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.

So it's okay to refuse an order of we disagree with the doctor's course of treatment?

So it's okay to refuse an order of we disagree with the doctor's course of treatment?

Since you're an LPN perhaps you haven't read the ANA Scope and Standards of Practice for RNs. I am reasonably sure that a lot of RNs haven't either. This is a sample of the parts relevant to this discussion, in my opinion.

Std. 7. Ethics (includes) Takes appropriate action regarding instances of illegal, unethical, or inappropriate behavior that can endanger or jeopardize the best interests of the healthcare consumer or situation.

Speaks up when appropriate to question healthcare practice when necessary for safety and quality improvement.

Std. 9. Evidence – based practice and research. (includes) Utilizes current evidence – based nursing knowledge, including research findings, to guide practice

.

Std 10. Quality of practice. (includes) Demonstrates quality by documenting the application of the nursing process in a responsible, accountable, and ethical manner.

Std. 12. Leadership. (includes) Oversees the nursing care given by others while retaining accountability for the quality of care given to the healthcare consumer. (GT note: this isn't just nursing care)

Develops communication and conflict resolution skills.

Std. 13. Collaboration. (includes) Partners with others to effect change and produce positive outcomes through the sharing of knowledge of the healthcare consumer and/or situation.

Communicates with the healthcare consumer, family, and healthcare providers regarding healthcare consumer care and the nurse's role in provision of that care.

Participates in building consensus or resolving conflict in the context of patient care.

Std. 15. Resource utilization. (includes) Assesses individual healthcare consumer care needs and resources available to achieve desired outcomes.

Identifies healthcare consumer care needs, potential for harm, complex of the of the task, and desired outcome when considering resource allocation.

Modifies practice when necessary to promote positive interaction between healthcare consumers, care providers, and technology.

I'll ask the doc just to clarify. There's been times he realized he'd ordered the wrong thing, and times when he explained his reasoning and it made made sense. If you're unsure about how to approach the doc so he won't think you're trying to show him up, ask if can explain why he ordered it--he'll take it as a teaching opportunity or at least get his ego stroked because you'll think he's a genius.

Specializes in ICU.

I agree with Tracy. I question orders all the time, request/suggest orders that I feel would benefit the patient- that is all in my scope of practice and I dont know any nurse who doesn't do these things. I would certainly refuse to carry out an order that I was uncomfortable with. Ive done it before (inappropriate orders), and I'll do it again. If it is something that I feel so strongly about, then it will be worth losing my job over. I'd tell the doctor they could carry out the order themself, find someone else to do it, or deal with it not being carried out. I don't think an unnecessary PICC line would get to this point, but I would still question it at least if I felt it inappropriate or unnecessary.

To the poster who said they run amio through an 18-gauge until central access is established- irritants should be run through the smallest gauge IV you have because the larger gauge IVs block more of the vein, and the smaller gauge IVs have room for more bloodflow around them providing more protection to the vein walls from the irritant.

Specializes in burn ICU, SICU, ER, Trauma Rapid Response.
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.

Uh NO! We are not subordinate to physicians (excepting those nurses hired directly by physicians) and not only CAN we refuse orders when inpappropiate we have a DUTY to refuse them. A PICC nurse is operating under her own lisence. It is a much more similar situation to when a physician consults another service. Just cause medicin consults sugery doesn't mean the suregon has to operate.

I am disterbed that there are nurses out there who feel it is their position to blindly follow orders. And FYI a PICC places the patient at risk for several things from thrombosis to infection.

I refuse inappropiate PICC orders all the time.

To the OP first your lisence is not at risk in this situation. Your job may be. However if that is what you are being told the first thing I would do is stop being a PICC nurse for that organization. They are clearly in the wrong. If you are not getting support in this matter from nursing time to search for another job. I wish you could tell us the name of this organization just to the rest of us could steer clear.

Every so often we have a physician who trys to tell us PICC nurses that we have to place an ordered PICC just cause he ordered it. It has almost gotten to be fun to correct their fantasy world.

Just, wow BrandonLPN.

'cause its your rear end on the line as well. Not like we all question orders routinely, but you sure betta if the situation warrants. smh. You may not be an RN, but you are still on the hot seat. You can question anything - ask why and then YOU decide ultimately every move you make. I suggest you read back through all of this from the beginning. IDK how you could have missed this HUGE responsibility you have to your patient and yourself as a nurse.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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.

Makes me wonder who's getting the revenue for that insertion.....:uhoh3:....the MD or the hospital......certainly it isn't the nurse.:rolleyes: Just saying.....;).

As nurses we have the right to refuse anytime we feel there is something inappropriate being done and performed on the patient. But....when you decide to make a stand you better be right and be ready for the consequences. The hospital will usually side with the MD for they are the ones that bring in revenue. Nurses just cost the hospital money.

