This RN is one of those people that you look forward to your shift when you know she is working. Great nurse, friendly and doesn't mind helping out if you need it.
A supervisor let it slip this nurse couldn't be the only RN on the floor. Of course, rumors started about narc diversion and the like. I reasoned that she wouldn't even be on the floor if this was the case, but people like to believe the worst.
I decided to look it up on my state's BON site. This nurse was working on the floor of a local hospital a year ago. One of her patients was on a vent and the family had decided to turn it off. The physician wrote an order that stated "remove life support after the patient's daughter arives at 1:00". The daughter arrived earlier than planned, said her goodbyes and after discussion with the rest of the family, told the nurse they were ready. The nurse found the RT and told her to go ahead and remove life support. The RT refused, stating that the order said 1:00 and she was waiting until then. The record didn't say how early it was, but I'm guessing it must have been a few hours since it did say the family did not want to wait until one. The nurse wrote an order that stated "ok to terminate life support now". When asked why she would write this, she said that this particular doc was one that she knew well, and every time she called to ask him for something he would say something along the lines of "whatever you want or whatever you want to do". So she felt comfortable writing the order. They went ahead and terminated life support and the patient died a few minutes later.
The record did not say who reported her to the board. It stated that initially, the BON wanted to suspend her license for two years, but settled on probation for two years. The stipulations include a minimum amount of hours to work every month, her employer has to send a letter to the BON every three months stating how she is performing, she can have only one job at a time and cannot work home health, clinic etc - has to be hospital. Another RN has to be her direct supervisor, but doesn't have to be on the same floor as she as long as the RN is in the building (which isn't what my supervisor said). The remedial education is significant and she has to pay for all of it. She went to the hearing without an attorney. Maybe the reprimand wouldn't be this harsh if she would have had one?
After finding out about this, I will never do this again and I will discourage my fellow nurses from it. The only times I've ever written orders like this are for things like air mattresses, and recently, for tele when my patient was on a drip and no monitor for three days (yeah, another story all together:madface:). I can confidently say I will never do this again. It scares the you-know-what out of me to even think about it.
Well my interpretation based on how the original poster described it is that daughter was arriving at 1 and it was okay to terminate after that.
What if the daughter had showed up late, would anyone interpret it was okay to terminate at 1 still? I doubt anyone would.
I'm not saying I disagree with anyone about calling the doc to do it early but playing devil's advocate if the daughter showed up early and came out and said okay, then the whole time thing is just semantics.
The focus of the order was daughter was arriving at 1 so not before daughter arrived.
I see some of the senior nurses do this all the time and I absolutely refuse to engage in it. The only thing I am willing to stick my neck out for is perhaps, when he forgets to write the route on a medication and I am 150% sure that the dose he wrote is correct because it would be a medication I have given probably 100 times, or the only way a medication is carried in our unit.
But to write an entire order or a medication dose? Forget it.
To me, that is why they get paid the big bucks...they get paid to be woke up, interrupted and otherwise, "bothered" when it is their patient.
Well my interpretation based on how the original poster described it is that daughter was arriving at 1 and it was okay to terminate after that.
What if the daughter had showed up late, would anyone interpret it was okay to terminate at 1 still? I doubt anyone would.
I'm not saying I disagree with anyone about calling the doc to do it early but playing devil's advocate if the daughter showed up early and came out and said okay, then the whole time thing is just semantics.
The focus of the order was daughter was arriving at 1 so not before daughter arrived.
I agree with you, but my thought is this: At that point, the patient's decision maker decided to refuse the treatment of being on the vent.
Also, since I assume the doc would still have to come pronounce, the call would've needed to happen anyway. Crappy situation.
Did anyone talk to the family about how they felt the nurse handled this? Probably not since I guess that's secondary.
Well my interpretation based on how the original poster described it is that daughter was arriving at 1 and it was okay to terminate after that.
What if the daughter had showed up late, would anyone interpret it was okay to terminate at 1 still? I doubt anyone would.
I'm not saying I disagree with anyone about calling the doc to do it early but playing devil's advocate if the daughter showed up early and came out and said okay, then the whole time thing is just semantics.
The focus of the order was daughter was arriving at 1 so not before daughter arrived.
This is how I feel about it. She arrived early, said her goodbyes and wanted to go ahead and terminate support. It reminds me though, that when it comes down to it, that you can't trust just anyone. Like somebody else said - CYA!
I worked with a nurse who told a group of us (after another RN called in the middle of the night for a Tylenol PRN for HA order) "a lot of times I'll just write a verbal order for Tylenol and the MD always signs it." My thought was 'oh my, they might always sign it, but if you write it for someone with unknown liver issues or if they have an unexpected rxn. to the tylenol that MD is not going to cosign it.' Anyway, I didn't express my discomfort that she was writing for tylenol...I can't even imagine a nurse taking a verbal order to discontinue life support, let alone make up the order.
Not at all removing blame from this nurse; however, I think the original order from the MD is pretty bad...'remove life support after XX time'... hours from now?? I would not feel comfortable with this order at all. For instance, what if the dtr. arrived from out of town and insisted not to have the life support removed? What if their was some change in condition from when the MD wrote the order? In the second case I would at least want the MD to evaluate the pt again before ending life support. Really sticky situation...
That's a PRETTY big order to write on behalf of the doctor. It's not a "the patient was desatting so I put them on 2L nasal cannula, can you write the order please" or "I ran a pregnancy test on the female teenager who will probably need an x-ray later" kinda thing to do. Seems like it would have been worth a call to the doctor.
This is a never ending problem. Many docs I work with expect me to operate as the attending physician and manage the patient EXACTLY as they would without ever disturbing thier sleep or the sleep of thier partners. I don't know a good answer except to make sure when you take an order you have the widest possible aplications that meet the goal of the physician. "Discontinue mechanical ventillation after eldest daughter arrives at bedside and gives approval" is a much clearer instruction than the order that was written. The order as written is more of a execution order for a death row resident than a comfort measure for a terminal patient. The event that activates the order should be the family having said thier goodbye not some arbritary point on the clock. The "repeat back" part of taking a telephone order is the ideal opportunity to make sure you are writing the order with the same intent as what the doctor wanted. As to written orders- some doctors may be lonely and are just asking for phone calls from the nurse.
I used to write "orders" if I knew the doctor would want it, harmless things. So did we all. The doctors routinely just signed their name to discharge sheets for nursing homes, too, and the nurse had to fill everything in on a blank signed paper. Just to save doctors some work. I absolutely quit cooperating in that years ago, because this is just practicing medicine without a license. Some of the older physicians had fits because they were being "bothered", and would chastise me to my face and to my manager. Too bad. That way of nursing practice has gone the way of the horse and buggy, never to return in our sue-happy society.
I have never in 32 years ever written an order that I didn't ask the MD myself about.......not ever.
Wow.....
Really? Not even a 2am order for tylenol, or a clarification, say, the MD wrote "zofran 4 mg IVP q6'" and you clarify it as a prn med? Or writing "NPO p MN" for a Pt who's having a procedure/surgery in the morning...nothing like that?
glutton4punishment
142 Posts
AWESOME point