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 Emergency & Trauma/Adult ICU.
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.
Word. Thanks for your comments.
Specializes in Emergency Nursing.

Why am I getting the feeling that these are things we like to tell ourselves which, in actual practice are often far from the truth? You can bet that many Physicians do not consider themselves our peers and members of a team, and that a lot of healthcare systems support them while paying lip-service to a more collaborative model.

I feel like I am just being realistic.

I realize that I am the last line of defense, and that I have a duty to advocate for my patients, often in the face of a physicians opinion and I am sure I will run up against problems. From what I can see, we all do. I will certainly do this, I am rare in nursing, I enjoy confrontation, but I also always want to be prepared and won't fight EVERY battle.

I find it interesting that this is about "refusing" an order, rather than questioning and seeking clarification...

I mean, I questioned orders all the time on the floor. After you pester the hospitalist group PA or NP enough - magically the hospitalist group admits get paramaters associated with their blood pressure medications (which was facility policy anyways - having parameters). But I had no problem calling and saying I was 'calling about patient so and so with a BP and HR of whatever and this is what is ordered - is this something you want given because it's on the border of where parameters usually are and I'm concerned over the potential for hypotension or bradycardia (depends on the drug) in this patient.'

The only thing I refused - was in person having a discussion with a physician. Physician (momentarily forgetting pt's IV access and refusal for line placement) orders the standard fluid bolus for hypotension - 500mL over 2 hours through a peripheral IV cannula (20g) in the patient's external jugular (placed by a physician in the ED because the patient had literally NO other veins)... Otherwise it's more of a conversation. PICCs have some up sides and have some down sides. As a floor nurse they were amazing for a lot of patients - the ability to do lab draws and run antibiotics long term was a huge blessing - for patients and floor nurses. Some people have no options and need access and become a candidate for a central line. Others, it's convenience (like my grandmother - the PICC she had for 6 weeks was convenience more than anything).

On the other hand - I have run some critical drips through PIVs. And some vesicants (vanc, phenergan, amiodarone etc). Sometimes it's what you have to do. Luckily vanc was the "last resort" at my old hospital/last place I worked as a floor nurse - and used as such (they'd write for vanc if nothing was working or to in suspected sepsis before possible sepsis could worsen). Phenergan isn't so bad considering we had to dilute it in >10mL 0.9% normal saline and then run it over 20+ minutes on a pump (facility policy included theses things, but they made sense). And running amiodarone through a PIV? Not optimal, but my patients were usually q1 or q2 vitals/telemetry strips (most of the drips I had were either during titration to achieve a controlled rate or titration to discontinue IV amiodarone therapy) - so I got a chance to see their PIV sites frequently.

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

The only thing I refused - was in person having a discussion with a physician. Physician (momentarily forgetting pt's IV access and refusal for line placement) orders the standard fluid bolus for hypotension - 500mL over 2 hours through a peripheral IV cannula (20g) in the patient's external jugular (placed by a physician in the ED because the patient had literally NO other veins

*** NS at 250 and hour would be a faster maitence IV rate, not a bolus at my hospital. We (the RRT) will run bags of NS with pressure bags or with the rapid infuser through EJ 20ga (usually placed by nurses here). What is the rational for refusing that order?

Specializes in Emergency Nursing.

250 bolus where I work is usually run over 15 minutes...

NS @ 250cc/hr is just a rapid dehydration rate...

Quick question - if you gave something was which caused the patient have an adverse reaction and you didnt notice until it was too late who's licence would be on the line? The Doctor?

To me it sounds like a lose - lose situation. You lose by bringing up concerns and you lose by not bringing them up at all.

Specializes in ICU.
250 bolus where I work is usually run over 15 minutes...

Yeah same here. I'm also confused as to why you would refuse that order.

Specializes in Oncology.
Quick question - if you gave something was which caused the patient have an adverse reaction and you didnt notice until it was too late who's licence would be on the line? The Doctor?To me it sounds like a lose - lose situation. You lose by bringing up concerns and you lose by not bringing them up at all.
It might fall on both, but ultimately you are responsible for anything you do as a nurse.
Specializes in Trauma Surgical ICU.
Quick question - if you gave something was which caused the patient have an adverse reaction and you didnt notice until it was too late who's licence would be on the line? The Doctor?

To me it sounds like a lose - lose situation. You lose by bringing up concerns and you lose by not bringing them up at all.

It is true you are responsible for your actions and practice. However, if the order is safe and the pt does not have a known allergy to it, you are not at fault nor is the MD unless you did nothing about it. Say the MD orders 30 mg dilaudid IV (from previous poster) and you gave it and the pt died; yes you both are liable. 30 mg is way outside the normal dose. This is an excellent example of not following an order because it is not safe.

This is why we also HAVE to know normal doses and appropriate meds; to catch this type of mistake. If the MD ordered an MRI with contrast and the pt is allergic to contrast it is your responsibility to notify the MD of the allergy BEFORE giving if he/she did not notice.. Just because it is written as an order does not mean we follow them blindly. We as well as the PCP/MD/NP have to be mindful.

Specializes in FNP, ONP.

I think Brandon is being unnecessarily castigated here. For the most part, you people are arguing about the word subordinate. Substitute, if you will, the term subaltern, which describes the relationship of one person to another when the dominant individual's role (in this case the physician/provider) is implied by the second person's, but the second person's role is not implied or defined by the former. The words are effectively synonyms but "subaltern" does not make a value judgement about the role of the nurse while still acknowledging the power of the physician. Happy now? Can we move on the the substance of the discussion? :laugh:

The crux of the situation is exceedingly simple. Just ask. There is nothing to be gained by staking out an adversarial position. Ask, for crying out loud. Fluffing your feathers and puffing your chest, and making a big show out of refusing to carry out an order is just ludicrous in most circumstances. Yes, you can refuse. But why? If you are "right," it is very rarely going to be necessary if the situation is handled deftly, lol. An infinitesimal number of physicians/providers are going to kill, or risk killing, a patient just to spite you. Honestly, carrying on as if you are Norma Rae is just going to make you look like an idiot most of the time. They will explain it to you, or thank you for pointing out an oversight or error. Good grief. It can be complicated enough without creating unnecessary angst and overly dramatized conflict.

Specializes in Critical Care.

I don't think anybody's advocated not clarifying the situation and simply refusing for the pure enjoyment of being difficult. The OP already included the MD's reasoning for the order (possible amiodarone), so then the question is what happens if there's no change to that reason with additional clarification.

It's not at all unheard of for the PICC Nurses where I work to 'veto' a PICC order when the indication (a required as part of the order) is not actually an indication for PICC line placement. This is a good thing, it ensures patients are not getting PICC's unnecessarily. We've got a few MD's with a hair trigger although I've never seen them upset when a PICC Nurse cancels their order, they depend on the PICC Nurses to know what's appropriate and what's not. It's not just the PICC Nurses, it happens with Foleys and blood transfusions surprisingly often as well.

It may turn out to be just a fad, but the current best practice for hierarchy is that it should be more flat than top-down. This produces safer and more effective care. This allows for a system of checks-and-balances without the need for chest puffing.

Ok, that's interesting. I had no idea that a PICC RN is considered to have a degree of parity with the physician when it comes to placement of a PICC. I was under the impression that said nurse was a floor nurse and that placing the PICC was simply one of her many daily orders. I was also under the impression that it's the doctor's privilege to order a PICC for any reason he felt necessary as part of the treatment plan. I didn't realize there's apparently a predetermined set of indications that have to be met. I was obviously misinformed about the role of a PICC nurse and that clearly puts a new complexion on the scenario of the OP.

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