Telephone Orders from a Local Physician

A physician on the staff of Omega Hospital calls the Omega emergency department and speaks to one of the nurses. He says that a patient of his is coming in with a migraine headache, and he wants the nurse to give the patient 100 mg of Demeral intramuscularly (a normal adult dose). The nurse knows that verbal orders for narcotics are not permitted.

In addition, both the nurse and the physician would be responsible for any problems that might arise, even though neither of them knows the patient or his problem. If the nurse refuses to obey the order, the community physician could make a lot of trouble for her. Should the nurse acquiesce? Should she give the call to the emergency physician? Or should she simply refuse the order?


Commentary

I fail to see any major ethical issue here for the nurse. Since I don't define life or relationships with other health professionals as a popularity contest, the right thing to do is to refuse the order from the local community physician. The hospital has sound reasons for their policy that nurses are not to take orders for narcotics over the phone. In the best interest of the patient, the nurse, the hospital and, in the long run, the local physician who is on the staff, this policy should be followed.

However, several questions arise. Why is the patient coming to the emergency department of the hospital for this injection rather than to the doctor's office? What do we know about this patient? Since this tends to be an on-going health problem, are there other medications that might be better for migraine headache that the physician could order and the patient have on hand?


After refusing to take the order for Demeral over the phone, the nurse could suggest that the local physician talk with the emergency physician (if he were available) or could indicate that she would ask the emergency physician to return the call as soon as he is available. If the community physician or other local physicians continue to call in orders for narcotics, the nurse will have to seek assistance to prevent this from reoccurring.

She could take this up with the head nurse, the nursing supervisor, or the director of nursing service. If nothing happens at these levels, she could take it up with the chief of the medical staff. All of these people have an obligation to make the hospital a safe place for patients and a legal and ethical place for staff.


What about the patient with the migraine? It is difficult to answer that question without more information, including the questions above. When the patient arrives, it seems reasonable that the nurse could treat this patient as any other and obtain a written order from the emergency physician, if institutional policy requires this, or she might have means at her disposal to treat this patient without an order.

This situation brings to the fore the problem of the possible differences between perceptions and reality, which refers to the statement, "the community physician could make a lot of trouble for her." Is this really true, and if so, what would be the nature of this trouble? Would the nurse not be in trouble with her employer if she violated the hospital policy on narcotics? If the medical or nursing administration allowed this physician to give her trouble, or if they themselves gave her trouble, in my opinion they are, at least, uncollegial and, at worse, unethical.


Two questions I have found useful when in a situation similar to this one are: What is the worst thing that could happen to me if I do what I think is right? How can I live with myself if I do not do what I think is the right course of action?

In this case, the nurse should refuse to take the phone order from the local physician and then proceed from there. She could make the suggestions mentioned above involving the emergency physician. When the patient arrives, she must not displace her irritation onto him but must meet her obligation to attempt to obtain the best possible solution to his health problem within the limitations of the situation.

One last general statement is needed. Policies are not written in stone, nor were they handed down from the mountain, but they are necessary and useful. We have policies to give us direction. They also take some of the decision-making burden off the individual practitioner who may not have the larger view of such issues as potential legal problems, allocation of resources, etc.


To the extent that a policy helps us function or keeps us within the law, it can, in general, be thought of as a useful policy. If a policy is not helpful or is left over from an earlier time and is now outdated, it should be examined to ascertain whether change is needed. I do not believe that the policy of no verbal orders for narcotics should be changed and, in this belief, it is not the nurse, but the patient, who is at the center of my concern.

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