply wants to keep his patient out of ICU, for whatever reason; perhaps he feels the patient, being 4 days out now, no longer needs IV meds?) I don't know, and neither do you--unless you ask!

Never be too intimidated to speak to doctors about their patients--doctors, in spite of what they may sometimes think, are not gods!

Here.I.Stand, BSN, RN · Sep 21, 2015

I can see if the assessment is clearly not indicated. For example, if the pt has been in the hospital for two weeks, probably not necessary to assess for DTs. If a 30 y/o, a&o pt is in for a lap chole, it's not necessary to check cranial nerves, even though it is part of a "head to toe assessment." Of course I would expect a "This is not necessary, and here's why..." vs a "stop it."

That said, the physician does not dictate nursing practice. Remember the venn diagram for medical and nursing? They overlap in that we carry out parts of the medical plan of care, and we need them to prescribe meds, etc. But there's that whole other section that is just nursing practice. Nurses dictate nursing practice, and assessment is part of nursing practice.

nursingaround1 · Sep 21, 2015

I would say generally not. We work together with doctor's, but also we are a separate entity and are accountable for our own actions. Just think of the number of times doctor's asses have been saved by nurses who knew better. At the end of the day, if you did what you felt was right, and can back it up with sound reasons and clinical data, then I think that generally, you can't do any harm to get extra data.

An instance where you may have to not make assessments, that I can think of and have experienced, is weighing anorexic patients. For various reasons, some plans involved weekly only checks, or daily - it all depended on the care plan. But the rationale for weekly instead of daily usually had to do with how focused a patient became on the numbers of their weight each day.

VANurse2010 · 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.

I actually disagree with this. There's pretty good chance a lawyer would try to nail a doctor for this. their pockets are much deeper.

imintrouble, BSN, RN · Sep 21, 2015

What the OP describes, usually involved the night nurses, who had to wake an MD up to report a change in condition.

It's a form of intimidation. We always looked out for the best interests of our patient when faced with that kind of pressure.

It simples it down.

littlepeopleRNICU · Sep 21, 2015

Yes, a doctor told me to "stop it" referring to one of the above assessments. My nursing judgement led me to believe that assessments were called for and my fellow, more experienced, nurses agreed. I discussed with the doctor asking for the assessments to be ordered, but did mention that myself and previous nurses had been doing them even though not ordered. At that point I was told to "stop it." I did not stop it. And I don't think the nurse that followed me "stopped it" either.

In those situations, you go above the MD. If it's a resident, call their attending. If it's an attending, call your hospital AOD or facility administrator. If you feel like an assessment of something is required and you see something that needs attention, get it. That's your role as the nurse and your job is to be an advocate for your patient. Like others said, situations in end of life care, etc. are different, but assuming this isn't what we're talking about, sounds like you did what you're supposed to.

anime09 · Sep 21, 2015

Just wondering if anyone asked the doctor why he was against the vital signs been taken. There can be no arguments, I think until there is clarification.

RNsRWe, ASN, RN · Sep 21, 2015

Worked on a med-surg floor where the standard of care/policy would have us taking vitals Q4h, then qshift as a patient moved through the post-op period of days. Had a doc order "vitals daily only". Thing was, the patient was on enough meds to warrant at least a q shift bp, pulse....and no one was about to give the barrage of medications due at 11am with no vitals taken because they had been taken at 0600 before nightshift left....or give meds at 1900 without knowing what the vitals were...and no one really cared WHAT they were at 0800, thanks muchly.

Patient complained to Doc that the nurses were "bothering" her with all these vitals (like,q 8hrs is such a bother when you're in the hospital--and q4 is too much when you're eating painkillers like they were Skittles?) and the doc subsequently complained to unit manager. Who then told him that if the nurses felt that a proper assessment of THEIR patients, given the medications HE had ordered, included vitals, they would do them. And if the patient was feeling well enough to complain about vitals being taken, she probably was well enough to go home. She did have a backbone present itself sometimes, LOL....

Jory, MSN, APRN, CNM · Sep 22, 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?

Yes, they sure can and it falls on them if something happens to the patient. Just document that they told you and use critical thinking if it's remotely appropriate. I would question it, then document their rationale.

I have had a physician to tell me to skip vital signs on a patient that had not been sleeping well. We very often stop vital signs on a patient that is in comfort care/hospice. Sometimes they will not order orthostatic BP's on a patient when they already know that the patient already will show a sustained drop in blood pressure. Sometimes neuro checks are skipped because of medications the patient is taking will give you false results.

Just say, "I'll be happy to skip that assessment, could you please educate me in the rationale?"

I used to ask physicians "why" and figured out the hard way that if you say, "educate me'..they take it as an opportunity to teach you versus you questioning them and even your most egotistical physician will tell you.

I would, however, refuse to NOT take a BP on a patient that was receiving blood pressure medication, etc. Again, critical thinking.

PMFB-RN, RN · Sep 23, 2015

I would say generally not. We work together with doctor's, but also we are a separate entity and are accountable for our own actions. Just think of the number of times doctor's asses have been saved by nurses who knew better. At the end of the day, if you did what you felt was right, and can back it up with sound reasons and clinical data, then I think that generally, you can't do any harm to get extra data.
An instance where you may have to not make assessments, that I can think of and have experienced, is weighing anorexic patients. For various reasons, some plans involved weekly only checks, or daily - it all depended on the care plan. But the rationale for weekly instead of daily usually had to do with how focused a patient became on the numbers of their weight each day.

My question for you and the other who say not, on what basis do you as a nurse determine what a physician may or not order? Certainly we can control what orders we fallow, but how can we control what a doctor can order?

nursingaround1 · Sep 23, 2015

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My question for you and the other who say not, on what basis do you as a nurse determine what a physician may or not order? Certainly we can control what orders we fallow, but how can we control what a doctor can order?

They are free to order what they want