Consultants and orders

Specialties LTC Directors


I think I have drifted into the Twilight Zone (and believe me, I'd rather be dealing with Rod Serling than the bunch I have). I've worked in 8 long term care facilities. In every case we had attending physicians and consultants. It has always been the standard that consultants make recommendations for medications and/or treatments and the attending MD either agreed or didn't but the attending had the final say.

Now I have a psychiatrist who wants to 'be in total charge' of a resident but doesn't want to be on staff. He doesn't want the attending to be able to disagree. I've told him that all facilities operate the same way. He is trying to get us to sign a waiver absolving him of any wrong doing if the attending disagrees with his recs. He is a bully of the worst kind...threatening me if he doesn't get his own way.

What do you all do? I've never been in a facility where the attending gave up oversight of the resident.


1,010 Posts

Specializes in ER CCU MICU SICU LTC/SNF.

this matter should be discussed with the medical director and the facility's p&p in securing consultations reviewed. there are certain locations where the services of some consultants are not easy to get hold of and the medical director may have to bend facility policies to acquire one.

generally, most consultants do not like the notion that a "general physician" has to "approve orders." afterall, you sought the services of an expert. a p&p statement that the attending physician has to "acknowledge orders" as opposed to "approve orders" may be more suitable. hence, if an order is inappropriate, direct communication from the medical director or attending physician to the consultant can prevent miscommunication.

CapeCodMermaid, RN

6,090 Posts

Specializes in Gerontology, Med surg, Home Health.

My medical director has had the same policy for 30 years. He says the attendings have to agree to all orders. I am the P&P writer for the facility. We've told this consultant that if he wishes to be in charge of the resident's total care, he's welcome to be credentialed and be on the staff. Only in this little town out in the middle of no where....


683 Posts

Specializes in Geriatrics, WCC.

I would treat him as any other consultant, orders needed to be approved by the attending. Have you tried to have your Medical Director speak with him? Sometimes they back down with the attitude when it is another MD speaking, instead of us "lowly nurses".

CapeCodMermaid, RN

6,090 Posts

Specializes in Gerontology, Med surg, Home Health.

"Lowly" or not, I make the rules and luckily both the ED and the Medical Director are in full support.

achot chavi

980 Posts

Specializes in acute care and geriatric.

Believe it or not I understand his concern even if I agree completely with you.

It sounds like he is worried that in this litigious society of ours he could be sued if something goes wrong with one of his patients and if he doesnt hold "total charge" that is more likely to happen.

He is obviously wrong as the attending doctor holds the ultimate responsibility for the pts well being medically and if the attending chooses not to follow the specialists recommendation (and that is all it is) then the attending doctor will have to answer why and take responsibility for the results.

If you have a legal consultant , I would refer the psychiatrist to him/her. What he is demanding is improper and dangerous, all orders have to come through one attending doctor for obvious reasons and if he doesn't understand that, he is not the psychiatrist for you. Something sounds fishy.

Your policy is sound and dont change it, not because others have the same policy but because it is the right thing to do and doing it his way is dangerous and could create serious problems.

BTW ...twilight zone? /////everyday by me....

Here's one, We have to send bookkeeping a slip of paper marking pts who are sent to the hosp and when they return so that she can authorize payment of the ambulance and ER visit etc. Lately nurses have been lazy and forgotten, and we have to run after them to write and sign the slips so the bills get paid,

While passing by, the bookkeeper pointed it out to me (ADON) and I wrote a note to our DON that we should bring it up at the next nurses meeting this coming Sunday, I get a nasty letter back from the DON that I should not interfere in such issues and I should refer the bookkeeper to her and if I dont remember her extension number here it is....

personally I didn't think it was such a big deal...

Another one:

Yesterday the Med Dir called me, furious that an order for AFP was neglected when the bloods were senton a specific pt and needs to be resent. I called the lab to see if they can still do the AFP on the existing blood that was still there and they said no( policy), so I asked the nurses to send it again. The nurse swears she sent it with the rest, so I referred her to the doctor, who berated her and wouldn't let her get a word in edgewise,

so we resent the blood the following morning, only to find out that it HAD been sent correctly and the doctor didn't notice the results in his computer- so it was done twice. you think the doctor apologized??? In your dreams!!

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