How to Deal With Ignorant Medical Professionals

[tencat]

Is it better working in a larger community? Is there a place where physicians actually embrace the idea of palliative care and hospice and where the rest of the medical community at least is willing to learn if they don't know about it?

For the second time in a month, I've had to deal with an ignorant fool of a physician who insists that hospice is responsible for killing his patients off because we give them too much morphine. I made the mistake yesterday of asking this ignorant horse-behind for an order for morphine as we were heading into a weekend and getting meds in a rural area is very difficult on Saturday and Sunday as we have no Walgreens. I made it very clear to the discharge planner that Horse Behind, MD could refuse the order, and I would understand perfectly, but would someone ask him anyway? That will be the LAST time I ever ask him for so much as a Tylenol for a patient. I met with the patient's family at the home to do the admission and when the issue of morphine came up, daughter showed me a script for 1mg Roxanol q 8 hours PRN. Ok, not what I asked for, but at least it will be in the house, I thought and that shows some progress. THEN daughter says, "Just so you know, Dr. Horse Behind told me I need to watch you carefully because you hospice nurses like to give patients too much morphine and hurt them with it, and I should not let you give him anything because I can't trust you won't hurt him. So I want you to know I AM watching you and you are not to give ANYTHING to my father."

So after picking my jaw up off the floor, I got hot under the collar and said, "I want YOU to know that Dr. Horse Behind is ignorant and knows NOTHING about hospice. In any case, I'm not giving anything to your father: You all are the ones who will do that, should you choose to." Then, knowing I was going to say something I would regret to a family who is not to blame for any of this I asked if we could take a break and I would come back in 10 minutes. I did, and everything went better after that.

I am absolutely furious, even 24 hours later. It wouldn't be such a big deal if it were one physician, but we have 9 physicians in town, and only ONE of them supports what we do, but he is an OB-GYN........We are constantly fighting with the medical community in this town and it is driving me crazy. And I want to get this particular incident addressed somehow because I feel it borders on slander, as there are only 2 hospice nurses in my town. Any advice?

[ObtundedRN, BSN, RN]

Sorry to hear about this. I don't work in hospice, but working in critical care, I fully support hospice and palliative care. I'm in a large city, with many hospitals. I'm at a large teaching hospital/level 1 trauma center. In my experience, our doctors are supportive of hospice and palliative care, but there are a few that don't seem to know when to consider it or bring the subject up with family.

[caroladybelle, BSN, RN]

I would speak to Dr. Horse *** personally, and remind him that slander is a serious charge. Do you have a hospice medical director who will give you orders in this scenario? How about asking the med director to talk with Horse ***. Of course this particular patient's family may not allow you anywhere near the patient, that is until, if and when, the poor patient is suffering in pain.

That.

There is no excuse for this kind of ignorance.

[dj973]

Could you possibly arrange a meeting between yourself and this doctor with his medical director and your supervisor present to review his behavior? I would say that his comments need to be addressed directly. See if he would own up to these statements when directly confronted. Clearly some professional boundaries need to be established if you are going to continue to treat his patients. If he refuses a meeting is there an HR department within his practice that you could report him to? If not may be a letter from your lawyer would put his behavior in check as it does sound like slander.

[leslie :-D]

Please do not do this in your nursing notes. This is a legal document and is only for facts. The appropriate way to note it is to say, "I (or RN) requested morphine from Dr. X. for unrelieved pain. Dr. X. refused to order." It is inappropriate and unprofessional to use your nursing notes to editorialize, even if you are directly quoting a physician's statement. Believe me, if you get called in to court you'll be embarrassed that you used your documentation as a soapbox.

thanks for your input.

i am all too aware of legal implications when i write notes.

when i do quote pts et al, it is always in context with the intent of my notes.

and, it has helped put certain points in perspective, when i have done so.

we'll just have to disagree as to how we attain our goals in writing notes...

since there doesn't seem to be any absolutes as to what constitutes legal, written records.

leslie

[newtress, LPN]

