“No Doctor.”
Posted by realityrounds on July 8, 2009
I have been lucky enough in my practice to never have felt the need to refuse an MD order. Well, not really anyway. I have been reading a post and comment thread on Unnecesarean on a practice called “pit to distress” where the drug pitocin is increased in a laboring woman to dramatic levels, to cause intense contractions to “distress” the baby. It is a way to let the baby declare him/herself, so to speak. Most nurses I know would hate to comply with this practice, but some would probably do it anyway. They might do it because they don’t know any better, or they have not seen any adverse effects from it, or they are afraid to contradict the physician, or they are apathetic. Who knows.
So what is a nurse to do if he does not want to comply with a doctor’s order? For me, I have almost always been able to communicate my way out of an MD order I felt was ludicrous. Example: A stable preemie who is weaning on inspired oxygen and has great oxygen saturations levels. MD orders a (painful) radial artery blood gas. Me: “Hey doc, baby is doing great. Why don’t I just watch him very closely and notify you immediately for any changes in oxygen or increased work of breathing, instead of sticking a needle into the baby’s artery. Sound like a plan?” Doctor: “OK.” But what if the doctor insists on this test? Well, I would expect a very good justification for it, and yes, I would do it. I would do it because it is a relatively benign procedure, I am good at it, and sometimes you have to choose your battles well.
Now, let’s take this same example, but the physician insists on doing a femoral artery blood gas, and asks me to assist. I would refuse, period. Why? Because this procedure is risky, very risky. It can cause artery spasm so severe the infant could lose his leg. Not worth the risk for a blood gas that is not really necessary anyway.
A nurse is ethically, morally and professionally obligated to advocate for her patients. We are not subordinate to physicians. We are our own profession, governed by other nurses. We are to assist physicians and carry out their orders in regards to the overall plan of care for the patient. We need to work as a team for the health and safety of the patient. A nurse CAN refuse to carry out a physician order. A prudent nurse should refuse any order she feels would cause harm to the patient (like “pit to distress), or was a procedure not legally consented for (“No I won’t assist with the circumcision until the paper is signed. Don’t care that you just talked to the parents”), or one that she is just plain uncomfortable with (“No I will not hand you any surgical instruments until we do a “Time Out” to make sure we are amputating the correct leg”).
The actually refusing of a physician order sounds much easier on paper (or the internet) than it is in real time. Can you just say “no doctor” and walk away. No, you can not. That would cause confusion, and communication breakdowns, and possible harm to the patient. So how to prudently refuse a physician order:
Reality Rounds Guide to Refusing a Physician Order
- Develop a good working relationship with your docs. Communicate with them. Ask questions. Use your critical thinking skills so you can work as a team in treating the patient. Just saying “no” to an order without some sound justification and evidence to back yourself up will go nowhere. And for goodness sake, don’t be all confrontational and argumentative in front of the patient. Take it outside.
- Communicate with the doctor as to why you will not carry out the order. Again, back yourself up with evidence.
- Use your chain of command. Every hospital should have a chain of command policy, get to know yours. If you are uncomfortable with the order, go to your charge nurse, then attending (if it is a resident order), then in-house attending (if you have one), then nursing supervisor, then nursing director and OB/medical director. Rarely have I seen a refusal of an order go all the way up the chain, but I have seen it. It can generally be resolved at the charge nurse level.
- If you are unsatisfied with the change of command result (let’s say everyone on the chain agrees with the MD order but you still do not), then ask for your assignment to be changed, or have another nurse perform the order. You need to document very carefully. No personal feelings or attitudes. Just the facts ma’am. (Example: Pitocin order to be increased by ___miliunits, patient’s contraction pattern shows hyperstimulation, notified physician at 0700, order given to increase pitocin. Pitocin not increased. Notified charge nurse at 0701 of contraction patterns and physician orders.)
