moderate sedation - a nurses right to refuse

OC_An Khe · Jun 21, 2014

You are correct, an MD can't absolve you from responsibility/ liability for actions you took under his direction. You always have the right to refuse to do any procedure, but the employer could then discipline you for that refusal.

I would talk with the head of the anesthesia department regarding your concerns as well as risk management if you haven't already done so.

Esme12, ASN, BSN, RN · Jun 21, 2014

I would call your malpractice insurance. If you don't have it...get it...ALL nurses should have malpractice...then ask them.

A nurse is responsible for her actions. If a MD is screaming at you to give a dose you KNOW is unsafe and you give it...you are held accountable.

However if the dosage is correct AND it can be argued that the patient would be "safe" and another practioner would give the medication...you can be accused of insubordination.

The debate over an airway appropriateness would come from anesthesia of they document the patient can tolerate moderate sedation then to refuse might be considered inappropriate.

What does you policy say about ASA III classification and moderate sedation?

nurseprnRN, BSN, RN · Jun 21, 2014

I am wondering if anyone could point me in the right direction. I have been working in an inpatient Endoscopy unit for many years providing moderate sedation. Where can I find out if a nurse has the right to refuse to provide moderate sedation for a patient if upon assessment he/she judges it to be unsafe...multiple co-morbidities, risk of aspiration or perforation, inability to adequately sedate patient in the past, ASA classification of 111 or above etc.. I have looked into the multiple regulatory agencies but have found them to be a bit confusing. We have been informed that we cannot refuse to provide moderated sedation if after discussion with the ordering physician he/she deems it to be appropriate. As awful as this sounds, the decision to go with moderate sedation vs propofol with a CRNA comes down to anesthesia availability or time constraints. We have been informed if there is an adverse outcome, only the physician will be liable. This doesn't sound quite right to me.

The reference you seek is the ANA Scope and Standards of Practice (about $12 at Amazon), and your state nurse practice act. If you are being asked to do something that in your professional judgment is unsafe or beyond your scope of practice, you have the right and obligation to refuse.

You "have been told" some foolishness ... by whom? Ask to see the policy or regulation in writing. You won't get it, because it doesn't exist. If you do something you aren't trained for, is out of your scope of practice, or that your professional assessment tells you is unsafe (be very sure you have your ducks lined up on that one), you and only you are the one who will hang for it. "The doctor told me to" will not cut it.

The only way the physician gets to shoulder the responsibility for a nursing task is if s/he takes the syringe out of your hand and gives the drug him/herself. And if s/he wants it given that badly, s/he can do that.

These may help you.

http://www.aana.com/resources2/professionalpractice/Documents/PPM%20Consid%204.2%20RNs%20Engaged%20in%20Sedation%20Analgesia.pdf

Conscious Sedation

American Association of Moderate Sedation Nurses

Susie2310 · Jun 21, 2014

I am not a CRNA, but my understanding is that if, as a nurse, I have reason to believe that administering a medication/dose, procedure, treatment, etc. would be contrary to my patient's best interests, i.e. would be contraindicated based on my patient's medical history/physical assessment, etc., then the Nurse's Code of Ethics and Standards of Practice requires me to question the order, and, if necessary, refuse to carry it out if I believe patient safety would be put at risk.

allnurses Guide · Jun 21, 2014

My state board advisory states in part:

"In administering medications to induce conscious sedation, the RN is required to have the same knowledge and skills as for any other medication the nurse administers.
This knowledge base includes but is not limited to: effects of medication; potential side effects of the medication; contraindications for the administration of the medication; the amount of the medication to be administered.
The requisite skills include the ability to: competently and safely administer the medication by the specified route; anticipate and recognize potential complications of the medication; recognize emergency situations and institute emergency procedures.
Thus the RN would be held accountable for knowledge of the medication and for ensuring that the proper safety measures are followed. National guidelines for administering conscious sedation should be consulted in establishing agency policies and procedures.
The registered nurse administering agents to render conscious sedation would conduct a nursing assessment to determine that administration of the drug is in the patient's best interest.
The RN would also ensure that all safety measures are in force, including back-up personnel skilled and trained in airway management, resuscitation, and emergency intubation, should complications occur.
RNs managing the care of patients receiving conscious sedation shall not leave the patient unattended or engage in tasks that would compromise continuous monitoring of the patient by the registered nurse.
The RN is held accountable for any act of nursing provided to a client. The RN has the right and obligation to act as the client's advocate by refusing to administer or continue to administer any medication not in the client's best interest; this includes medications which would render the client's level of sedation to deep sedation and/or loss of consciousness."
http://www.rn.ca.gov/pdfs/regulations/npr-b-06.pdf

Esme12, ASN, BSN, RN · Jun 21, 2014

IN Massachusetts it is rather vague....Administration of Medications for Sedation/Analgesia

