Risk for Aspiration - Should a nurse go against physician orders to raise HOB?

[Lorie Brown RN, MN, JD]

Hello Lorie

A 17 year old male went from agitated to obtunded after 40 mg. Geodon within a three-hour period. When the nurse approached the supine patient - who was now at risk for aspiration - in order to raise the head of the bed to 30 degrees and to assess him, the prescribing physician would not allow it, and the charge nurse agreed with the physician. The physician wrote an order: hold vital signs for ten minutes, then resume. The nurse manager insisted that the nurse should not go against the wishes of either the physician or the charge nurse. Is there not a duty imposed on the nurse, under the terms of the state-issued licensure, to act for the benefit of the patient and to intervene to remove the risk?

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Dear Disagreeing with Physician and Charge Nurse,

When you have a disagreement with a physician or charge nurse, your facility should have policies and procedures in place to go up the chain of command. There can be liability if you fail to question an inappropriate order. Your first responsibility is to your patient and should you believe an order is inappropriate or endangers the patient, you have a responsibility to go up the chain of command. If your facility does not have a policy and procedure to address this, ask your nurse manager for direction. Using the chain of command to advocate for your patient can protect you from liability.

Lorie

[Triddin]

I'm curious as the clinical reasoning behind keeping the patient supine as this is not a drug I'm familiar with. Could you have turned the patient to their side? No longer an aspiration risk

[amzyRN]

What about the prone or side-lying position?

[JKL33]

The concerned party should be interested to know the rationale(s) of the three people who disagreed about raising the HOB. The question can't fully be answered without knowing that information. After all, there are endless situations where something must be risked in favor of avoiding an even bigger risk. In other words, it doesn't always work to say that the nurse has a duty to intervene to remove what s/he believes to be a risk - specifically it doesn't work if the nurse happens to be incorrect. I'm not saying that was the case, but rather that if three reasonable people all disagree with the patient's nurse, the nurse's duty (in the patient's best interest) would then be to make sure the line of thinking isn't errant before doing the thing in question.

The nurse's actions/communications and responses received should be documented neutrally, which serves to show both the concern and the process of informing appropriate parties/using the chain of command.