OP: I personally wish there could be some other licensed entity that could manage and make the orders for the patients that are to be put on hospice. Some of you may have recently read my thread about loosing my father on Thanksgiving day [How do I walk back in a room]. Aside from the pure neglect for 10 days from the female caregiver he was living with, the small town internist turned "oncologist" who wasn't associated with a hospital, did not order hospice for my dad until two days before I could get an emergency flight out there. He passed away 72 hours after I arrived and after I called 911 to get him out of this woman's house and into the hospital. This doctor had no orders for NaCl fluids or any comfort care meds. There was absolutely nothing in this back bedroom he was in. He should have been on hospice at minimal 3 mo prior to him dying (not 3 days) an agonizing painful death. When we finally get the death certs we see that the primary cause of death on his death cert was severe malnutrition/dehydration, secondary was chronic lymphocytic leukemia. So there in shows doctors who don't seem to know when to introduce hospice into a care plan, or if when they do, fail to uphold their oath to do no harm and order the much needed palliative support and meds needed for those near death. I understand fully your frustration and how offensive this was to you.

[heron, ASN, RN]

Have you had a chat with your medical director?

Maybe your medical director needs to get out and do some informal education or at least back you guys up. At the very least, s/he can remind them that failure to relieve pain is grounds for a lawsuit, too.

You implied that your hospice operates in a smaller community ... and even in this day and age, there are docs that dig in their heels and are more worried about who's boss than about the peace and comfort of their patients.

Speaking as a small town girl, though, may I respectfully suggest going carefully. You aren't doing patients any good if you get yourself fired or referrals dry up and your agency suffers. This is why I suggest a chat with your med director and maybe your DON and risk management.

I'm not saying don't address it ... you absolutely have to, for the patients and to keep that kind of slander from turning into a lawsuit or criminal charges.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

If a patient or family tell me they don't trust me, I help them find another nurse. Perhaps the family has a friend in the health care field to help guide them. Maybe, since hospice nurses aren't to be trusted, the Horses Asterisk of a doctor can come up with some positive suggestions? And by all means document everything the family says the doctor told them and give a copy to your employer.

[sharkdiver]

You might ask the daughter if she would put that in writing for you word for word - or see if she will repeat it to someone else. If you can get some kind of documentation before you meet with Dr. H.A. it would be useful. If push comes to shove you could always use it to file an ethics complaint against him with the state BOM.

[tencat]

you wouldn't get that support?

is that what you're saying?

leslie

Yes. We mustn't annoy the doctors or they won't refer to us anymore (not my attitude, my bosses).....not that they do anyway unless they don't want to deal with a problem patient anymore as it stands now. So, no, I wouldn't have any support, except maybe from our medical director, who has been burned by the MDs in town himself. He was scheduled to give an information lecture to them at a monthly meeting they all have, and when he got there and started, one of them interrupted him and said "We know all about hospice, and we have other things we need to discuss in this meeting, so you only have 5 minutes more."

This is the second time this same doctor has said that our giving morphine to a patient will harm him. We just had another one with lung cancer and Parkinsons who got aspriation pneumonia, and Dr. Horse Behind told THAT family that the only reason he got pneumonia is because the hospice nurses gave him too much morphine and he couldn't breathe right.

[SilentfadesRPA]

OP: I personally wish there could be some other licensed entity that could manage and make the orders for the patients that are to be put on hospice. Some of you may have recently read my thread about loosing my father on Thanksgiving day [How do I walk back in a room]. Aside from the pure neglect for 10 days from the female caregiver he was living with, the small town internist turned "oncologist" who wasn't associated with a hospital, did not order hospice for my dad until two days before I could get an emergency flight out there. He passed away 72 hours after I arrived and after I called 911 to get him out of this woman's house and into the hospital. This doctor had no orders for NaCl fluids or any comfort care meds. There was absolutely nothing in this back bedroom he was in. He should have been on hospice at minimal 3 mo prior to him dying (not 3 days) an agonizing painful death. When we finally get the death certs we see that the primary cause of death on his death cert was severe malnutrition/dehydration, secondary was chronic lymphocytic leukemia. So there in shows doctors who don't seem to know when to introduce hospice into a care plan, or if when they do, fail to uphold their oath to do no harm and order the much needed palliative support and meds needed for those near death. I understand fully your frustration and how offensive this was to you.

I am so very very sorry your dad and you had such an expirience - your in my thoughts.

Marc