As nurses, we sometimes find ourselves asking, “What should I do here?” We seek guidance, support, and consensus from our colleagues and coworkers regarding complex situations. Bioethicists should be a part of the team that nurses consult when confronting these issues. Although they are often not healthcare providers, bioethicists can offer a distinct viewpoint or perspective that provides us with additional fuel for critical thinking. In the field of bioethics, we seek answers to tough moral questions in healthcare and the biological sciences by applying ethical theories to difficult cases, practices, and policies. The following discussion addresses how nurses should proceed when they question the safety or appropriateness of a healthcare provider's order.
—Alison M. Colbert, PhD, PHCNS-BC
WHEN A NURSE believes that an order is not in the best interests of the patient, it is his or her ethical obligation to question and discuss the decision with the provider. A nurse should never implement an order that he or she believes is unsafe or likely to cause serious harm.1,2 In some cases, however, an order does not qualify as unsafe, but the nurse still views it as incorrect. Although the order falls within acceptable medical practices, the patient may stand to be harmed to some degree in comparison with an alternative option. The nurse's ethical obligation in these situations is not always straightforward.
This article discusses how the application of a decision-making framework based on a spectrum of urgency can help nurses make sound decisions when faced with a questionable order issued by a physician or other healthcare provider with prescriptive authority.
An initial collaborative questioning and discussion is an appropriate first step. But what happens when communication breaks down, when the provider's explanation is not convincing, or, in emergencies, when there is no time for discussion? Should a nurse implement an order that he or she believes is not the best course of treatment? The ethical obligations in those situations are less clear if:
- the benefit of an alternate order might be small for the patient
- there is a legitimate possibility that the nurse is mistaken
- the patient could be harmed if the prescribed treatment is delayed.
Consider the spectrum of urgency
Nurses can apply a general decision-making framework to determine the best response in these difficult situations. It does not offer a cut-and-dry solution or provide a formula for a clear yes-or-no answer in every scenario, but it provides a way of thinking critically in situations in which a nurse is unsure about a provider's order. Originally described by Martin Benjamin (a bioethicist) and Joy Curtis (a nurse), the framework is based on what they defined as a spectrum of urgency.1
The idea is simple: Consider a range of scenarios from least urgent (a delay in care would not harm the patient) to most urgent (a delay in care would seriously harm the patient). They suggest that the decision to refrain from carrying out an order depends on where it falls on the spectrum of urgency. The more urgent the case, the stronger the nurse's reasons for carrying out the order. In sufficiently urgent cases, the reasons for implementing an order outweigh the reasons against it.
Benjamin and Curtis' framework supports a widely accepted view that it is perfectly acceptable to refrain from carrying out an order in low-urgency cases if the nurse believes an order is not in the patient's best interests. In such cases, “reflection, collection of further data, debate, and discussion” is appropriate.1 Because waiting incurs little harm and may yield a potentially significant benefit, this response is in the patient's best interests. The nurse can seek clarification on the rationale behind the order, and, if need be, make the argument against it. The provider can then respond. The subsequent discussion will (ideally) result in a resolution: Either one party concedes, or the parties realize that each position was partly correct and treatment can proceed. There is little to lose from this process in low-urgency cases.
For example, a patient comes to the ED with a deep laceration to her foot. She rates the pain intensity as a 4/0-10 and the ED physician prescribes an opioid analgesic. However, the patient has disclosed to the nurse that she is currently in recovery from opioid abuse, with 8 months of sobriety. The nurse suspects that the risk of relapse might outweigh the analgesic benefits of opioids at this time and that consultation with a substance abuse specialist prior to initiating medications would better serve the patient.
Despite the patient's moderate pain, this situation falls on the low-to-middle end of the spectrum of urgency, so the nurse has time to raise legitimate questions and delay the implementation of the physician's order. The nurse might ask if the physician was aware of the patient's history of opioid use disorder and has discussed alternative analgesics with the patient. If not, the nurse can inform the physician that the patient prefers to discuss other pain relief options before the administration of opioids. By taking this route, both the nurse and the patient can explore a risk-benefit analysis of pain relief versus the possibility of relapse, and weigh the benefits of delaying the administration of an opioid analgesic until less potentially addictive alternatives have been tried.
