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.

Specializes in Critical Care.

It is absolutely your job to question the appropriateness of an order, including indication, this is common to all state's NPA's. In the end it's up to the patient which is where this situation will get tricky. While the MD ordered the PICC, obtaining consent is the responsibility of the person performing the procedure, in this case the RN. Part of that consent is informing the patient of the indication, which is a little 'iffy' for amiodarone. Maybe your policy is different, but the policy where I work does not even put amiodarone on the list of "consider CL access for extended use". It is an irritant, but then again so is every antibiotic, LR, opiates, and a long list of solutions that are often administered peripherally routinely. A PICC does have a lower risk of CLASBI, but there is still a risk as well as risk of complications. This may require that the MD makes the case for a proper indication directly to the patient, rather than putting you in the position of trying to make a case for something you don't agree with, then it's up to the patient.

In terms of insubordination, no this is not insubordination. Typically MD's are not direct supervisors of Nurses and are in a completely different chain of command. I think the term "order" often causes some confusion. As an RN, there are many things you need an order for, but that in no way means you have to do them, it's still up to the RN to determine if it's appropriate and take the appropriate steps if you feel it's not.

Specializes in Med-Surg.

Goodness, if I always followed Dr's orders without questioning or being 'insubordinate' I'd have given GI bleeders IV heparin for long-term anemia related MI's, I'd have jammed PO Plavix and ASA down an intubated patient's throat, and countless other no-nos that other doctors have ordered. One thing we have to keep in mind is that we have much fewer patients than most doctors are responsible for. We are with them much longer than doctors are, and we know them much better. We are more likely to know about contraindications or problems with our patients that the doctors may not know about. We are our patient's best advocates because we know them best.

Nobody said not to question orders or to follow them blindly. The OP specifically said she thought she ought to *refuse* to carry out the order to place a PICC. Again, big difference.

And I will reiterate that the scenario the OP presented was a difference of opinion over the medical plan of care. I don't see how it was a "clear and present danger". I'm not saying her concerns aren't valid. And I am humble enough to admit she surely know far more than I re: post op cardiac pts. BUT she can't just flat out refuse to carry out said order in this case just because she disagrees, right?

Amio thru a central line and and amio thru a PIV are two different concentrations. Obviously, amio is tough on the veins, so that might have been where the Dr. was coming from. You thought the PICC was probably more invasive than necessary, which is fine, too. Neither of you are wrong. In instances where I have felt uncomfortable with an order, I always follow up with the person that wrote it. Never have I worried about being insubordinate until I read this post lol.

Specializes in Emergency & Trauma/Adult ICU.

In this particular scenario, the OP is in the somewhat more complicated position of being the *provider* asked to perform a more advanced invasive procedure (which will be directly billed by the way, unlike most RN functions). Food for thought.

I never meant to imply questioning orders was insubordination. I regret if that's the impression I gave. The OP is undoubedtly well informed and has valid concerns. The scenario of the OP seems like a clear case of a medical POV clashing with nursing POV. The nurse, in her "bigger picture, treat the patient" holistic mindset disagrees with the phys, who has an agressive "fight the disease" mindset. But actual, literal refusal is an extreme step for extreme situations. It's not for a disagreement. Refusal comes into pay when the order will do clear, direct harm.

Specializes in Emergency & Trauma/Adult ICU.
The scenario of the OP seems like a clear case of a medical POV clashing with nursing POV. The nurse, in her "bigger picture, treat the patient" holistic mindset disagrees with the phys, who has an agressive "fight the disease" mindset. But actual, literal refusal is an extreme step for extreme situations. It's not for a disagreement. Refusal comes into pay when the order will do clear, direct harm.
I respectfully disagree.

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.

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.

Specializes in Oncology.
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.

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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