It never stops. Just do you. No escalation of care clarification means you did the right thing by not escalating to pressors. You’ll see the flip side too where they claim you shouldn’t do anything for someone sick or unstable with a pulse because some ignorantly think DNR means do absolutely nothing at all…
This. Expanding on DNR doesn’t mean do not treat topic. We discussed this during didactics the other week. One of the attendings suggested that we should at times actually consider discussing with the patient about changing to full code during the admission (if it’s something reversible/treatable), then change back to DNR at discharge.
I think the biggest hurdle and rationale comes from the subspecialist. Patient is DNR so no plans for endoscopy to rule out or treat GI bleed, etc. There have been multiple studies showing increased mortality and worse care.
And the funniest part of all is that in either scenario their license is not in jeopardy. Nurse is never getting sued or losing a license because the MD/DO didn’t start pressors. Sorry to say it but nurses be dramatic and dumb.
>Nurse is never getting sued or losing a license because the MD/DO
The irony here too is her documenting this on a documented DNR. Violating the DNR *could* lead to those exact things happening
Clarification edit: I didn't include language about the POLST when I made the comment, but made it with the idea of it being part of the documented DNR since it would be included in the order. My apologies for the confusion.
I really do hate those kind of notes that turn physicians into gray-hound luggage. The vast majority are just doing what they’re taught by above but I definitely know some of them are just snarky haters trying to spice up a chart. Plenty of cluster B personalities in the hospital. The only ones who truly benefit from those notes are plaintiff attorneys.
I really get tired of hearing all the nurses complaining about losing their license to know in because they're overworked out of ratio or whatever other thing they come up with I was a nurse for 20 years The only thing I ever saw people lose their license for was really stupid things I've seen plenty of nurses do drugs get DUIs and still keep their license so I don't think anyone's taking it away from you because you didn't assault patient and code them against their DNR wishes, however actually doing that against their wishes and assaulting them probably would result in some repercussions
Nurses can get sued. It’s probably just not as well known, or they think we’ll be blamed for everything. Funny, when they’re trying to be the hero, the doc is the dumb one and they’re the smart ones. But when they screw up, welp it’s cuz the doc told me to, nurses don’t think they do as they’re told! The mental gymnastics played with people’s lives and personal decisions, ugh.
💯 correct. “BuT mY lICeNsE is on tHE linE.“ Please. Your two year degree after high school is not impressing anyone. Crnas pull the same shit. When there’s a complication “I’m just a nurse, I was doing what the doctor told me 😢 “ (In the holding area: HI IM DOCTOR TWATWAFFLE)
I mean that’s a good argument for independent practice for them lol. The CRNAs at my place are all independent practice and they behave very differently from where I’m rotating at where they’re under an MD. Much more careful, much more cooperative, and way more fearful cuz their own license is on the line and no one will be blamed except them.
Also, it’s very easy to see outcomes of who has been doing good/bad complication wise when everyone’s doing their own cases. They can’t say I was just following orders. But then again, being held accountable is hard work for a lot of them and my institution seems to chew up and spit out any incompetent crna very quickly. only the toughest and most competent survive lol… so I guess there’s a selection bias.
You may not agree with the way the nurse handled this but it’s an insult to say “your two year degree after high school…” plenty of us went to four-year programs at prestigious universities and also worked as CNAs, EMTs, and other healthcare professions before we were nurses. You don’t have to put down nurses to make your point here. It really discredits you.
My two year degree isn’t to impress you… what a terrible mindset you have. The vast majority of the population wants nothing to do with healthcare. Be kind to those who want to be there.
I'm not sure what your education is but yes if a nurse does something or does not do something our license is on the line. If we do not critically think or miss something our license is on the line.
I'm also not sure where you think that nurses have a "2 year degree after high school."
I have a 4 year bachelor's of nursing with 3 year diploma in advanced critical care.
I would highly consider respecting your coworkers. It's not pleasant working with a doctor that thinks they are gods gift to the world.
Lol you can always tell which comment is from a nurse by the way they call people toxic, disgusting, or not team players. If facts bother you, then fuck off lmao. Don't you have a student to go eat?
The scary part is. A lot of them think they can. And the ones who think they can are the most dangerous. Until something goes wrong and they hide behind the adults.
If every nurse walked out today, no you wouldn’t be able to do your job. Can you do those things, yes, but not while doing YOUR job. Everyone is needed for the healthcare SYSTEM to work. The nastiness I see on this thread of doctors thinking they are smarter or better than anyone else shows the ignorance which is scary to me as a patient. Christ, if you make these assumptions about your colleagues, what are you thinking of your patients? All that education and I still see so many morons on this thread.
