Can you hold medications without a doctor's order?

MunoRN, RN · Dec 11, 2021

On 12/10/2021 at 9:27 PM, LovingLife123 said:

No it’s not. I’ve often called a physician over meds and labs asking if they want to hold. I’m done cases where I thought to hold, the physician wanted it given. It’s not my scope of practice to make that decision. I don’t write the orders.

Also a physician will want to know about a change in the patients condition that they don’t require that med anymore.

Don’t be short sighted on what all it means to call a physician and discuss holding an order. I’m seen as a professional. That’s not something I worry about when I call to see if I should hold lovenox or a BP med. Sometimes you need to switch up the medication. Am I supposed to decide which med to look professional?

We don't order the medications but we're responsible for recognizing when administering a medication is clearly not appropriate and not administer it if that's our determination. A Physician cannot override our refusal to not administer a medication because we've determined it to be inappropriate. You are of course resonsible for that decision, just as you (not the Physician) are responsible for any consequences that result from still giving the med despite considering it inappropriate.

This is one of the main functions of a Nurse. It's like launching nuclear weapons, it's take two separate people to agree it's appropriate before it can happen. The difference is that's a positive/positive failsafe, while the Physican/Nurse failsafe is positive/negative (the Physician must approve, but the Nurse may dissaprove).

A nurse who believes a medication should not be administered but administers it anyway because the Physician told them to is failing to meet the requirements of their license.

Guest219794 · Dec 11, 2021

On 12/9/2021 at 1:06 AM, hydrochloro said:

Like insulin or for example if someone had a head injury and you hold trazadone so that symptoms of head injury isn't mistaken for side effects of the sleep aid.

Short answer to your question is yes.

But, your examples aren't great.

Certain meds, like insulin, should have hold parameters. Otherwise, it's a bad order, and needs to be corrected. That is your doctor's order to hold.

The trazodone thing is different. Unless there are orders to awaken a PT do do neuro checks, why hold it? If you believe that this PT's condition is severe enough to warrant frequent neuro check, then you are right, a sedative is contra-indicated. Maybe the doc just copied the home medication list, neglecting to hold the sedatives. Or, maybe you are misunderstanding the plan of care. Either way, this warrants a conversation with the doc.

If you think a medication is contra-indicated, it is your responsibility to hold it until this conversation happens.

Kitiger, RN · Dec 11, 2021

On 12/9/2021 at 10:31 PM, LovingLife123 said:

You always have to inform the physician and get their OK to hold a medication. Many meds have hold parameters for these situations, but you just can’t decide Willy nilly to hold a med.

You don't have to get the physician's OK to hold the medication, but you do have to inform him/her. As MunoRN said, "You aren't just allowed, but required, to not administer a medication if it's clearly inappropriate. If you gave the medication inappropriately then you would be held liable for the consequences, but keep in mind if you refuse to give it you'll also be held liable for the consequences if that decision was not warranted."

londonflo · Dec 11, 2021

Sometimes I wonder if you all would call to report the patient is having hair loss...should I give the chemo?

On this board I hear so many clamoring to see nursing as a profession and then I read:

13 hours ago, LovingLife123 said:

Don’t be short sighted on what all it means to call a physician and discuss holding an order. I’m seen as a professional. That’s not something I worry about when I call to see if I should hold lovenox or a BP med.

You would actually call for these? You are not talking about esoteric meds Let's take them one at a time.

. First of all, what are you asking?

1) for the MD to refuse a dose on Lovenox unless they were bleeding out.

2) If it is a day before a procedure

# 1 is self explanatory. #2 is common sense JUST STOP it. it doesn't need a Ph.D ( or of course that respected DNP) to figure that out ( that the MD doesn't see you as a professional who can't see the 'forest from the trees' ) ,

Susie2310 · Dec 11, 2021

On 12/11/2021 at 11:09 AM, londonflo said:

Sometimes I wonder if you all would call to report the patient is having hair loss...should I give the chemo?

On this board I hear so many clamoring to see nursing as a profession and then I read:

This is the way I understand the situation:

In some situations a medication/dosage is clearly contraindicated; for example a blood pressure medication dosage that you have good reason to believe is contraindicated given the patient's current blood pressure, clinical condition, etc. In that situation a prudent nurse would hold the blood pressure medication, timely notify the physician of the decision to hold the medication, and receive any orders from the physician for the patient.

However, in some situations, where the nurse believes there MAY be grounds for holding the medication on the basis of it being contraindicated for the patient, but the nurse isn't certain that the medication should be held, the nurse must consult with the physician about this situation. This means that IN THE INTERIM, until this conversation with the physician has taken place, the nurse must use their nursing judgment and other resources such as consulting with a pharmacist and/or a validated professional drug reference to weigh up the risks and benefits of holding the medication. Of course, once the conversation with the physician has taken place, the nurse must still be convinced that the medication/dosage is appropriate for the patient to receive prior to their administering it.

londonflo · Dec 11, 2021

On 12/10/2021 at 9:27 PM, LovingLife123 said:

No it’s not. I’ve often called a physician over meds and labs asking if they want to hold. I’m done cases where I thought to hold, the physician wanted it given. It’s not my scope of practice to make that decision.

