medicine without a license

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hello, I am new to this but there seem to be some intelligent people here. I have a question about LPN changing insulin dosing without a MD order? This is a nursing home, patient said he only wanted X amount of units, nurse granted request. I am looking for some verbage or legal document stating that this is practicing medicine without a license. We are in Georgia

HELP!:nono:

Specializes in Just about all of them.
if the order is for 10, that is the order...in this incidence, if it is during the day, the doc gets an immediate call. if it is the pm (hs) dose i would give the 5 and call at the end of med rounds.....no, we do not have that right to change anything med or dose. it has been traditionally granted. but it isnt the law.....if this patient is alert and oriented and handled his diabetes well before admission, what you need is an order that the patient determines his dose....had a patient with this order and he did very well with it. and took the burden off of the nurses entirely....

amen and thank you for having common sense

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Specializes in Just about all of them.
If it's chronic thing a doc needs to be notified so they can adjust the residents sliding scale. If random residents and occassionally saying "I think 10units is too much tonight." They have the right to refuse part of their dose.

If I were in the hospital and the doctor orders two tyl PM to help me sleep at night, chances are I'd refuse one because I know my body and I know two tyl pm are way to much for me. If my nurse stampped her foot down and told me I had to take two or none because it's what the doctor ordered, I would have the charge nurse in my room right away.

I'm sorry but who would be at fault for causing a residents blood sugar to drop from giving an insulin dose or having a blood glucose spike because a nurse had refused to give the med at all since the resident wouldn't take a full dose after the resident specifically said "I only want 5units instead of 10."

The nurse who didnt do her job and call and get an order.

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Specializes in Med/Surg, Geriatrics.
After researching most of the day, I have found that it is absolutely illegal to change the dose of any medication without an order, that includes giving a lesser or higher dose upon request without notifing and receiving clarification. Of course the patient can refuse all or part of any med or treatment, and we as nurses can and do use our judgement to deal with this issue. However, what I think has been unclear about this is the fact that this has been going on for Years apparently with no notification to the MD, the nurses just give him what he wants with no thought to the long term consequences, especially if the MD isnt aware of what is going on.

If a patient refuses part of his med, it is not necessary to call the doc to get him to change the order. What if he or she refuses to give the order? What if he or she disagrees that the patient needs half a dose? What then? Do you tell the patient, it's all or none? All that is needed is that the nurse document the refusal and yes....if it is a chronic refusal then the MD needs to be notified. But in the case you are describing, the nurse is not "changing the order" nor or they practicing medicine.

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Specializes in Just about all of them.
If a patient refuses part of his med, it is not necessary to call the doc to get him to change the order. What if he or she refuses to give the order? What if he or she disagrees that the patient needs half a dose? What then? Do you tell the patient, it's all or none? All that is needed is that the nurse document the refusal and yes....if it is a chronic refusal then the MD needs to be notified. But in the case you are describing, the nurse is not "changing the order" nor or they practicing medicine.

if the order read 10 u and the patient is requesting 5 and is given 5 you you have knowingly changed the order. That is practicing medicine. It is also a med error. Call the MD, he/she may very well refuse to order for you, that is what you document. You have done your part. But it is pretty rare that you wouldnt get that order, especially in a LTC setting where the resident and MD are well known to each other.

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If a patient refuses part of his med, it is not necessary to call the doc to get him to change the order. What if he or she refuses to give the order? What if he or she disagrees that the patient needs half a dose? What then? Do you tell the patient, it's all or none? All that is needed is that the nurse document the refusal and yes....if it is a chronic refusal then the MD needs to be notified. But in the case you are describing, the nurse is not "changing the order" nor or they practicing medicine.

Sorry, I also think you are way off base. It is practicing medicine. And you would tell the patient "all or none".

Lots of "what if"s in your statement. Thankfully, we have specifics in nursing, not alot of "what if"s.

"Here is the order-here is the medicine- this is what the Dr. said-I'm sorry you feel that way but my hands are tied-I understand, but there is nothing I can do"

Very simple. Don't change dosage. It isn't in our scope of practice.

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Specializes in Med/Surg, Geriatrics.
if the order read 10 u and the patient is requesting 5 and is given 5 you you have knowingly changed the order. That is practicing medicine. It is also a med error. Call the MD, he/she may very well refuse to order for you, that is what you document. You have done your part. But it is pretty rare that you wouldnt get that order, especially in a LTC setting where the resident and MD are well known to each other.

Sorry, I also think you are way off base. It is practicing medicine. And you would tell the patient "all or none".

Lots of "what if"s in your statement. Thankfully, we have specifics in nursing, not alot of "what if"s.

"Here is the order-here is the medicine- this is what the Dr. said-I'm sorry you feel that way but my hands are tied-I understand, but there is nothing I can do"

Very simple. Don't change dosage. It isn't in our scope of practice.

You are both wrong. A patient has the right to refuse part or all of any medications. We do not have the right to say "if you don't do it my way, then you get nothing". Is that what you have been telling patients: "doctor's orders there's nothing I can do?"

