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Thread: WHEN the Nurse Disagrees with the Doctor

  1. #1
    EmmaPeel
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    Thumbs up WHEN the Nurse Disagrees with the Doctor

    October 13, 2010, 11:36 am, New York Times
    By THERESA BROWN, R.N.

    A recent conversation with a physician at my hospital was laced with tension about the different roles of doctors and nurses.
    “When you get down to it,” he told me, “Patients come to me for care, Theresa, not you.” Both of us were called away before we could talk more, but his words have been ringing in my head ever since. I couldn’t believe that this doctor, who had always worked well with the nurses on my floor, had just suggested, at least in my mind, that a nurse’s opinion on patient care matters less because patients don’t directly make appointments with us.

    As I puzzled over our brief but heated exchange, I thought back to the events leading up to the conversation.

    It all began after the doctor read a story I had written about a leukemia patient in his 70s. The doctor had not been involved in the case, but he was troubled by my role in it. Due to the patient’s existing health problems, I was concerned that giving him chemotherapy would cause more harm than good. During the course of the treatment, the patient complained in agony, telling me “I can’t take it,” and I relayed his misgivings to the patient’s care team. A more aggressive lament from the patient — “What the hell are you doing to me?” — also got communicated to the team.

    I was the patient’s nurse and his advocate, and I worried that it was not ethical to subject him to more chemotherapy when he was clearly having a hard time with the treatment. The chemo we had given him before this latest round had already sent him into permanent renal failure and caused congestive heart failure. Other members of the team shared these concerns, but the man’s doctor did not. He checked in with the patient to see if he wanted to continue treatment. After some gentle prodding by the doctor (“You want to keep going, right? Right?”), the patient agreed.

    I recounted that story with great sadness, as it had been agonizing to watch my patient suffer through treatments that I believed he would not have chosen had he known the harm they could cause and the unlikeliness of being cured. He eventually was admitted to hospice and died, but only after the chemo had left him with unstoppable and painful bleeding in his bladder, robbing him of a more peaceful and more comfortable end to his life.

    The doctor colleague who cornered me at the nursing station was particularly unhappy with my aggressive objection to the patient’s care plan. This doctor felt strongly that for cancer patients, end-of-life decisions should ultimately be the responsibility of the physician in charge of his or her care. That physician, he argued, is in the best position to offer advice about care decisions because he knows the patient’s full history. Floor nurses, he said, usually only see a snapshot of the patient near the end of a long journey.

    I understood his point, but I also felt he was too quickly dismissing the observations of oncology nurses, who intimately confront the suffering sometimes caused by well intentioned treatment. And that’s when the conversation became tense.
    Obviously, doctors and nurses have different roles in the hospital. Our training is different, and so are our responsibilities.
    It’s also true that patients choose their doctor and only end up with a particular nurse through the luck of the draw. But when a doctor and a nurse disagree over patient care, should the doctor always prevail?

    Many of the nurses I know could share their own, dramatic stories of rescuing patients or catching frightening errors by other health care workers, including doctors. In fact, the same day the doctor cornered me at the nursing station, I had caught a potentially risky medication prescribing error by a doctor in training. I took my care question to a clinical pharmacist and the attending physician to insure that my patient was given the right treatment. Nurses don’t have the power to make certain types of care decisions, but they do have the power -– and the responsibility — to go up the ladder until they are satisfied that good decisions are being made.

    Nursing care is also an important factor in a patient’s recovery. Several studies now show a strong association between nurse staffing levels and rates of patient complications like pneumonia or internal bleeding during a hospital stay. Patients in hospitals with high nurse staffing ratios get better sooner and have shorter hospital stays. Many doctors will tell you that it’s nursing care, not physician care, that makes the biggest impact on a patient’s recovery.

    So is the doctor-patient relationship really more sacrosanct than the nurse-patient relationship? I don’t think so. Physicians have the ultimate responsibility for treatment decisions, but because nurses spend so much more time with hospital patients than doctors do, we have a unique view of how the patient is really doing. And at times, patients present very different faces to nurses and to doctors — complaining to a nurse in a way they never would to a doctor. And while my physician colleague said that nurses only see a snapshot, that picture is often one the doctor does not see.

    Later, I had another chance to talk to the doctor who raised this issue in the first place. I told him that I was planning to write about our discussion of the role of doctors and nurses. “Yes,’’ he said. “We never got to finish our conversation.” So we finished it. He shared difficulties he’d had with nurses criticizing treatment decisions when they had only known the patient for a few hours. I nodded. Then I said that physicians can have blinders on, too, and he nodded as well.

