What to do about refusing Dr. orders?

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.

Brandon's first post was not clearly stated, but he defines his point here, and I agree with him (and with respect, I rarely agree with Brandon. We just do not find much common ground, pal. )

It is not necessary for us, in our role as nurses, to concur or support the medical plan of care. It is our responsibility to implement it unless there are egregious circumstances that should prevent it, such as the patient does not consent, it falls squarely outside the standard of practice, or is otherwise contraindicated. In such an instance it is our responsibility to then inform the provider, respectfully, of the conflict and seek clarification or modification of the order. Get the facts.

It is not a contest of wills, but a cooperative effort toward the best outcome. Turning it into a fight is rarely in the best interest of the nurse or the patient. If you are confused about why something is ordered, inquire. (i.e., get the facts.)

Most providers have their patients' best interests in mind, as well as their own liability and do not entertain unnecessary risk lightly. There is probably good reason. Get the facts.

Refusing orders without clear understanding of why they were given in the first place is folly, and unprofessional. Get the facts.

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

Nope! This was in peds (kid was 20 tho) and we rarely give dilaudid and always give meds based on weight in kg. The doc had called hematology on the patient because he had sickle cell anemia, and they said 0.5mg-1 mg of dilaudid and the doc HEARD "per kg per dose" even though it was just per dose. And our med book wasn't terrible clear on the distinction either. I showed the doctor the dosing chart in our formulary, explained that it was JUST 0.5-1 mg, period, and she just wasn't hearing me. I ended up going to my charge nurse, who asked the doctor if the goal was to kill the patient or just treat the pain. That got me a fresh order.

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.

I also work on a cardiac step-down unit, Amiodarone can cause narcosis of the surrounding tissue, especially if it infiltrates. Whenever we have someone on this drip they HAVE to have a central line. I have seen many PIV's with this type of drip become infected. I will only start this drip via 18g in AC, while waiting for PICC line.

BrandonLPN said:

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.

Untrue again. If you read your ANA Scope and Standards of Practice (which does rule), you will see that it is very much in the RN scope to evaluate actions in the medical plan of care for safety, risk, and appropriateness, and to follow up to be sure those concerns are addressed. You might not like the answer, but you can go up the chain of command until you get the definitive answer. This means, of course, that it behooves you to be sure about your stance, having evidence-based practice standards to which to refer, and not just "I think..." or "I read somewhere..."

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.

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.

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.

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.