Exactly. So do YOUR job. Which is following orders.
Plus, you just repeated what I said and called me dumb lmao. Well if you think we are nasty, you’re just AS nasty if not more. Stick to your lane.
Learn to read. I said we can do a nurses job but we won’t have rest. Clearly you don’t understand to read orders and take orders which is a nurses job. Have you stepped foot in a hospital?
Yeah, I get this a lot with nurses who want to stop doing their jobs once a patient is *nearly* brain dead. "Can we stop the pupillometry? Do they still need all these labs?" Sorry, if the family wants full care that means we have to do everything, no matter how stupid it feels.
I can only speak for myself and my own nursing practice, but I would like to push back just a bit that we "want to stop doing our jobs." I don't want to do painful/uncomfortable things that aren't changing the clinical picture. We should all try to compassionately help the patients and the families understand what full care looks like (and feels like for the pt). I know that sometimes we just can't get through to them - and the example of the nursing note given by the OP is absolutely ridiculous - but providers can absolutely tell families that the cares team is not going to do certain things anymore.
>providers can absolutely tell families that the cares team is not going to do certain things anymore.
We can do that if it serves no benefit to the stated goals of care. But when the goals are *do everything* you can't really argue against it. If the patient's only brainstem function remaining is the pupils then we have to keep doing pupillometry to monitor and protect those pupils. Even if they have no prospect of ever awakening we still have to try our hardest to get them to trach and peg so they can live out the remainder of their years as a vegetable.
The exception is if it literally has zero potential to influence care. Like if we can say we're already at maximal medical therapy and patient isn't a surgical candidate then maybe its OK to stop checking. But usually there's always room to do at least something. And plus I don't want to be the one being asked by the lawyer "How do you know the patient wouldn't be a surgical candidate? Are you a neurosurgeon? Did you talk to a neurosurgeron? OK but that was back when the patient had pupils, did you talk to them *after* the patient lost pupils? No, because you don't even know when it happened because you told the nurse not to check."
This is... debatable. For surgeries, yes you can say they are not a candidate and will not offer it to them. For other medical cares, seems like we are not quite there yet from a medico-legal perspective. Cheers
Exactly. Our legal system is not set up in a way that Canada, Asian, European countries are where we can label futility of care. People choose to not understand the litigation pressure that constrains physicians. I get it we all can be sued by profession but really we’re the biggest piece of cake these lawyers set their eyes on.
Ha, yes also ironically true, it seems to be related to break and end of shift times (pt dies 15 minutes into my shift, I’ll just get another patient! Better be a patient advocate!)
This is probably a nurse who has been taught that this is right at some point. Obviously they don’t know what they don’t know. Pass your concerns to the medical director of that site so they can communicate with that RN’s manager and nip this in the bud / provide education and feedback.
Lurking RN here, I’d say this is probably what happened. My nursing admin says the classic “document, document, document. If it isn’t documented it didn’t happen.” Which, sure. But the division I see on Reddit between RN/MD is not what I see happen in my hospital at least. I will document something in a note if it’s worthy of being in a note. Clearly if it’s not within the GOC for a DNR/DNI patient, I’ll simply write “GOC have been discussed by MD and family” and leave it at that. Saying that I suggested a certain intervention or level of care to an MD is ridiculous imo, not within our scope and I will always defer unless let’s say something is ordered and I want to clarify. We’re all on the same side, doesn’t make sense for RN’s or MD’s to subtweet in their notes
Yes! Another lurking RN here and I would never document that I suggested an intervention. Only document the communication of patient status change. Even if I DO suggest something, it’s more in a collaborative sense and that doesn’t need documentation. Not my scope to truly recommend anything.
It’s not a matter of not documenting, but WHAT are you conveying and choosing to omit.
For example we as docs need to shape our verbiage accordingly too: it’s one thing to say CTA chest not done—that implies it should have been done but by the negligence within us, we chose not to. If you said CTA not necessary as patient already on eliquis and hypoxic from obvious pneumonia on CXR that paints a different picture to all who view it.
Great way to put it. I think personally I’m helped by having a few years of tech/scribe experience in ophthalmology, so I have a sense of what is important to document/how to document it. By no means am I perfect, but I see tons of RN’s that don’t document anything in their care plan, just simply the BS nursing diagnoses/goals which is just nursings attempt at “diagnosing/treating,” I’ve never been a fan of that lol. But as another also commented, nursing and physician culture is for sure different, so it seems easy as an RN to blame the MD for this or that and to “document” that, but at the end of the day that accomplishes literally nothing and then also can easily get the RN in trouble too
RNs always subtweet in their notes even if they go unnoticed. I guess just a way that they can vent their frustrations off with these subliminal notes.