    In the end he said, “The point is, it needs to be a conversation.” And we both agreed on that.

    But when in doubt, I will err on the side of aggressive advocacy for my patients. Nurses have a professional obligation to make sure that patients receive the best care possible and to insure that all care given in hospitals is safe. For better or for worse, patients who come into our hospital are the responsibility of the nurses, even if the patient has been admitted by a doctor of her own choosing.

    A good nurse will share his or her opinions with the medical staff — sometimes loudly — because that’s part of our job, even if we ruffle a few feathers in the process.

    http://well.blogs.nytimes.com/2010/1...go/?ref=health
    Last edited by Islander; 10-14-10 at 12:09 PM.

  2. #2
    Administrator Islander's Avatar
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Thanks, Emma. What a great perspective on the doctor-nurse-patient relationship!

  3. #3
    EmmaPeel
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Communication is the key. Unbiased open conversation. Nurses are the ones who are with patients from day one at the bedside, and they know much more than the doctor does about the patients history, personality, quirks, opinions and perspectives, and family input.

    Extremely valuable in the patients care!!

    I thought this was a great article too. That is why it is absolutely VITAL that a nurse have excellent communication and excellent self analysis skills above all! What she/he knows and assesses must be as easily communicated as what she/he doesn't know or was not able to assess for whatever reason...

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    Veteran Member Maurya's Avatar
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Thanks so much for this important perspective, Emma! The small sample of my own circle of friends and family includes many individuals who succumbed to the deadly results of the BULLYING they had received from the doctor in question in each case.

    The "non-informed consent" on the part of the patient that resulted in each miserable, painful death was in every case a product of the person's intimidation, and feelings of total lack of individual power and control of choices in their own life. When one is subjected to the treatment as a "patient" that differs so dramatically from the way one is treated in any other adult contractual relationship, the outcome is based on anything BUT informed consent.

    A patient advocate so often is recommended, such as a close friend or relative who will agree to attend the doctor appointment with the patient. Unless such an advocate is an actual health professional, such as a nurse, that advocate is susceptible to the same intimidation and bullying as is the patient, sometimes more so. Unless the advocate not only is conversant with medical terminology and practices, and has the natural temperament of a pit bull, the results more than likely would be a joint smoke blowing exercise.

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    Administrator Islander's Avatar
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Maurya, you had me right up until "joint smoke blowing." Sorry, my mind just went off in a totally different direction!

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    Veteran Member Reesacat's Avatar
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Even when you are a nurse or other health professional you get bullied by doctors.
    Once you are a patient you have to really be assertive and not give up your power.

  7. #7
    EmmaPeel
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Maurya, 'Informed Consent' sits on a slippery slope. That I know from personal and professional experience. Many of the doctors I know, do facilitate for close family to interpret and make decisions for their impaired loved one, but I agree, it means nil if the family member is out of touch, easily manipulated, or intimidated out of fear.

    What is worse, is family or the designated friend who interpret the information from their OWN personal perspective, rather than what they believe the 'patient' would have wanted. Sadly, I see it all the time...

    And yeh, joint smoke blowing up each other's butt...not giving a toss about what the patient believed in their whole lives.

    What do you do if you find yourself in a situation where you may not have the optimum situation of open communication in the team that is looking after your medical issue?

    Did you know that hospitals have 'ethical patient advocates' on staff separate from the bed-side caregivers? These are knowledgeable individuals who will get to know your issue and your wishes, and form open communication with hospital staff.

    You can even hire an medical advocate from reputable health agencies to attend appointments with you and document.

  8. #8
    EmmaPeel
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Quote Originally Posted by Reesacat
    Even when you are a nurse or other health professional you get bullied by doctors.
    Once you are a patient you have to really be assertive and not give up your power.
    Oh yeh...hmmmm....I know this first hand.

    Dragon Lady phobia.

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    Veteran Member Reesacat's Avatar
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    I do think having someone go with you helps-it gives a bit of a check to deal with 2 people rather than one.

    I am having to go through a situation right now. I am disabled, getting a monthly check from Social Security. I have been disabled for 20 years.
    If you are over 50 and disabled, you are entitled to get up to 1/2 deceased spouse's Social Security. I have been denied my widow's benefits once, and on the second application have been told I have to REQUALIFY as disabled to get my widow's benefits even though I am getting SSI.

