Questioning doctors orders

When a nurse questions a doctor's order, the nurse must notify the doctor and explain the rationale for questioning it. I've seen many nurses question the order, refuse to do it, and that's it. But, you are REQUIRED to call the doctor and discuss it. The doctor will either change the order or not. If not, the nurse is then obligated to follow the order. If the nurse still cannot follow the doctor's order, for ethical or moral reasons, or whatever, then the care of the patient should be turned over to another nurse who can meet the patient's needs. Nurse manager should also be notified of the question involved, and the need to transfer care to another nurse and why. A nurse is not forced to do something that is against her ethical or moral beliefs (as in participating in abortions, or etc.) However, the nurse *is* required to insure the care of the patient by turning over the care to another.

Document that the doctor was called to verify the order, doctor's response.

Not giving needed pain meds is a Biggie. The nurse could get sued for not giving, and the doc could be sued for not prescribing, if it's established that the dose ordered was correct for the patient's dx & pain level.

Correct dosing for pain management requires skill and individualized patient planning. It is our responsibility to learn these techniques, as nurses have more autonomy in the field of palliative care.

Hospice, palliative care, and pain management websites are very informative with respect to this issue.

Great response Youda! I would like to add that the sticky situation comes in when you have an ethical problem with giving a med to a patient, and the Doc doesn't agree with your ethical reasoning. In the end, the Doc has a right to know that you're not going to carry out the order and why, but also if the Doc doesn't agree with you, the patient still has a right to get whatever was ordered, even if it's not given by you, which means turning over your patient to someone else, or having someone else give the med. As far as what disciplinary action can be taken, that's usually an individual hospital policy. And several things factor into it. Was the Nurse just being belligerent for no good reason, or was there a legitimate reason for her concern? Does this Nurse have a history of having a problem with carrying out MD orders? I would think that the discipline could range from conference between the Nurse and the Doc to straighten out the problem, to termination for dereliction of duty. It might have a lot to do with how ticked the Doc was at the nurse for not carrying out his orders. The hospital will likely follow the Doc's lead on this, since most hospitals want to save their Docs more than they want to save their Nurses. Not saying it's right, just saying that it's true in most places I've been. Hope it all works out for the best.

Originally posted by ohbet

...refused to carry out a doctors order for a dying patient to receive MS...

Just wanted to give you this website that had some info on palliative care/pain management for the dying. Usually when I or a colleague was reluctant to give an ordered pain med to a dying pt, it had to do with respiratory depression s/e's. This is an excerpt from the nursing center CEU article called "Your patient is in pain: How do you respond?"

http://www.nursingcenter.com/prodev/ce_article.asp?tid=281593

(you may need to go to the main page, then browse for the article under CEU's)

excerpt from article Respiratory depression: Common concern, uncommon complication

Question 8: Respiratory depression (less than seven breaths/minute for an adult) probably occurs in at least 10% of patients who receive one or more doses of an opioid for relief of severe pain. FALSE.

Correctly answered by 60.5% (N=1,949 out of 3,224)

Discussion: Based on studies of I.M., intravenous (I.V.), and epidural administration routes for opioids, the likelihood of clinically significant, opioid-induced respiratory depression is less than 1%. Clinically significant respiratory depression occurs less often when opioids are administered by the epidural route (0.07% to 0.4%) or by I.V. patient-controlled analgesia (0.1% to 0.23%) than when delivered by the I.M. route (0.9%).

Clinicians have exaggerated fears about the likelihood of respiratory depression, probably because many were never taught which patients are at the greatest risk and how to prevent respiratory depression. Because tolerance to respiratory depression occurs over a period of days to weeks, the patients at most risk are opioid-naive, meaning that they haven't recently received regular daily doses of opioids. Many trauma and postoperative patients fit this description.

To prevent respiratory depression, monitor all opioid-naive patients receiving opioids for severe pain for both respiratory status and sedation level because sedation precedes respiratory depression. Use a sedation scale to identify increasing levels of sedation. This tells you when to decrease the dose of opioid to avoid respiratory depression. All facilities using opioids for severe pain should have standard sedation scales for use in all opioid-naive patients. The incidence of opioid-induced respiratory depression can be high when patients aren't monitored by nurses for sedation level. (McCaffery, Pasero, 1999, pp. 214, 263-264, 267-270)

Not giving a pain med due to sedation, therefore seems a more valid reason to hold it than withholding due to respiratory depression.