- Write an incident report and notify Risk Management of any physician order or procedure you felt was unsafe and possibly harmful to the patient. Documentation is key, because if there is no record of unsafe practices, there will be no consequences to the behavior. A pattern of unsafe practice is key, not an individual occurrence (we are all human).
- Can you be fired for refusing to carry out a physician order? Doubtful. First of all a physician can not fire a nurse, because they are not our superiors, nursing management is. It would actually be against the best interest of the physician and the hospital to fire a nurse for not carrying out an order. Just like the airline industry, you need checks and double checks, and refusing an order can be a safety net in some circumstances. If there is a pattern of a nurse refusing to carry out doctor’s orders or assisting with procedures, than that may be grounds for dismissal. This is true especially if the nurse went against policy and procedure and did not institute the chain of command.
I realize these steps may be hard to follow in the heat of the moment. It can be hard not to hand the physician a vacuum extractor when the head is crowning, or to stop giving chest compressions to the 99 year old who has been coding for an hour, or to refuse to give that dose of Narcan to the respiratory depressed baby with no prenatal care. We still need to try though, and cover our asses later.
RR
Diana J. said
That was a great post! Thanks for the information!
realityrounds said
Your welcome!
Labor and delivery RN said
I actually said no once….and I really thought I would lose my job. The doctor wanted to rupture membranes on a woman who had a variety of dates, anywhere from 34-37 weeks. LMP 37 weeks, 1st trimester u/s 34 weeks, 2nd trimester u/s put her at 36 weeks. It was not clear whether she was even in labor or not. She changed her cervix from 1 and thick to 2 and thick (1st was my exam, 2nd was his) and she was having mild contractions. He asked for an amnihook after his exam and I asked if we could discuss plan of care before rupturing. He was furious! I asked (while outside of the room)that we wait a little longer to see if labor would declare itself and wait until she was a least 5 centimeters before doing that. There was a behind the scenes discussion between him and management and a new nurse was assigned. Membranes were ruptured. Pitocin was started several hours later because nothing changed. A premature baby born with severe respiratory distress! All my co-workers said they admired me for sticking to my guns and only one would agree to take over care. It was a huge learning experience for all with many tears shed. Management said “it was a grey area”. Because the baby did not get transferred to a tertiary care center, this case was not discussed at the mortality and morbidity meeting. This happened about 5 years ago and not much has changed!
realityrounds said
Horrible, but not unheard of. Good for you for trying to do the right thing. I am not sure if readers who are not nurses can understand how hard that can be. I have known docs, residents and midwives, who will break a bag without even telling the primary nurse! She finds out when the bed is wet and the evidence is laying there.
My assumption is that this doc does things like this all the time. It sucks that your nurse manager or DON did not have the guts to stick up for you. Trust me, this was not a gray area. I still would have written it up and gave it to risk management, just so it was on file. My guess is your neos were not happy with this action. Did they confront the OB?
M'Lynn said
I’ll bet they didn’t. I worked in an OR with a GP who would cover general surgery weekend call, so the other general surgeons were thrilled. He was downright incompetent and NO ONE would believe it. They wouldn’t even believe anesthesia. We were all “overreacting.” It wasn’t until he screwed up BADLY in a case where I called in the right combination of surgeons to come in and save his ass, that the surgery committee did something.
I have always said, they’ll suspend our license if our CHECK bounces to the state board, but a doctor? They have to kill someone on videotape for anything to happen.
realityrounds said
Read this for more information on how hard it can be to not carry out a physician order. From the site Nursing Birth:
http://nursingbirth.wordpress.com/2009/07/08/%E2%80%9Cpit-to-distress%E2%80%9D-a-disturbing-reality/
nursingbirth said
Reality Rounds,
Thank you so much for writing about this!! Although many of my colleagues tell me that I have a pretty good set of “cohunes” for only being a nurse for 3 years sometimes I get really really intimidated. I found this post of yours to be most helpful! I really learned a lot!!!