    I have to go through complete psych evaluation in a couple weeks, then complete set of physicals, X-rays, PFT, etc. which I don't need, react to the chemicals, and won't find CFIDS because they are the wrong work-up.

    My beloved John always went with me to anything with SSI-he had my back. Now that I have to do it alone, I am a bit more overwhelmed. Just having him with me helped keep the abusive treatment down.

    I will be fine-EFTing to be calm and in control.

  10. #10
    Veteran Member Katee's Avatar
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Quote Originally Posted by Reesacat
    My beloved John always went with me to anything with SSI-he had my back. Now that I have to do it alone, I am a bit more overwhelmed. Just having him with me helped keep the abusive treatment down.

    I will be fine-EFTing to be calm and in control.
    Oh, Reesacat, don't you have someone who could go with you?

    I have been so badly handled by the doctors at hand who do these things.

    More than once now i've told my hubby that if i have to be hospitalized again, (last hospitalization was when we lost our 1st pregnancy 5 years ago), i will be my own "unit secretary" & make them bring me copies of the orders & labs. I've had too many screw ups when i was hospitalized before. But then i tend to back down because i don't want to be labeled as "difficult" & then have more problems with them. In both of my last hospitalizations, i SHOULD have carried thru with my intent, however, as each time several mistakes were made that i would have caught had i read the orders.

    Sigh.

    It is hard to "be strong" & stand up against the medical authority at hand, whether hospital worker (which i have been) or patient.

    I appreciate the article, Emma. It is a good one.

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    Veteran Member Maurya's Avatar
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Quote Originally Posted by Islander
    Maurya, you had me right up until "joint smoke blowing." Sorry, my mind just went off in a totally different direction!
    Perhaps this will learn me... to proofread prior to hitting the "submit" button.

    Reesacat, wish I just could beam myself over there, to be your pit bull. Nevertheless I believe that you will be totally calm, polite but firm, and in control of your situation at exactly the right time when this will be appropriate.

  12. #12
    Veteran Member Reesacat's Avatar
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Thank you Katee and Maurya! I will tap into my Steele Magnolia roots and go for it......they can KISS MY GRITS!!

  13. #13
    Administrator Islander's Avatar
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Quote Originally Posted by Reesacat
    Thank you Katee and Maurya! I will tap into my Steele Magnolia roots and go for it......they can KISS MY GRITS!!
    Attagirl, Reesacat. March right in there with ALL the paperwork and documentation of your history, and if they don't kiss your grits, tell 'em to BITE MY CLANK.

  14. #14
    EmmaPeel
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    You GO girl!! See if you can find someone trustworthy and strong to go with you Reesacat, okay? I know exactly what you mean when you have to go through these things alone, whether for the first time or the 21st time...

    Maurya, see! I told you Transporters would be a wonderful asset...! LOL

    Katee, I know what you mean. I have often told my loved one that if I ever go into the hospital, I want copies of my labwork and tests sent to my two closest friends who are wise, Amazonian "don't mess with me" nurses.

    One of them told me of her experiences this summer while being hospitalized for an emergency Hysterectomy in July...the absolute worst month to be having surgery!

    She is a proud nurse, and felt she could handle the staff, but she fast realized that when you are a patient you are very vulnerable especially if you are in pain. They labeled her a 'difficult' patient when she asked for better pain control (they had to take her bowel out as she has so many adhesion's from Endometriosis).

    They were snippy with her after I called and gave them a tongue lashing for not being on top of her pain management...so she left the hospital early with permission from the surgeon since she had grown daughters at home and me less than 5 minutes away...

    So yes, even healthcare professionals are subject to needing advocacy.

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    Veteran Member bmc65's Avatar
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    Default Re: WHEN the Nurse Disagrees with the Doctor

    Hope all goes well Reesacat.
    EmmaPeel thanks for posting this. I will have to read it now and again when I need a bit of pepping up.
    Now, I apologize for bringing JM into this conversation, but did anyone else notice that on his site, when you go to your profile edit page you are asked if you are a health care practitioner, and RN is about the only field not mentioned? How is a certified personal trainer or LMT more relevant as a health care practitioner than an RN? Sorry, but that just bugs me and I bring it up because it seems to tie in to the dynamic between doctors and nurses.
    Last edited by bmc65; 11-21-10 at 05:04 PM.

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