Conscientious Objections (Bad Orders)

An 18-year-old asthmatic with an acute exacerbation of her condition arrives in the emergency department. The examining physician asks the nurse to give the patient 0.3 cc of epinephrine, 1:10,000 dilution. (The normal dose is 0.3 cc of epinephrine, 1:1,000 dilution.) The nurse questions the order, but the physician is adamant. The nurse is aware that in this case the drug will not cause any ill effect to the patient.

However, delay of correct treatment may be detrimental. She has several options: (a) she could give the standard drug dose, (b) she could question the physician again, (c) she could contact another physician (a phone call to his home), or (d) she could follow the emergency physician's orders. She has to work with the ordering physician about every other day. What should she do? Would it make any difference if the physician in this case is a resident? What if he is the patient's outside, private attending physician?


Commentary

A consensus has emerged in recent years that nurses bear some responsibility for ensuring that physicians' orders are appropriate. Professional, ethical, and legal guide­lines, however, are somewhat imprecise regarding the standards and procedures gov­erning the nurse challenging a physician's orders. As a consequence, each specific case must be analyzed to ascertain whether a nurse should object to a physician's instructions and, if so, how she should implement the objection.

SHOULD THE NURSE OBJECT?


In this case, four primary entities will be affected by the nurse's actions: the patient, the nurse, the physician, and the hospital. The nature and magnitude of each entity's interest will be examined to determine how this nurse ought to proceed.

Patient's Interests

The patient has an interest in receiving appropriate medical treatment for her condition. Her goal is to obtain from the emergency department the dose of epinephrine that will bring her relief as soon as possible. If she receives the lower dose prescribed by the physician, her distress will be prolonged and her risk of suffering harm from the episode will increase.


This patient's interest in appropriate treatment supports the nurse acting to provide such treatment. This interest, however, is less weighty than it would be if the physician's orders presented a more serious and imminent health threat.

Nurse's Interests

The nurse confronts a complex set of interests in this case, for risks are inherent in any course of conduct she chooses to pursue. If she follows the incorrect order and the patient suffers harm from the delay of proper medication, she could be held liable in a subsequent malpractice action. Further, she could face disciplinary action by the hospital administration and state nursing board for her contribution to the patient's inappropriate treatment.

Blind obedience to physicians is no longer an ethically or legally defensible approach for nurses. Modern ethical codes, as well as legal standards, require nurses to question the authority of physicians who issue inappropriate orders that could result in harm to patients.


Yet the nurse will encounter hazards if she challenges the physician. Because of the broader social context in which nurses and physicians work, the nurse who overtly disagrees with a doctor is especially vulnerable. The nurse's refusal to carry out the emergency physician's order will jeopardize her relationship with him. Further, she could be subjected to informal harassment and retaliation by the emergency physician and others who might take his side.

The physician could file a complaint with the hospital or with the state nursing board, claiming that the nurse exceeded the legal scope of nursing practice. Some state nursing practice acts permit nurses to engage in certain forms of diagnosis and treatment, while many statutes are imprecise on this matter. Imposition of formal legal sanctions, however, would be unlikely in this case. As long as the nurse carefully orchestrates her objection, the persuasive arguments in favor of her conduct should protect her from official action. But the solid basis of her refusal to follow the physician's order might not protect her from unofficial punishment.


Unfortunately, the nurse cannot avoid exposure to a common fate of "whistle blowers": informal persecution and ostracism. This threat can be minimized, however, by the method in which she challenges the order. Thus, although the nurse will incur some risk in opposing the order, the balance of considerations indicates that it is most advisable for her to ensure that the patient is properly treated.

Physician's Interests

A third set of interests relevant to this conflict is that of the physician. To practice medicine, he needs the cooperation and assistance of other members of the emergency department staff, including the nurse. Yet he will also gain if the nurse acts to ensure that the patient receives the correct dose of medication, for by doing so she deflects a potential malpractice claim against him. Although his pride may be damaged by her challenge, this consideration has little merit and ought not influence the nurse's decision.


Hospital's Interest

The hospital is the fourth entity that will be significantly affected by the nurse's conduct. A smoothly operating institution is one in which members of a health care team work together without serious conflict. More important to the hospital, however, is a system in which individuals on a health care team act as checks against the errors of others. Avoiding harm to patients from improper care, then, is the hospital's overriding concern in this case. As a result, the overall goals of the hospital are best advanced if nurses attempt to rectify physicians' errors.

STATUS OF PHYSICIAN IRRELEVANT


This characterization of the interests at stake remains essentially unchanged if the physician involved is a resident or a private attending. If the physician is a resident, the nurse has even greater reason to challenge the order.

Residents are physicians-in-training who must be monitored by more experienced health care personnel, to protect hospital patients. If the physician is a private attending, rather than a staff physician, the nurse probably incurs a lower risk in refusing to carry out the order, for she is likely to have less contact with a private physician and the danger of unpleasant future encounters is correspondingly reduced.


In sum, an analysis of the interests of the parties involved in this case indicates that the nurse should act to protect the patient by objecting to the physician's order. How, then, should she proceed? This question can be answered by once again investi­gating various interests affected by the nurse's behavior.

HOW SHOULD THE NURSE IMPLEMENT HER OBJECTIONS?


The patient's interest is in receiving prompt relief. This is not a case in which lengthy discussion and negotiation between nurse and physician will benefit the patient. Thus, for the patient's sake, the nurse needs to act quickly. The nurse's interest in maintaining a good relationship with the physician suggests that she should approach him one more time, explaining her doubts about the order and perhaps presenting to him evidence that the standard dose is much higher than the one he has requested.

If the physician refuses to change his order, the nurse should seek assistance from another person with authority over emergency department patient care. To protect herself, she ought not administer the appropriate dose on her own.


Accordingly, she should first telephone the other physician and describe the situation. The nurse should present her case professionally, without extreme anger or hostility. Her aim is to enlist institutional support for her position, rather than to encourage her listener to condemn the emergency physician's acts.

Unfortunately, physicians at times are reluctant to override another physician's decision, especially in support of a nurse's conflicting view. If the second physician refuses to issue the appropriate order or to visit the emergency department to examine the patient, the nurse should notify her supervisor of the problem. In the face of an error as obvious as this one, the supervisor is likely to recognize the mistake and arrange for a physician to order the appropriate dose.


Again, by calling the case to the attention of the hospital authorities, the nurse safeguards her professional interests to a greater extent than she would by acting alone. In addition, she should keep detailed notes of her actions in the patient's records, to ensure that an accurate account of the incident is documented in the event of further inquiry into the matter.

The nurse's responsibilities in this case could extend beyond the immediate sit­uation. If the emergency physician refuses to change his order after having ample opportunity to do so, his professional competence is in question. For the good of future emergency department patients, the nurse should raise this issue with her supervisor.


Many hospitals and all state medical boards have procedures for reporting and investi­gating incidents like this one. By reporting the incident, the nurse once more risks informal sanction. Her vulnerability, however, will decrease if others in the hospital support her willingness to challenge the physician.

Further, the hospital administrators, as well as other physicians, have ethical and legal grounds for concern about the com­petence of this physician. Thus, the nurse should, at minimum, consult her supervisor on whether to report this incident to hospital or state medical authorities.

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