In my long career....I have refused a few things and when I did I meant it. I choose my battles carefully. A particular one recently was about a pedi patient receiving 1000mgs of doxycylline instead of 80 mgs...every eight hours.......because the MD ordered it......the pharmacy thought it was ok....but they thought the patient was 80kg....not 80lbs. I called the MD (known to be a donkey) because the new grad was afraid and informed him of the mistake and the order needed to be changed.

Well........lets just say my final statement to him was....."If you want it given at this dose I suggest you come and administer it yourself for I will not allow this dose be given to this child" Of course he said he would have my job:rolleyes: and I told him he could have it and I would meet with him in HR in the AM with the CNO,CEO,the head of pharmacy and pediatrics and risk management.

He was a no show.:roflmao:

That this MD wanted a PICC for amiodarone? Depends on the policy of your facility. I have worked at facilities that state it needs to be central ASAP. When I was a Cardiac Anesthesia Nurse Assistant (which is a nice way of saying I was a wet nurse to the cardiac fellows so they didn't hurt anyone......especially on transport) I had a cardiac surgeon that insisted on PICC's/centrals for all his high volume warmed blood pump lines for he had an infiltration under the drapes and the woman lost her arm.

So you never know the reasoning. But you have a right to question...you are performing an invasive procedure. It's your right.

Specializes in Emergency Nursing.

Fwiw, New Nurse agrees with DNP: get the facts. If the facts are not readily available (e.g. The doc doesn't think s/he has to explain him or herself to you) use your chain of command.

As far as the whole "are nurses subordinate to doctors" question, I am terribly naive and old-fashioned: I believe that, for the much greater part, we are, and that in the majority of cases, healthcare, when it works properly, works like this). I've questioned orders, but I always tend to do so in a non-threatening, "hey, doc, help me understand" kind of way. It's been my (admittedly limited) experience that most physicians, if approached properly enjoy the opportunity to teach.

Specializes in NICU, PICU, PACU.

We can refuse any order until it is clarified and deemed needed/ safe. Always think to yourself....what would the reasonably prudent nurse do.

Prudent nursing sometimes involves questioning orders. A PICC is likely something I wouldn't question as it is easier for patients in the long term. However, in the hospital, a doctor wanted me to give IVP digoxin- 1st dose- on the night shift- with no doctor on the floor- to a patient with chronic bradycardia (we were trying to get his Bp up). It was against our policy to do the first IVP of cardiac drugs first of all, but second- no way. I told him he could come in and give it himself, because I wasn't doing it. He came in early in the morning, assessed the patient and HR himself, and chose to start a po dig instead. It is not unsubordination to refuse a doctor's order if the order is irrational or violates a policy.

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.
Yeah, let's have a conversation with the doctor first before we decide we can't carry out the treatment plan. Having good communication among the healthcare team benefits the patient.
Specializes in burn ICU, SICU, ER, Trauma Rapid Response.

Nurses are NOT subordinate to physicians. We are a team who, along with some other members, has been put in place to deliver the care a patient needs. I recognize the physician is the team leader but that is their job, to lead, not rule. Doctors order treatments and other care measures for patients, they do not give orders to nurses in the manner a sargeant gives orders to a private in the army.

If something is ordered on my patient that doesn't seem like a good idea to me, or that I don't understand I WILL ALWAYS ask the physician for clairification. Sometimes (usually) this is a learning oppertunity for me, sometimes it reveals a mistake in the order. It is my DUTY as an RN to questions these orders and it is the DUTY of the physician to provide an explanation. There have been occasions in my career when a physician had ordered something inappropiate for my patient and has either refused to provide a clear explanation, or was unable to do so and I refused to carry out the order. In every case this has worked out well for me and my patient, despite being threatened with losing my job from a physician on the scene.

However a PICC nurses is in a very different situation than a staff RN assinged to a patient. The PICC RN is providing an independant service under her own lisence and can be held liable for such things as placing a PICC inappropiatly. In realiety PICC orders should be PICC consults. In my faciliety a common occurance is the LPN on the IV team is unable to place an IV and tells the staff RN a PICC is needed. The RN picks up the phone and calls an on call resident and tells them the patient needs a PICC cause we can't get IV access. The resident who more than likely has never seen this patient and only recieved a scetchy sign out from the day resident assumes the RN knows what they are talking about and orders the PICC. It isn't until the PICC RN arrives to assess that any critical thinking is applied to the situation. In many cases we are able to ontain a PIV or two thus eliminating the need for a PICC.

In other situations the patient has contraindications to a PICC that they physician didn't know were contraindications per our policy. Usually just a call to the MD to let them know of the contraindications is all it takes. On a few occasions an uppity resident has ordered us to go ahead with the PICC with a "how dare you question my orders" attitude. It's almost gotten fun to disabuse them of their silly notions.

If one isn't the confrontational type, like one of our day shift PICC RNs, there is alwasy the option of slapping the untrasound on the patient's arms then declairing no suitabe vessels could be found.

I will say that since I work in a non-Magnet, union, hospital with a fantastic and supportive nurse manager and medical director it's easy for us to stand up to physicians.

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