Which to follow: MD or Policy?

macawake, MSN · Mar 10, 2015

I work part time at an LTC facility. We have a clear policy that states when a patient is transferred to the hospital and stays out of our facility for more than 24 hours, the orders at our facility must be discontinued and new orders written. A returning patient happened to come back on the 25^th hour. The charge nurse told me that the MD didn't want to be bothered with discontinuing and writing new orders since the patient returned just an hour outside of the 24 hour window. She then said she's just going to follow the MDs old/current orders because that's what the MD instructed, and she didn't want to bother herself with transcribing the same exact orders.

Would you follow the policy (which could use some revising IMO) or just follow the MDs current orders?

For me this would depend entirely on the type of facility/unit I was working in. If I have a good working relationship with the physicians and know that they are "stand-up" type of people and the organization isn't punitive/issue write-ups for looking cross-eyed at someone, then I'd just chart "MD and charge aware" and happily medicate my patient. My critical thinking tells me that the difference between 24 and 25 hours is negligible anyway.

If on the other hand the above terms aren't met, I'd cover my behind and insist on new orders.

If this is a recurring problem I think that the policy either needs to be amended or the physicians should be required to actually abide by it. Even though I don't have a problem administering the meds in this scenario I don't think it's something that a nurse should have to deal with on a regular basis. I can see that it might be stressful to some and potentially lead to disciplinary action against the nurse. Also, where do you draw the line? Twenty-five hours isn't a problem in my opinion, but how about thirty-six or forty-eight?

Edit: Oops, I just noticed that I did some sloppy reading :) and that you didn't specifically say that you'd personally talked to the physician, only that the charge nurse had. I would actually call the physician before charting "MD aware" and not take my charge nurse's word that the physician didn't want to write new orders.

MunoRN, RN · Mar 10, 2015

There's actually a third basis for decision making that takes precedent over both the MD and policy which is nursing judgement.

In this situation I'm not sure there's much of an option, it's the MD who is choosing not to rewrite the orders not you. If your nursing judgement told you to force the issue, then you could D/C all of the previous orders regardless of the MD's preference, but while you can D/C them per policy, you can't write new ones per policy, so that only leaves you (and the patient) with no orders, which overall may not be better for the patient.

BSNbeauty, BSN, RN · Mar 10, 2015

I would follow policy . Can never go wrong with that in my opinion.

loriangel14, RN · Mar 10, 2015

He really doesn't need to rewrite the orders. He could just give an order to resume all previous meds.

Angeljho, MSN, NP · Mar 10, 2015

I can't tell you how many times the nurses have been fighting with the MDs because they didn't want to follow the policy. I agree in some cases, its not that big of a deal. There was an incident a couple of months back where the time span was much greater and the nurses were still following the old MD orders. Everyone who gave meds were written up for administering medication without an MD order.

BSNbeauty, BSN, RN · Mar 10, 2015

When in doubt follow policy. If the MDs have a problem with , oh well.

MunoRN, RN · Mar 10, 2015

I would follow policy . Can never go wrong with that in my opinion.

I cringe a little when I hear that. I review and evaluate adverse events, and every once in a while avoidable harm comes to the patient when a nurse followed policy perfectly, the problem is they should have known not to follow policy in that situation. If policies where foolproof and were always correct in every patient and every situation, we wouldn't need nurses, just people with task skills who will blindly follow policy.

caliotter3 · Mar 10, 2015

He really doesn't need to rewrite the orders. He could just give an order to resume all previous meds.

This is what I would write as the order. I've seen it often enough.

allnurses Guide · Mar 11, 2015

Why would you not resumed the medications as ordered? If that was my patient, and orders were held for that reason, I would be livid.

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macawake, MSN · Mar 11, 2015

Why would you not resumed the medications as ordered? If that was my patient, and orders were held for that reason, I would be livid.
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From what I understand of OP's post there's a policy in place that states that the physician first has to discontinue the old order and then write a new one and this apparently hadn't been done. Seems like a cumbersome policy to me and amending it seems like a good idea. It does seem to give both the nurses and the providers headaches :sour:

MunoRN, RN · Mar 11, 2015

Why would you not resumed the medications as ordered? If that was my patient, and orders were held for that reason, I would be livid.
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It's a pretty common policy that all orders must be reviewed by the MD before being continued whenever a change in the level of care occurs. Just writing "continue previous orders" doesn't do anything to confirm that the MD has reviewed the orders. The reason for this is that it's not hard to find examples of a patient continuing on a med that they shouldn't continue on, for instance if they're sent out from the nursing home to the hospital, where it's found they have a subdural hematoma, then they go back to the nursing home and MD writes "continue previous orders" which included coumadin. The best way to ensure the MD is aware of the coumadin and making a conscious decision about continuing or D/C'ing it is to review and reorder all the meds individually.