Can a physician deny an order to transport from LTC?

[anangelsmommy, ADN, BSN, RN]

I am writing a paper for an ethics class. And I have all my sources and most of the actual paper but I am stuck on one part. I do not work in long term care and do not know much about what goes on there or the actual structure of how things would work in this situation. And after searching every journal I could not locate one source that addressed this topic. So I in order to actually understand how this would work, I wanted to know, if a patient were dying and needed immediate care was of sound mind and wanted to be transported to the hospital from a LTC facility, and you the nurse call for the order and the physician says NO and hangs up, what would you do? Is there a medical director to call, another doctor on call? or would you simply send the patient without the order?

I am taking the position of the patient advocate since he has stated his wishes and you do not have time to actually help him work through another option at this time. The time to cover other options would be at a less critical time. But I do not think it would be ethical to let him die.

[VANurse2010]

If your assessment reveals that the patient needs emergency medical attention (deoxygenation, hemodynamically unstable, extremely febrile etc.) you are required to get emergency medical attention for the patient regardless of physician order - lest you be held liable for failure to rescue. It's a very tricky situation.

[nurseprnRN, BSN, RN]

The patient can aways refuse a physician plan of care or any part thereof. And LTC is not jail. Call 911 and have him transported. You would also have the option of going to the medical staff chief or chief of service for a physician prescription to transport, but I think this is a registered nurse decision based on our responsibility to the patient. We don't work for the physicians, we work for the patients. We have our own standard of practice and code of ethics (you can get a copy of the ANA Code of Ethics and the Scope and Standards of Practice at Amazon and they would nicely inform your work on this section of your paper).

[classicdame, MSN, EdD]

this may differ from state to state, but in general an LTC facility is a "residence". The MD is like a family doctor in some regards. They come to see the patient, sometimes the patient goes to the MD office, but when an emergency occurs the "family (in this case the staff) call 9-1-1. What is most important is whether or not a advance directives are on file so the "family" knows the patient's wishes.

[anangelsmommy, ADN, BSN, RN]

according to our outline, there are advance directives and the patient is competent. I was just looking at some other posts and someone had said that when they sent a patient to the hospital from the ltc they almost got fired, and I was of the impression as classicdame said that it was a residence and that I could simply call for transport since it might even take a while to get an order. of course in our scenairo, the doctor "denied" the order. I had not actually heard of that happening before. And of course in this scenario it is emergent, I do not have time to get an ethics consult. and there is advance directive instructing me to "do everything". but I wasnt sure what ltc protocols are? what would happen if you went against a physician order? anything? do you report a dr that goes against an advance directive? we dont have futile care act in our state.

thank you!

[anangelsmommy, ADN, BSN, RN]

oh and yes in this case family is there and on board with the advance directives.

[nurseprnRN, BSN, RN]

This is not a procedural question, it's an ethical question. Think of it in that framework and your path becomes quite clear.

[anangelsmommy, ADN, BSN, RN]

i think its the whole way they present the scenario. I just havent ever dealt with healthcare professionals that were that treated me or anyone else that way. :) just lucky I guess. but you are right. I always think of everything very black and white! It took me a long time to think differently before taking nclex! must be my past haunting me lol!!

[MunoRN, RN]

according to our outline, there are advance directives and the patient is competent. I was just looking at some other posts and someone had said that when they sent a patient to the hospital from the ltc they almost got fired, and I was of the impression as classicdame said that it was a residence and that I could simply call for transport since it might even take a while to get an order. of course in our scenairo, the doctor "denied" the order. I had not actually heard of that happening before. And of course in this scenario it is emergent, I do not have time to get an ethics consult. and there is advance directive instructing me to "do everything". but I wasnt sure what ltc protocols are? what would happen if you went against a physician order? anything? do you report a dr that goes against an advance directive? we dont have futile care act in our state.

thank you!

I think the thread you're referring to was about a patient who had expressed wishes that they did not want to be sent to the hospital for any reason, yet staff called 911 anyway.

[Nascar nurse, ASN, RN]

As a long time LTC nurse and a DON - I would always transport a resident to the ER if they appear acutely ill and are requesting to go whether or not I had an order from the Dr. As I've aged & have become more confident in my decision making (and dependent on how acutely ill the resident actually is), I'm more than willing to call for transport and then call the MD and tell them "so & so is on their way to the hospital for acute respiratory distress. I'll write that order for transfer".

In the end, the resident/family member can sue me for a bad outcome. The Dr. isn't going to sue me and the ER staff (who sometimes think we should never send a resident to them) can't sue me. As someone else said, ultimately, I'm working for that resident and no one else.

Now on the other hand OP. There has been a huge national push to reduce the hospital readmission rates for patients with certain diagnosis. This is leading to some management taking a very harsh stance on their staff sending residents to the ER...needlessly or not is up for debate. This may be where you are hearing stories of some being threatened with termination for sending someone to the ER. I try very hard to teach my staff to be proactive. Identify those residents at high risk for readmission - stay on top of the disease process - keep communicating with the Dr....BUT when they reach that point and they are a full code and they/family says they gotta go then I'm sending them!

[KelRN215, BSN, RN]

according to our outline, there are advance directives and the patient is competent. I was just looking at some other posts and someone had said that when they sent a patient to the hospital from the ltc they almost got fired, and I was of the impression as classicdame said that it was a residence and that I could simply call for transport since it might even take a while to get an order. of course in our scenairo, the doctor "denied" the order. I had not actually heard of that happening before. And of course in this scenario it is emergent, I do not have time to get an ethics consult. and there is advance directive instructing me to "do everything". but I wasnt sure what ltc protocols are? what would happen if you went against a physician order? anything? do you report a dr that goes against an advance directive? we dont have futile care act in our state.

thank you!

I don't and have never worked LTC but I'd view this kind of the same way as calling a code or a rapid response in the hospital. If my assessment of the patient indicates that I should call a code, I call a code. I don't call the MD and request permission to call a code.

As far as going against physician orders go, I think the important question in this scenario is not "what would happen if you went against a physician order?" but, rather, what would happen if you DIDN'T go against the physician's order. As GrnTea says, we don't work for the physician and we are not obligated to follow orders that are not in the patient's best interest. In fact, we have a duty to NOT follow those orders. The patient is of sound mind and wants to be transported, you have them transported.

[BrandonLPN, LPN]

Several parts of the OP's scenario just don't make sense. If a non-hospice resident was literally and clearly dying, no nurse would waste time calling the physician. He would call 911.

And even if he did call the doctor, no doctor I know would refuse the transfer and just hang up. If that did happen, yes, the ethical thing to do would be to send the resident out regardless. But that's a highly implausible scenario.