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Discussion

What to do about refusing Dr. orders?

I am being told I will lose by job if I refuse to follow a doctor's order. The doctor ordered a PICC line on a patient just because she might need it for Amiodrome. She was post op open heart and had not been on any drips requiring central placement for over 12 hours. She still had a cordes in that was going to be removed. The patient was currently on saline drip only. She also had veins for a PIV. I did not feel the PICC line was appropriate. When I raised my concerns, I was told to put it in anyway. I was told I could be fired for insubordination if I refused to follow the doctor's order. Because of this, I placed the line. Other nurses have been told the same thing. We are being told that we cannot say no to this doctor even if we feel the ordered treatment is inappropriate. I can not afford to lose my job or my license. Any suggestions on how to proceed would be most welcome.

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    • Solved by BrandonLPN

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    Who did you raise your concerns with? The physician or the charge RN? There may be various reasons you are not aware of for the PICC line. I would definitely ask the physician his rationale for the PICC before I decide on whether I object. I do this with any order I may question. I don't even bother to speak to the charge RN unless I have spoken with the M.D. first. Often, I find, while speaking with the M.D. about rationale, he wil realize he is wrong; or I will realize I am mis-informed. I learn a lot this way, and the M.Ds do as well.

    If you still object to an order after this; I would weigh the danger to the patient of an order before I start a battle. If an order is simply not necessary, but will not hurt the patient in the long run, than why start a fight? Now, if you see imminent danger coming to the patient because a physician is making the wrong order, than you must stand up. It is written within the nurse practice act. Let them try to fire you for following the practice act.

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    • Experts

    For each situation, you have to weigh your options and ask yourself, "Is this situation worth losing my job over? Is the patient in sufficient danger from this order that I should risk my job -- and perhaps, my career?"

    While it is certainly a nurse's right (and obligation) to question an order he/she has concerns about ... it's also true that nurses are not in charge of medical practice. You can question the order, but you cannot change it yourself. You are not the one that makes medical management decisions. Your job is to work WITH the physician and assist in the implementation of the medical plan (along with the nursing pla) -- unless there is a strong reason not to, such as danger to the patient. When you have concerns, you need to work WITH your colleagues to try to resolve them in an amicable way if at all possible.

    "Pulling the trigger" on the ultimate option of refusing an order is a tactic that should be used only in fairly extreme cases. There are times it has to be done, but they should be rare. You should pursue all your other avenues first -- and you must be prepared to be fired in the process. If you escalate the situation by taking such an extreme step, you need to prepared to deal with some big-time fall out.

    I write this as someone who has taken such a stand once in my career. I did refuse a direct order -- and it was under unusual and extreme circumstances. It was a very public action that could have seriously hurt my career. But I was smart enough to get the support of all the senior nurses in the unit before I did it. I succeeded, but only because of that suport. And we all had to live with the physician-nurse tension for a long time.

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    • Guides

    Agree with discussing the order with the physician.

    You made valid points about the indication for central venous access in a patient who is not on vasopressors and is not a difficult peripheral IV access. PICC's as a form of central venous access is not a benign line and has complications as you are aware. Physicians, however, for the most part think through an order before writing it. This physician is responsible for the outcome of this surgery and any extraneous factors (such as the risk of an infected PICC) has been thought about I'm sure. Could it be that the Amiodarone explanation is not really the reason behind the order? Is it possible that the patient has other indications for a PICC such as a valve repair for endocarditis requiring 6 weeks of antibiotics?

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    • Solution

    Refusing a doctor's orders IS insubordination. That's pretty much the definition of the word. Placing a PICC poses no clear or inevitable threat. Therefore you have no right, as a nurse, to refuse the order. That's not your call to make.

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    Placing a PICC poses no clear or inevitable threat.

    This I disagree with. In my pedi ICU, at the end of every patients rounds, the patients nurse summarizes the plan for the day. This includes stating what we have for central access and if the access is necessary. Once central access is no longer warranted it's removed. The risk of a CLABSI increased with every day a central line is placed. If it is unnescessary it should not be placed

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    We have to chart the need for every central line (for example: TPN, chemo, vesicants, long term ABX, poor venous access, etc.). If there is no need for the line we must contact the doctor. As far as I know, amio is not a reason for a central line. If the pt is ordered a central line, the the doctor should be contact. If he/she says to place it/continue it anyway, you chart this, but I don't think you have the authority to simply not follow the order since you don't see a need for it.

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    I agree that you have a right to refuse to carry out orders that are unsafe and harmful to the patient, but I think it's important to pick your battles. Many times I've seen tests or diagnostics run on patients that seem unnecessary or overkill. I'll question and if the doctor still wants them, OK. There have been exactly two orders I've refused to carry out: one for 30 mg IV dilaudid (had to take that up my chain of command BC the doctor kept insisting the dose was OK) and one for nicotine gum on a patient we were transferring to the cath lab. Regarding a PICC line, did you ask the doctor directly why it was needed? Perhaps he/she could have given you a good justification for it that would have put you at ease.

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    Odd...I work on a telly floor. We give Amiodarone through a PIV all the time. Don't lose your job/career over something like that. Unless it's a faulty order/med, something that will do harm to the patient.

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    Holy cow, 30 mg IV.. Must have been thinking about toradol... That is a crazy order

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    Refusing a doctor's orders IS insubordination. That's pretty much the definition of the word. Placing a PICC poses no clear or inevitable threat. Therefore you have no right, as a nurse, to refuse the order. That's not your call to make.

    Couldn't disagree more. As a nurse, it's my duty to refuse an unsafe order. I have my own license for this reason- I am not working under the physician's license. Further, to be "insubordinate" I would have to be the physician's subordinate, which as an RN, I am not. I am my unit's nurse manager's subordinate. Central access is an infection risk and a pneumothorax is a not totally unheard of complication of central lines, though less so with PICCs. Central access is also a common cause of thrombis, which a post heart surgery patient is already at high risk for. If due to the high risk for thrombis the patient is on anticoagulation, then you have a bleeding risk.

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    Couldn't disagree more. As a nurse, it's my duty to refuse an unsafe order. I have my own license for this reason- I am not working under the physician's license. Further, to be "insubordinate" I would have to be the physician's subordinate, which as an RN, I am not. I am my unit's nurse manager's subordinate. Central access is an infection risk and a pneumothorax is a not totally unheard of complication of central lines, though less so with PICCs. Central access is also a common cause of thrombis, which a post heart surgery patient is already at high risk for. If due to the high risk for thrombis the patient is on anticoagulation, then you have a bleeding risk.
    I never said to follow unsafe orders. But it's not your call to refuse to follow an order just because you don't agree with the medical treatment plan the doctor has decided on. Of course inserting a PICC is a risk for infection. It's an invasive procedure. That's true for ANY pt. You don't think a PICC is necessary. Well, the doctor does. Again, not your call. We can't start cherry-picking which orders to obey based on what WE think is the best treatment plan. this isn't a case of refusing an order because it poses a clear and imminent danger. This is a case of refusing an order because the nurse disagrees with a medical decision. Big difference.
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    And, as others have said, there's a myriad of reasons the doctor might think a PICC is necessary at this stage. Maybe they need long term IV ABX. Maybe there's a concern that IV pacerone would cause some nasty phlebitis. Maybe there's other reasons he thinks a peripheral IV is unsuitable to the medication regimen he has in mind. I'm sure the doctor would elaborate if asked.

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