Going toe-to-toe with a physician

Approached without rancor, many physicians will adjust the dosage or defer to your judgment. Others will confirm that the order is correct, believing that’s all that’s necessary. And an occasional doctor may angrily insist that you to do as you’re told or fill the order as is, no questions asked. If you express further doubts, Cooperman adds, a physician may go so far as to vouch for the patient’s safety. “I’m willing to take full responsibility for this,” he or she might say.

Then what?

Don’t ever agree to such an arrangement. It may be the doctor’s order, but if you carry it out despite serious doubts, it’s your license at risk. The only exception: life-threatening emergencies, where “Act now, question later” prevails.

When in doubt, speak up

The American Nurses Association (ANA) code makes it clear that RNs have a duty to advocate what’s best for their patients. Fulfilling that duty requires that you question any order you believe to be below the standard of care, in violation of a hospital or employer policy or procedure or contrary to a patient’s best interests. That extends to any order for a drug or treatment whose safety and efficacy you have reason to doubt, as well as to unclear or illegible orders.

Facilities should have prohibitions against dispensing or following ambiguous orders, consistent with state practice acts. Gayle H. Sullivan, JD, RN, an attorney based in Fairfield, Conn., boils it down to three simple words: “Appropriate. Legible. Complete.” Additionally, any time you have a question that a conversation with the doctor does not address to your satisfaction, you have a professional duty to refuse to carry out the order until your question has been answered or the issue has been clarified. Notify your supervisor as well.

Unwise as it is to accept a doctor’s word without question, however, it’s equally important to realize that there will likely be times when the physician has a solid rationale for an order or action that strikes you as unacceptable. The key is to approach the doctor with an open mind but to insist on more than reassurance before you acquiesce.

If you ask, “Doctor, that is four times the normal adult dose. Is that what you meant to order?” for instance, and she says Yes, request further clarification: “That dosage is contraindicated according to the manufacturer’s directions,” you might say. “Do you have any evidence of its safety and efficacy?” Even if the physician provides a published study or other written material as back-up, however, do not administer the drug until you have conferred with—and received confirmation from—your facility’s pharmacist. Be sure to document your conversations with both providers.

Stick to your convictions

There are times, too, when you will need to confront a physician not with a request for more information, a clarification or a discussion about the particulars of an order, but to make it clear that you cannot—or will not— carry it out. When you’re convinced that compliance would jeopardize patient safety, failure to stick to your convictions can have disastrous results.

A lawsuit in which a hospital was found liable for the actions of a nurse who caved in under pressure is a case in point. The RN was with a patient who had just come out of the OR when a doctor asked her to accompany him to another patient’s bedside. She said No, explaining that she had not yet completed the postop monitoring that hospital policy required. When the doctor persisted, however, the nurse relented and left the room. The postop patient arrested and was left permanently paralyzed and semi- comatose.¹

Challenge a failure to act

As a nurse, you also have a duty to speak up and to follow through when you believe a doctor’s inaction is endangering a patient—if he fails to provide adequate pain relief or to order antibiotics for what appears to be a massive bacterial infection, for example. In one such case, an RN asked a physician to order morphine IV push for a patient in severe pain because the patient-controlled analgesia on order was not available. But the doctor said the patient could wait and - reprimanded the nurse for “insisting on an order.”²

Although the RN did not persist, she should have, according to Sullivan. “Any time you believe a patient’s pain is not being adequately addressed, you have an obligation to take your concerns up the chain of command,” she says.

Nurses must comply with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) pain management standards. These standards recognize patients’ right to appropriate assessment and management, require that accredited institutions ensure staff competency in pain management and require facilities to establish policies and procedures that support the appropriate use of pain medications.

Whenever you find yourself requesting that a doctor take action (or, for that matter, find yourself questioning a physician’s order or refusing to carry one out), keep in mind that thorough documentation is a must. Remember: Not documented, not done.

REFERENCES
1. Calloway, S. 0. (2001). Preventing communication breakdowns.RN, 64(1), 71.
2. Advice of Counsel. September 1, 2001. www/rmweb.com (10 Oct 2002).