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

ebrooks1013 · Sep 23, 2015

So I'm not sure if this fits but often in the ED patients have vital signs that fluctuate between ones that the physician can discharge and ones that they probably can't such as high bp or temp. Often if a patient has been trending high every 15 min or 30 minutes and I get ONE within limits they will tell me to stop the automatic machine and they will go ahead and discharge them. To me if they feel this is necessary other measures need to be taken especially if we have already attempted to treat it and we aren't having much success but most times they rush them out the door. I'm still under a year in the ED. Do you guys feel this is normal?

PMFB-RN, RN · Sep 23, 2015

So I'm not sure if this fits but often in the ED patients have vital signs that fluctuate between ones that the physician can discharge and ones that they probably can't such as high bp or temp. Often if a patient has been trending high every 15 min or 30 minutes and I get ONE within limits they will tell me to stop the automatic machine and they will go ahead and discharge them. To me if they feel this is necessary other measures need to be taken especially if we have already attempted to treat it and we aren't having much success but most times they rush them out the door. I'm still under a year in the ED. Do you guys feel this is normal?

Yes, perfectly normal. Your physicians are working against a system that doesn't allow them to use their professional judgment. In cases like you describe obviously the physician does not feel that patient needs to be admitted. Obviously the hospital wants as many admissions as possible to keep revenue up so there are silly rules about what vital signs must be admitted,

ebrooks1013 · Sep 24, 2015

Yes, perfectly normal. Your physicians are working against a system that doesn't allow them to use their professional judgment. In cases like you describe obviously the physician does not feel that patient needs to be admitted. Obviously the hospital wants as many admissions as possible to keep revenue up so there are silly rules about what vital signs must be admitted,

Thank you for your input

icuRNmaggie, BSN, RN · Sep 24, 2015

I had to work with a pulmonologist who would write "do not turn patient, do not awaken patient for nursing care" for every stable ventilator patient. I suspected that a family member complained about us disrupting her sleep.

Of course, we ignored that order, turned our patients and adhered to all ventilator patient standards of assessment and care, and documented accordingly.

You just have to have rationale for what you are doing and you will be fine.

Jory, MSN, APRN, CNM · Sep 24, 2015

I had to work with a pulmonologist who would write "do not turn patient, do not awaken patient for nursing care" for every stable ventilator patient. I suspected that a family member complained about us disrupting her sleep.
Of course, we ignored that order, turned our patients and adhered to all ventilator patient standards of assessment and care, and documented accordingly.
You just have to have rationale for what you are doing and you will be fine.

However, this is the incorrect way to go about it.

You cannot "ignore" an order and do nothing else. That will get you into trouble because you have no backup.

For example, ventilator patients absolutely have to be turned. We all know why. Any doctor is doing a grave disservice to any patient that orders otherwise, unless they are getting ready for a terminal wean. The family member just needs to understand why and if they disagree with it, then that falls under the category of too bad. They are going to be the first to sue if pneumonia or a pressure ulcer develops too.

However, let's say the physician had a medical rationale for not doing so (I can't think of one...but for the sake of argument), then you are interfering with his plan of care.

As soon as you see an odd order like that, you have to call the physician and explain hospital policy. If you disagree with their rationale, SOMEBODY up the ladder has to give you permission to continue.

If you make a unilateral decision like that, you can find yourself fired.

MunoRN, RN · Sep 24, 2015

However, this is the incorrect way to go about it.
You cannot "ignore" an order and do nothing else. That will get you into trouble because you have no backup.
For example, ventilator patients absolutely have to be turned. We all know why. Any doctor is doing a grave disservice to any patient that orders otherwise, unless they are getting ready for a terminal wean. The family member just needs to understand why and if they disagree with it, then that falls under the category of too bad. They are going to be the first to sue if pneumonia or a pressure ulcer develops too.
However, let's say the physician had a medical rationale for not doing so (I can't think of one...but for the sake of argument), then you are interfering with his plan of care.
As soon as you see an odd order like that, you have to call the physician and explain hospital policy. If you disagree with their rationale, SOMEBODY up the ladder has to give you permission to continue.
If you make a unilateral decision like that, you can find yourself fired.

