When Nurses Question ‘Doctor’s Orders’

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Doctor updates orders All nurses are aware of “doctor’s orders.” The expression is so much part of the general lexicon that it has crept into movie and pop song titles.

But the meaning is more fully “obey doctor’s orders.” And it is universally understood that nurses are supposed to do just that.

That understanding is the basis of many a dilemma. It is almost inevitable that a nurse will be motivated to second-guess a physician now and again. What’s debatable is the extent to which questioning or even defying a physician is OK.

Should a nurse change a doctor’s order?

This discussion came to a head in a Reddit thread in 2016 when a first-semester nursing student wrote that a second-year nursing student said she had been altering a certain patient’s insulin doses from what the physician had prescribed. She promised the spouse would have the same attitude after attaining her level of experience.

None of the Reddit commenters condoned what the second-year nurse did. They said she deserved to lose her license and would be lucky if she weren’t fired or even held criminally negligent.

“So, the patient will be discharged home on ineffective regimens and will likely end up back in the hospital,” one said, and others agreed the nurse had made it impossible for the physician to know the patient’s true condition. Some said the nurse risked accusations that she was “diverting,” or stealing, meds.

So the insulin case seemed cut-and-dried. But there are many scenarios where a nurse faces a true dilemma — either hurting a patient or violating a policy and/or alienating a physician. Some of the experts’ answers and prevailing opinions surrounding these dilemmas may not be worthy of edicts, but they are worth considering if a nurse feels compelled to question authority.

What if the doctor’s orders seem to contradict hospital policy?

“A nurse who outright refuses to carry out a physician’s order is going to immediately be persona non grata with the physician and possibly the hospital and licensing board,” warned health-care attorney Carolyn Buppert, MSN, JD, in a 2015 Medscape article.

Buppert says an order that conflicts with hospital policy should be challenged, partly because it’s a sign that “there is likely something wrong with the process. A nurse shouldn’t be caught between two genuine authority figures. If a nurse is put in this difficult position, one thing that he or she can do is turn the interaction with the physician over to a supervisor.”

Before involving a supervisor, Buppert suggests “responding, ‘That would violate hospital policy,’ in a neutral tone of voice,” in an effort to start a discussion with the physician.

“If the physician balks, then saying, ‘I’ll need to check that out with the charge nurse’ might be a way to let the physician know that it’s not just the nurse being difficult, enabling the nurse to pass the decision up the corporate chain of command,” she says.

What if the nurse is experienced and the physician is new?

In a California case, a veteran nurse challenged a young physician’s order to intubate a patient at bedside instead of in the far-better-equipped intensive care unit. She defied the order, wheeling the patient over, a five-minute transfer. He died 30 minutes later, and she ultimately found herself losing court cases.

“This case tells us that it is permissible for a registered nurse to disobey a physician’s order that is inaccurate or dangerous to the patient, but it’s not permissible otherwise,” Buppert wrote. “It is key to understand that it doesn’t matter whether the nurse thinks the physician’s order is dangerous; what matters is whether a majority of other experts would believe the physician’s order was reasonable or dangerous.”

What if the physician commands the nurse to do something that only physicians are supposed to do?

Buppert says the nurse who follows those orders “risks … being accused of exceeding scope of practice, and violating hospital policy. It is not worth these negative consequences for a nurse to enter the order.”

What if the nurse is far more familiar with the patient than the physician is?

“Nursing responsibilities have expanded as physicians spend less time with patients and rely more on nurses to follow through on changes in the patient’s condition,” wrote James W. Slater, an Ohio attorney, in an analysis of Buppert’s Medscape article.

Nurses are increasingly making house calls and are often the primary contacts for patients in remote medicine. They are front-line interpreters of computer data. They may have reason to challenge a physician whose picture of the patient might be less clear than the nurse’s.

What if there’s no time for a conversation?

Beginning with triage, nurses often must make diagnoses and decisions before a physician sees the patient. If nurses are making these decisions, should they be entitled to second-guess a physician’s amendments to those decisions?

Obliged to second-guess

Some nurses contend they’re not only entitled to second-guess but also required to do so. “Doing or saying nothing when action is required may be the worst offense of a nurse on duty,” legal nurse Rita Kae Restrepo told Slater. The author himself noted that many of the duties nurses are sworn to fulfill make them subject to lawsuits. His list included “failure to follow standards of care … failure to communicate … (and) failure to act as patient advocate.”

Furthermore, nurses are increasingly taught to excel at taking control, and some say that means they should not be stifled.

“Nurses who feel in control will call a physician repeatedly, even when they think the physician might get angry,” San Francisco nurse/consultant Laura Malmeister told Slater.

No simple answers

The key seems to be willingness to confront the physician. That seemed to be the insulin-boosting student nurse’s failure.

But to other nurses, it’s probably never that simple. How do you handle similar situations? Let us know at editorial@onlinenursing.wilkes.edu or visit our Facebook page.

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