Writing doctors orders without an actual doctors order

[Toadroad]

Hi all. So I recently started a new job in a CVICU and am wondering if it is common practice at other places to put in orders without actually getting it from the doctor? I'm new to the ICU and nurses in the unit im on write orders for the doctor all the time without actually getting them. It's one specific Ct surgeon that they do it for bc he doesn't want to be bothered. Nurses order things like abgs, bicarbonate, amiodarone, calcium, bipap, chest x-rays, haldol, and other things without calling the doctor. The doctor doesn't want to be bothered especially at night so nurses are expected to order drugs and such that we think the patient needs. I don't totally feel comfortable doing this and am wondering if this is generally what is expected of me if I work in an ICU? I had a situation last night where I called the doctor on some abnormal abg results and patient was having some respiratory distress and he got real annoyed at me and said "I can't see the patient you make the decision on whether he needs to be intubated or not". Btw im still in orientation and just wanted to get some feedback

[caliotter3]

I've worked in facilities where nurses did this, but only with certain doctors. If you are uncomfortable, you will have to find a way to work around this or leave the job, as I doubt that management will change the culture surrounding this doctor. Perhaps you could get a colleague to help you with this situation.

[MunoRN, RN]

It sounds like what is actually an acceptable practice has been taken too far, intubation for instance is a medical intervention that really should be based on the MD's personal assessment.

But in general, nurses particularly in the ICU are expected to act with a common understanding with the MD, this means that actual orders are not always required. If it is well established that in certain situations or under certain criteria that the MD would expect you would get an ABG or check electrolytes then no specific order is required, the order comes from that common understanding. If there's any question as to what the common understanding might be, or if the MD is legitimately just being a lazy-ass, then that should be addressed.

[albyRN805]

It's a cultural issue in that unit. Do not second guess yourself, call that doctor if you have an issue. Direct the problem to the specialist. Cardio-pulmonary intensivist

[Here.I.Stand, BSN, RN]

Where is Dr. Sleepingbeauty going to be, when an RN gets charged with practicing medicine without a license?

I mean if someone had a BG of 40 I'd give D50 first and notify 2nd... and I've sent labs like an ABG when the breathing pattern was ineffective and the pt was unarousable even with NT suctioning (true story) BUT I always *communicated* with the dr about it.

No way in hades would I ever order a psychotropic med or invasive procedure. It's not about knowing what the pt needs...it's about that medical license which I don't have -- and the nursing license I want to keep.

[psu_213, BSN, RN]

I can understand ABGs and chest X-rays. I can't imagine a situation where that would come back to bite the nurse.

Meds though? What if a patient has an adverse reaction to the Haldol (amio, etc.)? To paraphrase what I heard quite a while ago on AN--that doctor is going to go running for the hills. No need to "over" call him to just prove your point, but when in doubt, call.

[Okami_CCRN, BSN, RN]

I have witnessed nurses who thought they were doing right by their patients by placing order for lactates, ABG's, and chest x-rays when they were "missing".

Well a nurse once placed an order for a some lab that came back critical and when she went to inform the physician his reply was " I didn't order that test, who ordered that?", it was a VERY awkward situation and thank god he didn't escalate it, but sternly told the nurse that he should be called prior or orders being placed.

[PeakRN]

It is not an uncommon practice, especially in EDs, ICUs, and PICUs. Like Muno suggested we have a common understanding with our physicians about the standard of care and what orders we are going to initiate either when they are busy (what if the physician is attending to a more sick/overcompensating patient) or not immediately available. For example if a patient suddenly arouses after RSI are you going to page the MD while the patient fervently tries to self-extubate or give a little propofol bolus or a push of versed? I would use your preceptor and charge nurse as they should have far more experience on the unit and with those medical providers.

That being said you should not be scolded for asking questions or expressing that you are uncomfortable on giving your opinion on a medical decision, that is still their responsibility. It is also okay to have a difference of opinion, I have certainly had some heated discussions with our medical providers about care but they understand that it is for the benefit of the patient and nobody takes it personally.

[llg, PhD, RN]

I would not be practicing medicine without a license. If anything went wrong, the RN's would be in big trouble. If there is a need for nurses to make some independent judgements beyond the scope of their practice, then there should be "standing orders" or "protocols" in place to give the nurses a legal foundation to stand on. ICU's often have such protocols in place to provide legal coverage for the staff. That's the way to handle it. I would never take it upon myself to go beyond the nurse practice act and into the practice of medicine without being covered by a formal policy, protocol or standing order.

[WestCoastSunRN, MSN, CNS]

I would not be practicing medicine without a license. If anything went wrong, the RN's would be in big trouble. If there is a need for nurses to make some independent judgements beyond the scope of their practice, then there should be "standing orders" or "protocols" in place to give the nurses a legal foundation to stand on. ICU's often have such protocols in place to provide legal coverage for the staff. That's the way to handle it. I would never take it upon myself to go beyond the nurse practice act and into the practice of medicine without being covered by a formal policy, protocol or standing order.

Yep. This is what protocols are for. You can do a ton with a liberal protocol -- but it needs to be there, in the books -- to cover everyone.

[Medic/Nurse, BSN, RN]

While that sounds like an almost lovely place to work - not having to wake the crabby ass doc and do what needs to be done for your sick patient anyway? I mean, who wants to get talked to like a freaking idiot by the real idiot and you aren't into misery - right? Plus, this stuff should take place on a recorded line - shouldn't it? Yeah, that would STOP these bullies, baddies and nonsense!

I would tread carefully. Very carefully.

I will not ever do anything I could not defend to the BON by clinical competencies, policy or standard of care.

- THAT IS MY OFFICIAL ANSWER.

IF DOC SLEEPYTIME WANTS TO DO STANDING ORDER SETS, IN THE EVENT OF XXXXX -- HE CAN GET THOSE APPROVED

If the MD doesn't do their job, go to house officer or other recourse.

See, while it seems OKAY, cause everyone is doing it - that's not true. When it goes sideways, it won't be everyone taking the hit. Custom and practice is not a defense. Count on it.

Just say no.

:angel:

[saongiri]

In any situation you feel uncomfortable executing an action, call the doctor. Ordering labs is one thing but ordering medications a complete other. You are a brand new nurse. If your patient declines (as patients are prone to do at times) you will be the one in court testifying that you ordered the medication without consulting the doctor because he didn't like being woken up. Or that you didn't notify him or her of a status change. Do you think a judge will side with you in that? Probably you won't have an issue but you might and you must always act as any other prudent nurse would act in a similar situation.