Conflicts between nurses and doctors

[Severina]

I don't know if anyone else has this problem, but I'm curious. There are certain things that come up as a source of dissagreement between the nurses and our medical director. 1. Our use of ativan standing order, or the use of ativan at all. 2. the use of foley catheters 3. Allowing patients to continue meds they have been on that have worked (usually benzos).

Our medical director is one of those docs who have a lot of predjudice against the benzo family. It is true that they can cause confusion and delerium in elderly patients at times, but she tends to D/C our standing orders of this for anxiety wanting us to substitute haldol. The problem with this is that haldol is not an anti-anxiety med, but an antipsycotic. For people with true anxiety disorders, it doesn't work. Plus, ativan works marvelously when combined with roxanal for shortness of breath/resp. distress.

Also, she has a problem with foleys because of the infection risk (point well taken), but she will tend to make us D/C a foley that we have put in for comfort. An example is someone who has skin breakdown or is at high risk for it, is bedbound and incontinent. She will sometimes D/C foleys on pre-active patients, and ones who have trouble getting in and out of bed due to pain or shortness of breath.

The third thing is when patients come in with something like xanax, it will be the first thing to go, even if the patient has been on it for years. This leads to lots of angry patients and families. It also leads us to risking getting in trouble by going around her to get the med back, and advocating for our patients. So what if xanax has a more complicated clearing process (physiologically). This is the end of life and whatever makes the patient most comfortable should be used in our opinion.

This happened this weekend where there was another, more reasonable doc on call who re-ordered xanax for a patient who had been on it for years and for whom it was the only thing she had tried which had the least S.E. and helped her rest the most. My CN also talked to the pts. DPOA who wanted us to bring it back, and everything was documented thouroughly. Now on Monday, my CN is afraid that she is going to get in trouble when the medical director comes in and finds out that the order is back in place. We shouldn't have to fear for our jobs when advocating for a patient's needs.

Just a big rant, I guess, but curious to know if anyone else has the same problems.

Severina :angryfire

[saribeth]

Wow, you've got your hands full! We have the total opposite...our med director is lost in the black hole! I cannot believe that she would discontinue a foley because of possible infection...that is ridiculous to say the least, and Haldol...well as they say it is the "gold standard" but I think it's awful! Ativan is the absolute best for the whole terminal restlessness, anxiety etc...remember we are advocates for our pts and we must do what is best for them (unless you have a med dir that is on another wave lenght, which is what you have)....goooooooooood luck! I feel for you! hang in there and keep up the good work! Janie :)

[UM Review RN, ASN, RN]

I wonder if she's ever had a Neb treatment?

After my first neb treatment while noticing that I was trembling uncontrollably, I realized why most of my COPD'ers were on Xanax and I blessed the manufacturer of that drug.

I can't imagine anyone on frequent Albuterol/Atrovent Nebulizer treatments without it. Those few who have been without it are restless and unable to sleep. It deprives them of needed rest.

Not really sure if this Med Director ought to be overriding the orders of the patient's PCP, though. Seems to me that it's rude at the very least, implies the PCP doesn't order appropriate medications.

[leslie :-D]

my sentiments exactly angie-

i wouldn't hesitate to contact the pcp, explain what's going on and hopefully s/he will rewrite the previous orders. sounds like the med director is new at this and just doesn't get the big picture.

leslie

[webblarsk]

Not really sure if this Med Director ought to be overriding the orders of the patient's PCP, though. Seems to me that it's rude at the very least, implies the PCP doesn't order appropriate medications.

That's what I was thinking. I can't see overriding the PCP orders. We don't seem to have a problem with things like that. Our Medical Directors are wonderful, they often offer advice but never override PCP orders.

[Severina]

What do you mean by PCP? When a patient comes into our facility, our medical director takes over their care. They come with a list of meds that they are on and between the Med dir. and HP, they decide which ones to keep and not or switch to same kind covered by HP.

Severina

[UM Review RN, ASN, RN]

What do you mean by PCP?

Wow. That sucks. In my state a resident can keep his/her PCP--Primary Care Physician--and the Medical Director of the facility usually just generally oversees things, and is able to step in if a patient's PCP is not responding to pages or whatever. Usually it has to be an extreme emergency before the Med. Director has to step in, though.

Guess I won't want a loved one to be in your state in a nursing home. That system is kinda like signing all your rights away, IMO.

[Severina]

I don't think it works that way in nursing homes. Just at our hospice. Although, we have a few Docs who oversee things and write order etc. and we have one NP. Sometimes they do collaborate with the PCP if the family or pt wants them to. But generally, when someone comes to our residence, they are managed by our team. Its not a bad place to be by any means. People are pretty happy at Arbor Hospice and most have very good deaths. If they don't, its generally because we couldn't get on top of symptoms of some some sort. The med and procedure conflicts that I am speaking about flare up the most over our longer term patients. Plus, we nurses are powerful advocates for our patients, AND we tell the families about the things that the doc tends to D/C and encourage them to be advocates for themselves, to insist that their loved one gets the meds they need to manage their symptoms. We have our ways of getting what we need.

BTW I know a lot of docs across the board are predjudiced against benzodiazapines. I myself have encountered it. I have an anxiety disorder and used to has this psychiatrist who wouldn't give me bezos of any kind. He tried to manage my anxiety with risperidol, which just made me feel like an anxious zombie. And then he tried to manage it with Clonidine of all things, which dropped my BP to 50/32. He was convinced that I would become an addict. My therapist had to have a one on one phone call to get me some ativan so that I could go to the dentist. Needless to say, I got rid of him, and now I have been managed pretty well with antidepressants and Klonapin. I take a little bit every day, and yes, I would have withdrawl if I just quit taking it, BUT that isn't the same thing as addiction. I am taking the appropriate amount of the med to manage legitamate symptoms, not for recreation. I know thats OT, but I just thought I would add that.

Severina