As long as you inform the patient of the potential consequences of their actions, document the refusal AND notify the physician of the patient's refusal then the nurse has done no wrong. The nurse did not change the dose; the patient refused it. There is a difference.

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You are both wrong. A patient has the right to refuse part or all of any medications. We do not have the right to say "if you don't do it my way, then you get nothing". Is that what you have been telling patients: "doctor's orders there's nothing I can do?"

As long as you inform the patient of the potential consequences of their actions, document the refusal AND notify the physician of the patient's refusal then the nurse has done no wrong. The nurse did not change the dose; the patient refused it. There is a difference.

Exactly.

Here's the deal: if you, the supposed DON/OP is researching the subject so that you can update the institutional policy and educate your staff accordingly with NO BLAME, then great. Do so.

What disturbs me are your repeated accusations that this nurse has been practicing medicine when you have NO indications that she had any intent to do so. As you can see from this thread, this is not a clear-cut case of wrongdoing. I really hope you're not out to get her, because that's certainly the impression I'm getting. I hope I'm wrong.

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Exactly.

Here's the deal: if you, the supposed DON/OP is researching the subject so that you can update the institutional policy and educate your staff accordingly with NO BLAME, then great. Do so.

What disturbs me are your repeated accusations that this nurse has been practicing medicine when you have NO indications that she had any intent to do so. As you can see from this thread, this is not a clear-cut case of wrongdoing. I really hope you're not out to get her, because that's certainly the impression I'm getting. I hope I'm wrong.

This whole thing is kind of interesting. For the OP here is the appropriate law from the medical practice act 43-34-26:

(a) If any person shall hold himself out to the public as being engaged in the diagnosis or treatment of disease or injuries of human beings, or shall suggest, recommend, or prescribe any form of treatment for the palliation, relief, or cure of any physical or mental ailment of any person, with the intention of receiving therefor, either directly or indirectly, any fee, gift, or compensation whatsoever, or shall maintain an office for the reception, examination, or treatment of diseased or injured human beings, or shall attach the title "M.D.," "Oph.," "D.," "Dop.," "Surgeon," "Doctor," "D.O.," "Doctor of Osteopathy," either alone or in connection with other words, or any other word or abbreviation to his name indicative that he is engaged in the treatment of diseased, defective, or injured human beings, and shall not in any of these cases then possess a valid license to practice medicine under the laws of this state, he shall be deemed to be practicing medicine without complying with this chapter and shall be deemed in violation of this chapter.

The appropriate nursing law is here:

(8) "Practice nursing as a registered professional nurse" means to practice nursing by performing for compensation any of the following:

stuff cut

(J) Administering medications and treatments as prescribed by a physician practicing medicine in accordance with Article 2 of Chapter 34 of this title, a dentist practicing dentistry in accordance with Chapter 11 of this title, or a podiatrist practicing podiatry in accordance with Chapter 35 of this title;

The interesting thing that prescribe is not defined in either the nurse practice act, physician practice act or pharmacy practice act. However my understanding is that prescribe defines a prescription drug order that has the drug, amount prescribed and directions for use. Moreover, in the medical practice act there is specific law to authorize physicians to delegate the modification of drug therapy for specific conditions. The law very specifically states that only pharmacists can modify the therapy (and only specific pharmacists with explicit parameters and with explicit communications expectations).

While I understand the thoughts behind patient advocacy, this is not an issue of patient advocacy. A competent patient has an absolute right to participate or decide not to participate in medical care. The patient does not have the right to dictate that particulars of the care, that is the practice of medicine. In the case above what the nurse is doing is modifying a written drug order. Under Georgia law, unless that nurse is working as a pharmacist with written authorization then they are violating the medical practice act (at least as I interpret it). If the prescriber wants the patient (or the nurse) to have a choice in the dosage they could write it as a range order (Insulin 5-10 units AC per patients choice). While this order would be hard to defend in court it would be perfectly legal. No different than an order for Dilaudid 1-2mg IV Q4hr PRN pain where the amount is deferred to the nurse using their professional judgement.

Look at it another way. If there is an absolute right for the patient to determine their care why could the patient not decide on what medications they want or how they took them. If a patient on Oxycodone wanted Dilaudid instead would the nurse give them this under the concept of patient autonomy?

There is a written drug order. The nurse in their professional judgement could refuse to carry it out if they felt it was improper or dangerous. The patient could refuse the order for whatever reason if they are competent. What neither party can do is modify the order without a new order. That is practice of medicine. If the provider wants to allow the patient choice then the appropriate thing to do is to provide a range order for the nurse to carry out.

Just my take

David Carpenter, PA-C

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Specializes in ICU/PACU.

Why are you looking to get the person fired?

Or are you trying to report them to the BON? Sounds like it. Glad I don't work for you. Clearly, there are many other "intelligent" people on this board who agree with the LPN in that it isn't practicing medicine to give a lower dose of insulin than ordered when the pt refuses. So, guess they aren't "intelligent" or "doing their jobs"?