It is within your scope of practice to withhold a medicine that will not be warranted based on the current patient's condition. Warranted means you understand the patient's health problem and treatment plan, how this medication folds into the treatment plan and when the medication will cause more harm than good.

On 12/10/2021 at 9:27 PM, LovingLife123 said:

I’ve often called a physician

And that is why we will never be a respected profession. Let's just keep on calling...... Look at your drug book first (if you don't have one -- GET one) , Micromedix next and call the physician last,

And then we have the NP programs, who do not require any NP School-ready requirements beyond getting your RN and with 560 clinicals hours and ..POOF! your able to prescribe!

Kitiger, RN · Dec 11, 2021

On 12/11/2021 at 1:25 PM, londonflo said:

It is within your scope of practice to withhold a medicine that will not be warranted based on the current patient's condition. Warranted means you understand the patient's health problem and treatment plan, how this medication folds into the treatment plan and when the medication will cause more harm than good.

And that is why we will never be a respected profession. Let's just keep on calling...... Look at your drug book first (if you don't have one -- GET one) , Micromedix next and call the physician last,

Londonflo, are you saying that you would not notify the physician when you hold a medication? You would just let the physician continue to think that the plan of care was being followed? Even when it wasn't?

How professional is that? I just don't understand your thinking.

londonflo · Dec 11, 2021

On 12/11/2021 at 1:40 PM, Kitiger said:

you would not notify the physician when you hold a medication?

No, I don't call for every little thing --( 1.patient on stools softeners and having diarrhea? 2. Patient on an antihypertensive and now low normal BP on a low sodium diet) and I would pass it on in report. The next nurse seeing the physician would communicate it to the MD.

I attended a great professional program that stressed .... when you call an MD what do you want them to do? You provide the assessment info and what are you expecting?

A telephone call:

MD: Hello

RN: Mr. JJ Smith is having loose stools, actually diarrhea .

MD: OK

RN: Ummm should I hold his Dulcolax tabs?

On 12/11/2021 at 1:40 PM, Kitiger said:

You would just let the physician continue to think that the plan of care was being followed? Even when it wasn't?

Communication is the key to the plan of care being effective but communication doesn't mean calling the MD in the evening, and at night. Do you not trust your co-worker following you to communicate your decision? If the plan of care depended on that one medication, why is the patient still in the hospital? (I am not talking about IVPBs such as antibiotics). Rather it seems like the patient is doing well on the plan of care and can continue it at home. A decision like that can be made the next morning.

I will give you an example. I was an evening (3-11PM) nurse. Old days when people came in the night before their surgery. It was one of our jobs to review the CXR results and labs that were done prior to surgery. I didn't get around to it before after my shift ended..like midnight. One man (who was going to have a mastectomy) showed he had TB on his CXR. I called the OR and alerted them to cancel his surgery. (YES, On MY OWN I DID THAT). You cannot have someone in the OR, on the respiratory equipment unless it was life threatening ).

I reported to the midnight nurse what I had done and said wouldn't it make more sense to call the surgeon in the morning a couple of hours before the case was scheduled?. He was a surgeon with a long day of cases ahead of him.

Since this is before we had special rooms with negative air floor, and no additional hooded masks, I suggested the night nurse wear a (already plentiful )mask if she had to go in there,. The man had come in from the community earlier that day. ...Oh no she had itchy fingers (or the "I'm awake so you should also be awake" syndrome) and called in the MD at 2:00 for an order for an isolation cart outside a door. Yeah she got the isolation cart with the masks...the same stuff available already on the floor.

Hoosier_RN, MSN · Dec 11, 2021

On 12/11/2021 at 2:18 PM, londonflo said:

No, I don't call for every little thing --( 1.patient on stools softeners and having diarrhea? 2. Patient on an antihypertensive and now low normal BP on a low sodium diet) and I would pass it on in report. The next nurse seeing the physician would communicate it to the MD.

I attended a great professional program that stressed .... when you call an MD what do you want them to do? You provide the assessment info and what are you expecting?

A telephone call:

MD: Hello

RN: Mr. JJ Smith is having loose stools, actually diarrhea .

MD: OK

RN: Ummm should I hold his Dulcolax tabs?

Communication is the key to the plan of care being effective but communication doesn't mean calling the MD in the evening, and at night. Do you not trust your co-worker following you to communicate your decision? If the plan of care depended on that one medication, why is the patient still in the hospital? (I am not talking about IVPBs such as antibiotics). Rather it seems like the patient is doing well on the plan of care and can continue it at home. A decision like that can be made the next morning.