Hospice nurses??? any input???

(Good topic, ohbet, I've seen this one come up lots of times in LTC)

Why would you with hold pain relief from a dying patient?

the new rulings state that pain meds are to be given to a terminal patient even if it would hasten their death. I for one have no proplem keeping a dieing patient comfortable. I do not want to die in pain!

Mark, these silly nurses are afraid they'll "kill" the patient 30 minutes early. Although I've known a couple of wouldn't give it because they didn't want the death on their shift. That's when I really hope in the concept of karma.

Originally posted by mark_LD_RN

Why would you with hold pain relief from a dying patient?

the new rulings state that pain meds are to be given to a terminal patient even if it would hasten their death. I for one have no proplem keeping a dieing patient comfortable. I do not want to die in pain!

I hope I have a nurse like you if I'm ever dying a painful death. Who cares if I live a bit longer in agony without the pain meds?>??? Gimme the damn drugs!

Originally posted by mark_LD_RN

Why would you with hold pain relief from a dying patient?

the new rulings state that pain meds are to be given to a terminal patient even if it would hasten their death. I for one have no proplem keeping a dieing patient comfortable. I do not want to die in pain!

I agree 200%!!!!!!!!!!!!

AMEN, Youda and Furball!!!! Me too! I don't care if I die sooner because I got pain meds! If I'm dying anyway, it doesn't do my family, friends, or me any good for me to lay in that bed suffering any longer! Now if there's a potential for quality of life later, that's one thing, but if the patient was admittedly dying, I would feel better by allowing the patient a peaceful painless death. I would have no ethical or moral problem with doing that. Not that I don't respect the opinion of those who couldn't, but I wouldn't ahve a problem with that, and I would hope that the nurse taking care of me while I'm on my deathbed would do the same.

originally posted by mark_ld_rn

why would you with hold pain relief from a dying patient?

the new rulings state that pain meds are to be given to a terminal patient even if it would hasten their death. i for one have no proplem keeping a dieing patient comfortable. i do not want to die in pain!

amen!!!

my feelings exactly. i could just choke a few of the nurses i work with when there is a pt who is in extreme pain and they don't want to give the narcotic for fear of hastening their death!! i say give the drugs and let nature take its course. the other thing i have heard about giving increasing narcotics to a terminal patient is the line that they may become addicted? my reply to that is: "probably the best thing that has happened to them for a long time." you can bet your bottom dollar that if my parents or any of my other loved ones are laying in hospital bed dying an agonizing death, i will make darn sure they are given the appropiate meds, or there will be a big time fuss made!! i also believe a lot of doctors need more education in this area. some of my biggest hurdles are the doctors!!

originally posted by mark_ld_rn

why would you with hold pain relief from a dying patient?

the new rulings state that pain meds are to be given to a terminal patient even if it would hasten their death. i for one have no proplem keeping a dieing patient comfortable. i do not want to die in pain!

amen!!!

my feelings exactly. i could just choke a few of the nurses i work with when there is a pt who is in extreme pain and they don't want to give the narcotic for fear of hastening their death!! i say give the drugs and let nature take its course. the other thing i have heard about giving increasing narcotics to a terminal patient is the line that they may become addicted? my reply to that is: "probably the best thing that has happened to them for a long time." you can bet your bottom dollar that if my parents or any of my other loved ones are laying in hospital bed dying an agonizing death, i will make darn sure they are given the appropiate meds, or there will be a big time fuss made!! i also believe a lot of doctors need more education in this area. some of my biggest hurdles are the doctors!!

I certainly agree with Youda and the rest of you. My DPOAHC is empowered to initiate a lawsuit against: 1) anyone who refuses to administer morphine or other pain killers as prescribed, and 2) anyone who attempts to administer any treatments or procedures that I have proscribed in my advance directives.

I always like these people who won't do certain things because they say it is "like playing god." Well, what do they think it is when CPR is performed, or cardiac bypass surgery or IVF or administering antibiotics, for that matter? Most of the stuff we and doctors do is "playing god," in that we attempt to circumvent "letting nature take its course."

Presumably, their karma will enable them to learn such lessons sooner or later.