Quick story: One time when I was the scrub nurse for a scheduled, non emergent cesarean section the doctor, (who wanted to get back to the office pronto) was himming and hawing over how “slow” I was giving him his instruments. (Note: I was RIGHT OFF orientation and this doctor has a habit of hording instruments on the field making them difficult for me to keep count. So he is right, I was certainly not as fast as a scrub nurse who had been doing it for 20 years. But I was doing my job well!). Well it came time to close the fascia and I couldn’t find a mousetooth forceps. He kept asking for his “stitch” (meaning the suture) and I wouldn’t give it to him because I was trying to get the resident to look in the catch-all drape to see if it had fallen down. He asked me for the umpteenth time and I said “Dr. B I can’t find a mousetooth!” He looked right at me and said, and I quote…”I’m tired of your silly games. You can do you stupid count later now GIVE ME MY STITCH!” I was completely floored. He wanted to stitch that woman up without knowing that we had accounted for all of his instruments! The entire room went silent and I couldn’t say a word. But I didn’t give him that damn stitch!! And guess what! That friggin mousetooth HAD fallen into the catch-all drape…ON DR. B’s SIDE!! So I wasn’t going crazy!! What an a**hole! (Excuse me! Haha!)
But seriously, I can’t believe I have to deal with this crap and I know I am not alone!! To L&D RN, your story infuriates and inspires me!! Thank you for sticking to your guns!! Sometimes they work around us but we have got to stay strong and know that we are in the right!! One time I refused to assist a doc with an amniotomy for a -3 station and ballotable baby. He was furious with me but I thought I had done the right thing! Turns out that when I left the nurse’s station to attend to another patient the doc snuck in and broke her water anyways. DAMNIT! But at least my name wasn’t on that chart!! Thank god there wasn’t a cord prolapse…that time anyways!
Oh and M’Lynn…we had a doc like that once too. He actually mutilated two babies using high outlet forceps (both babies passed away shortly after birth) before he was ousted. It was so awful!
Okay, waaaaaaaaaaaaaay too long of a comment! Sorry!
~Melissa
http://www.nursingbirth.com
realityrounds said
There is a notorious obstetrician who many nurses from many different hospital have worked with. He likes to throw bloody instruments at the nurses in the OR. Yeah.
I never understood why a surgeon would want to rush the surgery or the count. It is asking for a lawsuit. Plus, if that count is wrong, the surgeon has to physically wait in the OR with the patient until an xray can be done. Better to be patient and accurate I would think.
M'Lynn said
One of those bloody instruments hits *me*? After the case, said thrower would be arrested for assault. It will be the “M’Lynn Surgical Pavilion” after that if administration put up with it. I quit a job because I was told that a thrower was “a major investor in our surgery center and has a lot of influence.” I DON’T CARE. If I hadn’t JUST moved from that spot, the laparoscopic clip applier that he had just pulled out of the patient would have hit me. He threw it AT me. NO, NO, NO.
I later worked for a medical device company, and a surgeon threw something bloody behind him, where I was standing. I waited, and after the case, told him that I’d appreciate it in the future, if he didn’t throw things. I did it quietly away from everyone. He started yelling at me that “it wasn’t my place to tell him that.” I told him that if it compromises my safety, it does. The sales rep that supervised me was mortified that I had spoken up, but my district manager had my back. Lucky for me, the circulating nurse had already gone to the OR director and reported the throwing incident. He was sheepish when they did call him on the carpet for it. Not that he ever apologized to *me*.
I love it when the sponge count is wrong, and we inform the surgeon over and over again. We are told, “It’s not in there. I guarantee it’s not in there.” The xray happens and…wow! The sponge IS in there. Not only does the surgeon have to hang out and wait for the xray…he then has to REOPEN THE PATIENT, take the damn sponge out, and reclose. He’s a lot nicer about it, though…
Change of Shift Begins Fourth Year: Volume Four, Number One // Emergiblog said
[...] [...]
pinky said
I used to be more confrontational. Perhaps when I was a nurse of 3 years I was not as comfortable as I am now. I find that it is far better to sway their opinion instead of going head to head with them. Give them a chance to save face.