In some situations, however, a lengthy discussion about an order or a delay in implementing it could be dangerous. Someone must make the decision in time-sensitive cases—or, when patients are capable of making the decision and there is time to do so, facilitate the informed-consent process and recommend treatment. Legally, physicians and others with prescriptive authority have that responsibility due to their specific education, training, and expertise.3
In high-urgency cases, anything beyond a relatively quick initial questioning of a possible error risks patient safety. Because a delay in care would likely be worse than a suboptimal but not unsafe course of treatment, the best thing for the patient is to carry out the order in a timely fashion.1 After the treatment proceeds, a more in-depth discussion with the provider can occur.1
For example, imagine that a physician recommends immediate surgery for a 75-year-old patient with acute appendicitis. Given the risks of surgery for older adults, a nurse believes that the overall best treatment is to immediately administer I.V. antibiotics and possibly avoid a risky surgical procedure. Due to the serious consequences that could result from a delay in care, this is a high-urgency case. Despite what the nurse believes regarding the risks of surgery for this patient, surgery is not outside the bounds of proper medical practice. Although the nurse does not believe surgery is the best possible option, the physician has the right and obligation to weigh the risks and benefits of surgery for this particular patient. This is a case in which the nurse would be right to prepare the patient for surgery after a brief initial questioning. Initiating a lengthy conversation about whether antibiotics would be preferable to surgery or going up the chain of command would cause a delay in care that could be more harmful to the patient.
Each individual case will be a judgment call on the part of the nurse in assessing where the situation falls on the spectrum of urgency. Determining the level of urgency necessary to implement an order with which the nurse disagrees will also be a judgment call. Although nurses will have differing views on where to draw the line, the spectrum of urgency offers a rational guide for decision-making.
Making judgment calls
This framework does not imply that nurses should follow orders blindly in high-urgency cases, nor does it apply to orders that the nurse knows are unsafe, even in high-urgency situations. If the order stands to harm the patient significantly, the nurse should refrain from implementing it no matter what the level of urgency. Carrying out an unsafe order will be worse than a delay in care. That said, it can be controversial to determine when an order rises to the level of being unsafe versus when it is merely not the best option for the patient, which is another kind of judgment call the nurse may have to make.
Finally, the framework leaves room for briefly questioning safe orders in high-urgency cases. We must distinguish between questioning an order, such as by asking for an explanation of the order's rationale or voicing some level of disagreement, and refraining from implementing one. In some high-urgency cases, there may be a short time period to question an order but the length and degree of questioning should be calibrated, in part, based on the urgency of the situation.
Clinical vs. ethical disagreements
So far, we have focused on clinical disagreements in which nurses and providers disagree about a clinical issue with a bearing on a patient's best interests, but what about ethical disagreements? An ethical disagreement is a dispute about the morality of a certain act given a mutual understanding of the factual, clinical aspects of the case. Does the spectrum of urgency apply to these cases as well?
Consider a situation in which a competent patient has clearly requested a do-not-resuscitate (DNR) order, but the physician has refused to write it because he or she believes that the patient is making the wrong decision. When the nurse asks the physician why he or she will not write a DNR order, the physician states that the prospects for recovery after CPR are relatively good for this patient. The nurse agrees with the physician in that regard. In fact, the nurse does not disagree with the physician about any clinical, medical, or scientific facts relevant to this patient's treatment. The disagreement is about whether performing CPR on this patient would be morally right. The physician's rationale for not writing the DNR order is straightforwardly paternalistic, and the nurse believes that paternalism is unethical, especially in cases of treatment refusals by competent adult patients.
If the patient experiences cardiopulmonary arrest in the nurse's presence, this would be an extremely urgent case. Based on the spectrum of urgency, the nurse would perform CPR as required according to hospital policy and laws that mandate CPR in the absence of a DNR order. That said, before the patient experiences such a crisis, the nurse could (and probably should) initiate an ethics consultation to advocate for the patient's wishes. If the patient arrests before that is done, many would argue that it is ethically proper for a nurse to refuse to perform CPR despite the potential legal implications, given the patient's clear and competent refusal of treatment. Situations like this suggest the spectrum of urgency applies to clinical disagreements only, not ethical ones.
An inherent part of the spectrum of urgency is deference to someone with authority in the area of dispute. That way, serious harm from a delay in care can be minimized or prevented. In the case of disputes involving medical decisions, the physician has the expertise and authority to make the call. When it comes to ethical disputes, however, neither physicians nor nurses have that kind of authority—in other words, a physician has no greater ethical insight or expertise than a nurse.
Consequently, the spectrum of urgency framework appears inapplicable to purely ethical disagreements. Nurses should apply the framework to clinical disputes only, and they should feel more free to refuse to implement orders when all the clinical facts are agreed upon and the dispute is purely ethical in nature.
Balancing risks and benefits
Nurses sometimes disagree with healthcare providers' orders, even after collaborative discussion. Because delays in care have the potential to harm patients, it is helpful to have a general framework in place for deciding when refraining from carrying out an order is appropriate. The spectrum of urgency framework balances the risks of a delay in care with the benefits of correcting an order that may not be in a patient's best interests.
Although this framework is subjective to some extent, it provides a rational and ethical basis for these decisions, particularly in high-urgency cases. Individual nurses will have to decide on a case-by-case basis whether the benefits of improved patient care outweigh the risks of a delay in care, but the spectrum of urgency framework can offer guidance in a variety of clinical situations.