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Conscious Sedation
The challenge: keeping your patient safe while protecting your license in the practice and care of patients receiving mild to moderate sedation
From the Massachusetts Nurse Newsletter
October 2010 Edition
By the MNA’s Congress on Nursing Practice with assistance from the Mass. Board of Registration in Nursing
The administration of conscious sedation is becoming common practice for the registered nurse in the clinical setting. Responsibilities may include the administration and management of mild to moderate sedation. Areas of practice for the nurse in this procedure often include the emergency room, intensive care areas, surgical and outpatient services. The nurse’s role in these settings often includes caring for the patient receiving mild to moderate sedation. There are several challenges RNs face when administering conscious sedation in the work setting. For example, consideration must be given to the following criteria:
the competency of the prescriber;
the policies of the hospital;
the effect of the medication ordered;
the competence of the nurse experienced in airway management;
advanced life support skills to monitor the patient during and after administration.
The American Society of Anesthesiologists (ASA) define the levels of sedation as follows:
“Minimal Sedation is defined as a druginduced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilation and cardiovascular functions are unaffected.”
“Moderate Sedation /Analgesia is defined as a drug-induced depression of consciousness during which patients respond purposely to verbal commands, either alone or accompanied by light tactile stimulations; patients do not require intervention to maintain a patent airway, maintain adequate spontaneous ventilation, and usually do not require intervention to maintain cardiovascular function.”
“Deep Sedation /Analgesia are defined as a drug-induced depression of consciousness during which the patient can be easily aroused, but responds purposely following repeated or painful stimulations. Independent ventilator function may be impaired. The patient may require assistance to maintain a patent airway. Spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.”
The Massachusetts Board of Registration in Nursing Advisory revised ruling on June 10, 2009 can be found on the Board’s Web site at www.mass.gov/dph/boards/rn, scroll to “Nursing Practice,” and then scroll to “Advisory Rulings on Nursing Practice.”
Advisory Ruling 9101 Procedural Sedation and/or Mild to Moderate Sedation/Analgesia states
That the registered nurse licensed by the Board will engage in the practice of nursing in accordance with accepted professional standards.
Further, it is the Board’s position that these standards, in the context of the care of the patient receiving RN administered minimal to moderate sedation/analgesia, recognize the nurse as responsible and accountable for:
Verifying the orders are written by a duly authorized prescriber
Possessing the knowledge, skills, and abilities to perform the activity safely, effectively, and competently
Ensuring that there are organizational policies for the RN role that include but are not limited to:
Listing the specific medications for mild to moderate sedation
Nursing care responsibilities for care of the patient
Emergency protocols
Protocols for assessing and documenting the education and validation for RN initial and continued competency
The Massachusetts Board of Registration in Nursing continues to receive inquiries about the licensed nurse’s role in administration of sedating medications. In April 2010, the issue regarding deep sedation was presented to the Board with unanimous agreement for the following findings:
Find that: Registered Nurses who are duly trained and qualified may receive, accept, and transcribe orders from duly authorized prescribers for medications capable of producing deep sedation.
Find that: the Registered Nurse must ensure that there are organizational policies that include protocols for registered nurses who administer appropriately prescribed medications intended to produce deep sedation in the non-intubated patient. The policies must require that the registered nurse do so in the presence of a provider trained in anesthesia or expert in airway management whose sole responsibility is to manage that patient’s airway.
Find that: It is within the scope of practice for a Registered Nurse to administer medications intended for deep sedation when ordered by a duly authorized prescriber for deep sedation in a patient who is already intubated.
The Massachusetts Board of Registration in Nursing also reissued an Advisory Ruling on Verification of Orders on Dec. 9, 2009. This advisory was formerly titled “Verification of Medication Orders.” It once again emphasizes the nurse’s role in the delivery of safe patient care with accepted standards of care to minimize error.
In reviewing the nurse’s role in mild to moderate sedation, the criteria are specific. The workplace will have an infrastructure to ensure the safety of the patient, defining policy, nursing practice and competency.
The MNA reminds nurses that RNs are accountable for ensuring that the orders executed are consistent with current standards of care and should ask themselves the following questions to ensure patient safety and to protect his (her) nursing license:
Does the workplace have a policy/procedure to ensure the prescriber has the education and training to manage the potential complications of sedation/ anesthesia?
Will the anesthesia provider be present throughout the entire sedation period, be ACLS trained and have the management of the patient’s airway as their sole responsibility?
Does the nurse administering the medication possess the knowledge, skills and abilities to perform the activity safely, effectively and competently?
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Kooky Korky, BSN, RN · Jun 21, 2014

IN Massachusetts it is rather vague....Administration of Medications for Sedation/Analgesia

pretty serious business

It is infuriating that bosses would intentionally expose nursing staff to such risk, knowing that they aren't properly educated and skilled; not that nurses can't become prepared, just that so many times the education isn't given;

we have to stand up for ourselves, while not being deemed insubordinate; what a way to live;