I will give you an example. I was an evening (3-11PM) nurse. Old days when people came in the night before their surgery. It was one of our jobs to review the CXR results and labs that were done prior to surgery. I didn't get around to it before after my shift ended..like midnight. One man (who was going to have a mastectomy) showed he had TB on his CXR. I called the OR and alerted them to cancel his surgery. (YES, On MY OWN I DID THAT). You cannot have someone in the OR, on the respiratory equipment unless it was life threatening ).

I reported to the midnight nurse what I had done and said wouldn't it make more sense to call the surgeon in the morning a couple of hours before the case was scheduled?. He was a surgeon with a long day of cases ahead of him.

. Since this is before we had special rooms with negative air floor, and no additional hooded masks, I suggested the night nurse wear a (already plentiful )mask if she had to go in there,. The man had come in from the community earlier that day. ...Oh no she had itchy fingers (or the "I'm awake so you should also be awake" syndrome) and called in the MD at 2:00 for an order for an isolation cart outside a door. Yeah she got the isolation cart with the masks...the same stuff available already on the floor.

Semantics/variation of explanation...the MD is still being notified at 1 point or another. Some situations are more emergent than others, and require immediate attention. Either way, the ordering provider needs to be made aware at some point in time

ladedah1, BSN, RN · Dec 11, 2021

For me, the answer to this question isn't a simple yes or no. Nursing judgment is an important aspect of providing safe patient care. However, we must understand where those boundaries lie and truly be honest with ourselves about the amount of experience / knowledge contributing to that judgement. I've been a nurse for quite some time now and the are plenty of decisions that I have a decent level of confidence in making independently, especially if it is something that has a rather predictable response from physicians.

Holding a beta-blocker, for instance, would be appropriate if someone's blood pressure is 95/60 and their heart rate is on the lower end. I'm a night shift nurse and overnight hospitalists have a lot going on; if the patient's vitals trend supports the decision, then I'm not going to page them about a judgement call that I already know they are going to make - I just document on the MAR that it's not given due to contraindication and cite the vitals. Now, if it's prescribed to help with rate control and they are currently (or have a tendency to become) quite tachy, I tend to start looking at their trends in vitals around the medication's adminstration. If similar numbers have existed and resulted in improved rate control without impact on the blood pressure, it may still be useful. If I have any bit of intuition that tells me it may result in a problem, I will page the physician and delay the medication's administration until hearing back.

There have also been a number of times that my intuition has told me that giving a prescribed amount of nighttime insulin is going to result in a problem, despite meeting the parameter. At that point, I will usually ask the patient about any historical experience with insulin; some will have a fairly good understanding of their response to it, some won't. If they are unsure, I will often explain my concerns about their trend and ask them if they still want to receive it... usually the answer is no... so I just document the patient's "refusal" in the MAR and leave it at that. I can't tell you how many times that intuition has steered me right... and a patient who didn't get those extra units woke up with a blood glucose around 100. But that comes from years of experience and a firm understanding of relevant factors pertaining to the situation.

Some things, though, may be a little more muddy and it's best not to take the chance without further insight from the physician... and sometimes, it's clear what you should reasonably be doing, but the situation requires a bit of confirmation discussion with the physician merely for CYA. I am also not above a healthy discussion of rationale when a physician still wants something that I am very uncomfortable with ?.

More or less, there isn't a yes or no answer, as it all really depends on the situation.

londonflo · Dec 11, 2021

This was the original post. Whether to call right away or not.

Quote

Semantics/variation of explanation...the MD is still being notified at 1 point or another.

No one stated here it was an emergent situation. No one stated the ordering provider would not be notified. The ordering physician does need to be notified. No one in this thread suggested not communicated with the ordering physician.

The original post came from this comment: Not mine

Quote

Otherwise,

regardless of med,

I'd call MD for order to hold

(hold med until after call and document well), if I had good reason to believe it needs held. If MD states to give anyway, make sure to document that too

londonflo · Dec 12, 2021

On 12/10/2021 at 9:27 PM, LovingLife123 said:

Don’t be short sighted on what all it means to call a physician and discuss holding an order. I’m seen as a professional. That’s not something I worry about when I call to see if I should hold lovenox or a BP med. Sometimes you need to switch up the medication. Am I supposed to decide which med to look professional?

Yes, You are a professional. The case presented was to HOLD a medicine not switch up a medicine. The remedy to prevent short sightedness is not to call when it is obvious giving the medication will cause more harm than good.

On 12/10/2021 at 9:27 PM, LovingLife123 said:

I’m seen as a professional.

Then frankly think and act as a professional.

I sound mean, I agree, but until we will be recognized as a professionals, we need to up our game. Ask any doctor about the calls they receive that shouldn't have been made and you will find out how 'helpless' nurses act, when it comes to medications.