Bizarre doctor's order

  1. I had a pt who had been NPO due to swallowing issues and aspirating. No one can figure out why this patient has swallowing problems since he did not have a stroke. When the pt was initially admitted he was in the ICU and the neurologist told the family he would come around and he has made tremendous improvement compared to what his initial condition was when he came in. On the day I had him he was oriented and this was the first day out of 10 days that he was oriented. He did say bizarre things but I don't know if any of that could have been due to the fact that he has schizophrenia.

    The bottom line is his swallowing and aspirating. On the second day I cared for him I received an order from a doctor to order a pureed diet and thickened liquids as long as the patient/family understands that he can aspirate and die. I repeated the order back to the doctor and told him I was writing the order exactly as I read it back to him. Well I knew if I talked to the patient he'd want to eat. I called his 2 daughters and the first daughter deferred to her sister since she is a nurse. I talked to her and she said she didn't feel comfortable with proceeding with feeding him. She has actually been waiting for the psychologist to write a letter stating if the patient is competent to make decisions on his behalf or not. I contacted everyone I could think of - my nurse manager, the primary doc/physician assistant, speech therapist, nutritionist, and case manager. Basically this gi doc feels like he can't do anything because the patient is flat out saying he doesn't want a feeding tube and he can't eat. As soon as the doc came up I made him sign this order that I took so I feel like I am covered. I also documented my conversation with the daughter.

    I just don't agree with this and don't know what else I could've done. Have you ever received an absurd order like this before?
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    Joined: Apr '04; Posts: 352; Likes: 216
    Specialty: 4 year(s) of experience in Telemetry, Oncology, Progressive Care


  3. by   TazziRN
    If the pt is not competent to make his own decisions and his sister is uncomfortable with the order, then you might be covered.
  4. by   RedCell
    This does not seem absurd to me. Sounds like he was covering his a$$ like any practitioner would do. I think it is probably just his way of letting the family know that for the time being, a g-tube/NG/dobhoff/whatever, might be the safest option. If the family wants to feed him regardless that is fine, but at least they can't get some cream puff trial lawyer to sue him by saying that the family was ignorant to the matter when the dude gets the big 8.5mm ETT placed just shy of the carina.
  5. by   MrChicagoRN
    So treatment options are PO, TPN, G-tube or starvation?

    In Illinois, a patient is competent until declared imcompetent by a judge.

    He has the right to refuse treatment, schizophrenic or not.

    You can certainly attempt to feed him, but will need to stop (and notify the MD) if the patient can't tolerate it. Is it documented that the PATIENT was told he could aspirate, and that he said something like "I don't care if I might choke."

    What about his psych issues? Could this be a psychogenic issue? Have they brought a psychiatrist in to be sure he's being treated optimally with meds & to provide the supportive therapy he needs?
  6. by   CRNI-ICU20
    how old is the patient?
  7. by   rn undisclosed name
    This patient is 80 years old and up to this point has been taking care of himself and not allowing anyone to do anything for him.

    The patient himself has said he does not want any feeding tubes. He has had ng tubes which he pulled out even with restraints on. The NG was before I was taking care of him. Since that one was pulled they have been unsuccessful in placing another one. He wants nothing to be done. Anytime he finds out he is going for another test he gets hysterical and refuses and the docs end up cancelling the orders. Right now his only option for nutrition is the g-tube. They could do TPN (well it would have to be PPN) but he pulls out his IV. He keeps finding a way out of the restraints. He does let us restart IVs and then tells us he will pull it out again.

    But really my question was about the doctor's order. I haven't been a nurse for that long and was looking for feedback regarding the doc's order. Thanks for all the information so far.
  8. by   TazziRN
    AH! Okay, I thought you were asking what to do. Nothing wrong with the order, he's covering his patootie.
  9. by   Happeetxn
    Only thing close to this is I called a Doc to tell him his patient failed his dysphagiagram and I need an order to change his meds from po to NGT. The doc responded with, and I quote..........."Well, just have him use small sips of water" Luckily there was another doc I could call and the pt's meds were changed to "via GI tube".
  10. by   Lisa CCU RN
    Quote from TazziRN
    AH! Okay, I thought you were asking what to do. Nothing wrong with the order, he's covering his patootie.
    I'm confused. How is the doc covering himself?

    I thought the OP was asking why isn't this patient being declared incompetent and having a g tube placed?

    Well, he is probably gonna try to pull it out anyway, so what do you do in this situation?
    Last edit by Lisa CCU RN on Apr 25, '07
  11. by   Spidey's mom
    Strange - there is another thread about another elderly person who wants to eat and is NPO and everyone is saying feed him. (me too).

    And now this thread . . .

    I don't see a problem with the doc's order at all.

  12. by   bubblymom373
    We have a negotiated risk agreement that the resident or POA signs stating that the risk of aspiration is realized and that the facility is released from responsiblity if it happens. We have the occasional resident that needs thickened liquids but wants thin instead. We encourage the thickened liquids but if they insist on regular we are covered.
  13. by   Becca608
    Sounds like the daughter is getting things into place where she can make the decisions. She doesn't feel comfortable with feeding him, he refuses to do anything but eat. Sounds like you are covered.

    Just curious though...does the client having any living wills/advanced directives in place for this?
  14. by   classicdame
    is there an ethics committee at your hospital? Might need to bump this up the chain of command.