A nurse doesn't need the physician's permission to use their judgement or act on that judgement in providing nursing care.

I've never seen an actual physician directed order to turn q2, turning and other preventive skin protection is a nurse driven component of care, but whether we're acting on the physicians plan or not we're responsible for the care we provide, not the physician. I take very seriously any suggestions the physician has, but ultimately that aspect of care falls on me.

The need to do so is extremely rare, but when a physician's order falls outside of what a nurse considers prudent practice, "interfering with his plan of care" is what we get paid to do.

PMFB-RN, RN · Sep 25, 2015

You cannot "ignore" an order and do nothing else. That will get you into trouble because you have no backup.

Can not ignore an order? I once woke a cardiology fellow (she insisted we call her cell vs using a pager) up at 3AM to report her patient had just gone into 3rd degree heart block. I received this order:

"Um, OK, Baked potato PO BID"

Of course I ignored the order, set my patient up for transcutaneous pacing, and called her back. Once she arrived at the bedside she asked me "did you call me once before or was I dreaming?" I informed her that yes I called he once before and yes she was dreaming. Then I told her "Good thing you said PO with the baked potato, who knows where I might have put it!".

We still laugh about this incident today, years later.

Jory, MSN, APRN, CNM · Sep 26, 2015

A nurse doesn't need the physician's permission to use their judgement or act on that judgement in providing nursing care.
I've never seen an actual physician directed order to turn q2, turning and other preventive skin protection is a nurse driven component of care, but whether we're acting on the physicians plan or not we're responsible for the care we provide, not the physician. I take very seriously any suggestions the physician has, but ultimately that aspect of care falls on me.
The need to do so is extremely rare, but when a physician's order falls outside of what a nurse considers prudent practice, "interfering with his plan of care" is what we get paid to do.

Don't confuse policy with a written physician's order. They are not the same and you seem to think they are.

I stand by my answer. When you post later that you are suspended because you unilaterally did not follow physician's orders I can assure you that no one in the hospital is going to back you up.

You seem to think orders are "suggestions". Honestly...that's a bit terrifying that you work as a nurse and don't know the difference.

If you want to know where the Q2 turns are, try looking it up in your facility policy. Do you even know how to access it? You should know how to access every policy.

I sit on a committee at the hospital and this is a big deal, especially in the last year or so. They can and nurses are routinely suspended and/or fired for this. Nurses picking and choosing which written directives to follow without involving anyone else. You can't do that.

Both nurses and physicians have different roles in patient care.

Back to the original question: Can the physician order you not to do something? They can and once they write it down it's an order just like anything else. You can use your nursing judgement and the chain of command to question it, but you can't just decide that on your own. If you want to make decisions completely on your own then go to NP or med school.

I'll give you an example of a recent case. Nurse comes back from vacation and has a patient that is on comfort care. Patient is a DNR. Orders are no turns, give the family privacy, Q12 vital signs, plus others by those are the important ones. The patient was not in hospice because they were waiting for two other family members to get there, one of which was the decision maker.. This nurse, who did not ask anyone, got into a huge argument with the family because she was constantly in the room, said she was going to keep turning the patient who had severe osteoarthritis plus a broken hip. She proceeded to take vital signs q4 because she thought it was "ridiculous" to take them q12.

Again, she involved no one. She asked no questions.

Nurse was suspended for a week without pay and ordered to go through the same training brand new nurses go through that are educated on policy and physician orders. This nurse has 15 years of experience.

So this family was more focused on the nurse than their loved one because she decided her job was more important. The patient lived three days after being placed on comfort care.

The family was so upset that six of them wrote a separate letter to talk about her insensitivity. Her "argument" was that she was following policy.

She didn't have a leg to stand on.