Why did you ask the question if you already know you know the answer and are right?

Speak with your docs and get them to change the sliding scale, so they won't have to be bothered in the middle of the night because the pt was given 2 unit less than ordered. I hope you are a little more understanding with the lpn, as many seem confused on this matter. Thanks.

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Specializes in Just about all of them.
You are both wrong. A patient has the right to refuse part or all of any medications. We do not have the right to say "if you don't do it my way, then you get nothing". Is that what you have been telling patients: "doctor's orders there's nothing I can do?"

As long as you inform the patient of the potential consequences of their actions, document the refusal AND notify the physician of the patient's refusal then the nurse has done no wrong. The nurse did not change the dose; the patient refused it. There is a difference.

So...did you give them the partial dose?

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Specializes in Just about all of them.
Why are you looking to get the person fired?

Or are you trying to report them to the BON? Sounds like it. Glad I don't work for you. Clearly, there are many other "intelligent" people on this board who agree with the LPN in that it isn't practicing medicine to give a lower dose of insulin than ordered when the pt refuses. So, guess they aren't "intelligent" or "doing their jobs"?

Why did you ask the question if you already know you know the answer and are right?

Speak with your docs and get them to change the sliding scale, so they won't have to be bothered in the middle of the night because the pt was given 2 unit less than ordered. I hope you are a little more understanding with the lpn, as many seem confused on this matter. Thanks.

This is an issue of education, not discipline, if you read all the threads carefully you will see that. And, I asked the question looking for some verbage, again if you read carefully you will see that.

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Specializes in Just about all of them.
This whole thing is kind of interesting. For the OP here is the appropriate law from the medical practice act 43-34-26:

(a) If any person shall hold himself out to the public as being engaged in the diagnosis or treatment of disease or injuries of human beings, or shall suggest, recommend, or prescribe any form of treatment for the palliation, relief, or cure of any physical or mental ailment of any person, with the intention of receiving therefor, either directly or indirectly, any fee, gift, or compensation whatsoever, or shall maintain an office for the reception, examination, or treatment of diseased or injured human beings, or shall attach the title "M.D.," "Oph.," "D.," "Dop.," "Surgeon," "Doctor," "D.O.," "Doctor of Osteopathy," either alone or in connection with other words, or any other word or abbreviation to his name indicative that he is engaged in the treatment of diseased, defective, or injured human beings, and shall not in any of these cases then possess a valid license to practice medicine under the laws of this state, he shall be deemed to be practicing medicine without complying with this chapter and shall be deemed in violation of this chapter.

The appropriate nursing law is here:

(8) "Practice nursing as a registered professional nurse" means to practice nursing by performing for compensation any of the following:

stuff cut

(J) Administering medications and treatments as prescribed by a physician practicing medicine in accordance with Article 2 of Chapter 34 of this title, a dentist practicing dentistry in accordance with Chapter 11 of this title, or a podiatrist practicing podiatry in accordance with Chapter 35 of this title;

The interesting thing that prescribe is not defined in either the nurse practice act, physician practice act or pharmacy practice act. However my understanding is that prescribe defines a prescription drug order that has the drug, amount prescribed and directions for use. Moreover, in the medical practice act there is specific law to authorize physicians to delegate the modification of drug therapy for specific conditions. The law very specifically states that only pharmacists can modify the therapy (and only specific pharmacists with explicit parameters and with explicit communications expectations).

While I understand the thoughts behind patient advocacy, this is not an issue of patient advocacy. A competent patient has an absolute right to participate or decide not to participate in medical care. The patient does not have the right to dictate that particulars of the care, that is the practice of medicine. In the case above what the nurse is doing is modifying a written drug order. Under Georgia law, unless that nurse is working as a pharmacist with written authorization then they are violating the medical practice act (at least as I interpret it). If the prescriber wants the patient (or the nurse) to have a choice in the dosage they could write it as a range order (Insulin 5-10 units AC per patients choice). While this order would be hard to defend in court it would be perfectly legal. No different than an order for Dilaudid 1-2mg IV Q4hr PRN pain where the amount is deferred to the nurse using their professional judgement.

Look at it another way. If there is an absolute right for the patient to determine their care why could the patient not decide on what medications they want or how they took them. If a patient on Oxycodone wanted Dilaudid instead would the nurse give them this under the concept of patient autonomy?

There is a written drug order. The nurse in their professional judgement could refuse to carry it out if they felt it was improper or dangerous. The patient could refuse the order for whatever reason if they are competent. What neither party can do is modify the order without a new order. That is practice of medicine. If the provider wants to allow the patient choice then the appropriate thing to do is to provide a range order for the nurse to carry out.

Just my take

David Carpenter, PA-C

Thank you so much for your take on things. I appreciate a reply that does not immediately judge me, or because I am DON automatically think I am out to "get" someone. You have given me infor that I can use to benefit myself, my staff and my residents. After all thats what it is all about, the residents and advocating for safe professional care. :yeah:

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