If you have to go head to head all the time, maybe you work in the wrong place. Last time I had to go all the way up the chain is when we the nursing staff disagreed with one of my favorite Doctors. He is MFM and I think he has written a bunch of papers and folks geneflect when they pass him in the halls. I really really get a long great with the guy. Which does help in a disareement. We did end up doing things his way. But first we called the Nurse Manager at home and our clinical educator to make sure it was a reasonable order for the patient since we were unaccomstomed to his intervention. Also the research he showed me on the topic did not convince me and I told him so which made him yell at me just a bit. This is uncharactoristic of this guy.
I agree with choose your battles. I have lost sponges and we kept the surgery going. Why? Cause it is usually in a few tell tale places. Not in the abdomen. When a Doc sticks a sponge in the abdomen, I put a kelly on my gown to keep track of it. So not usually a big deal but if you are new to scrubbing I can see where that would flip someone out.
I have raised my voice at Docs who throw their needle drivers on my mayo. Why? Because the needle driver has a needle on it. The needle can pop off and it will take f-ing forever to find it. And I hate X-rays. We usually take like 4 or 5. She comes she takes a picture. Brings it to radiology. She comes back takes another picture. This is a f-ing 3 hour tour without Gilligan. I find when my Docs are wrong, like throwing their needle driver on the mayo and I yell at them, they apologize. Why? Cause they know I know they are wrong. We all know they are wrong. And they don’t have 3 hours to spend in the OR taking x-rays either.
realityrounds said
It certainly can be a complicated world we work in. I agree with fight your battles, although the blogosphere does not. Have you ever read “From Novice to Expert?” Great book.
Thanks for the comment.
M'Lynn said
Pinky,
That is in L&D, yes? I find that docs who have to manage patients for non-surgical reasons tend to be a bit more…personable, as a rule. (Ortho, ob-gyn, urology, etc) Other docs, who tend to be more…assembly line oriented, shall we say (neuro, general, cardiovascular) tend to be more prima donna. I have wanted to call for the neck tourniquet to be brought to my room more than once. There are, of course, exceptions to this.
realityrounds said
L&D nurses may disagree with the OB’s being reasonable part
I found NICU docs great and very much team players. Part of the reason I have worked NICU for so long.
pinky said
The thing about Ob Docs is that they have to interact with the nurses in other areas. NOt just surgery. So many of the Ob Docs will be more reasonable than say, the Cardiac surgeon or the thoracic surgeon.
I love the idea of the neck tourniquet. Although I am also a big fan of the electric cattle prod. I think it is clinically indicated in some situations. Do you think NANDA could write up a nursing diagnosis for that?
Weekly News Round-Up « Women’s Health News said
[...] Posted by Rachel on July 12, 2009 Go get sucked down a blog rabbithole with all of the “pit to distress” posts of late, on obstetric providers who allegedly push pitocin on laboring women in an attempt to make the fetus “prove” itself – by coming out vaginally or forcing a c-section for fetal distress. Start with Unnecesarean, Keyboard Revolutionary, and NursingBirth. Those starting points also include links to various other posts on the topic. Relatedly, RealityRounds has written a guide for nurses to refusing physician orders. [...]
It’s Distressing « Woman to Woman Childbirth Education said
[...] the nurse/midwife side of things: Ciarin at a Midwife’s Tale; Reality Rounds (NICU nurse), on nurses declining to follow a doctor’s order that they disagree with; a triad [...]
Weekly News Round-Up « My Blog said
[...] Go get sucked down a blog rabbithole with all of the “pit to distress” posts of late, on obstetric providers who allegedly push pitocin on laboring women in an attempt to make the fetus “prove” itself – by coming out vaginally or forcing a c-section for fetal distress. Start with Unnecesarean, Keyboard Revolutionary, and NursingBirth. Those starting points also include links to various other posts on the topic. Relatedly, RealityRounds has written a guide for nurses to refusing physician orders. [...]