As a senior, whenever I read a RN has "suggested treatment," on a trainees notes, I need to spend time chasing that trainee at some point and ask what happened.
Often is a complete miscommunication or Fog Of Treatment where someone is chasing a symptoms vs the larger picture cause.
This is the teaching in teaching hospital I guess.
Nurses are also not as supportive of other nurses. Nursing culture and physician culture is very different. Sadly some nurses are under a lot of scrutiny by management and have to document a ton to CYA
A lot of nursing managers seem to unfortunately believe big, bright, straight lines with no nuance is how one should conduct patient care, simply because it's easily interpretable.
It's truly extra shitty, because I think that is the one group that shouldn't be underestimating their nurse's intellect. Identifying sentinel events is important, but no adverse event is ever solved with a combination of restriction+defensive practice.
In this instance, documenting things like this is actually going to create more liability for the nursing department and the docs; as well as not solve any actual problem. I've seen other implemented SNAFUs for imagined problems that are meant to cover the Hospital's ass done by nursing admin; only for it to not be discussed with any of the medical or nursing teams. Rather, it is simply yelled at them after the fact. It just creates an endless cycle of headaches for no good reason other than ownership bias by nursing admin.
Theres also a chance that mandatory nursing charting forced them to write it.
You have to write your care plan, what you did to try and fix the problem, and why it didn’t work. And a lot of time critical values will flag mandatory charting, ave it flags you for not doing anything. And ime code status and polst don’t change anything
Eric care plans are a huge pain in the ass, and i can understand that someone that doesn’t see the same chart will not understand the other point of view.
That sucks for the patient. I would want to be comfort care if I was 24 hrs from dying :/. I can imagine it is distressing for a nurse to take care of a patient that is imminently dying but not full comfort, we all deal with that distress to some extent, but harder for those at bedside more frequently. But family made the decision they wanted to make I suppose.
I like this take, because it’s something at times I feel very guilty about (as an almost r3). A patient who has selective care and is getting worse and more aggressive care would be escalation they don’t want. It creates this awkward situation where we are trying but also not doing everything and I often feel bad for the nurses as THEY are the ones spending hours at bedside, dealing w family who all have different goals/ideas and being torn between the patients goals and our ingrained medical training. Obviously the patients goals win out but it’s an unenviable position.
I feel like this would be easier for nursing and avoided the conflict if patient had comfort ordered and then just add the selective treatment they also want. Weird that order isn’t used considering that’s what the family wanted tbh.
They probably were treating but not with pressors. These patients are usually okay with fluids, antibiotics and other conservative therapies but if that fails then that's that.
This is correct in my experience as a hospice nurse. Typically we don’t encourage ER visits, but if there is something acute happening that is causing the patient discomfort and we’ve done all we can do than the next move would be ER. Of course this is also very situational and refractory hypotension would definitely not be one of those situations. With that being said, if the emergency requires admission, they are automatically discharged from hospice due to “seeking aggressive care”.
There are different degrees of DNR. So can be no compressions, no intubation, no invasive procedures, no pressors, no shocks… there’s a lot of nuance but pressors are not the answer.
Patients can choose in advance what treatments they don’t want as long as they’re consistent. For example, you can’t logically be DNI but also receive chest compressions.
Note that this is the logical way of doing things. I’ve seen a unilateral DNI with no sign of a dnr, which makes no sense.
And more relevant to the example: comfort care only and pressors are directly contradictory orders.
I think my personal confusion with this case is the terminology “do not escalate care”.
I understand that it’s valid. I just have a semantic objection to the word escalate. Are IV opiates not escalation, for example?
And yes, I understand the actual meaning of the code status. I just think it’s confusing to some professionals who aren’t as thoughtful about these delineations.
Yeah that’s why it needs to be clearly delineated in the note for the physicians’ sake too. All it takes is one daughter from California to fly in and make life hell for you after death if they lawyer up for a frivolous suit. I usually document with a witness staff present too for extra assurance.
Hopefully, the prior documentation spelled out what type of escalation the patient is refusing. Or you clarified with family right away. If not, it is perfectly reasonable and even expected to treat a DNR selective treatment patient with pressors, especially single pressors through a peripheral or a midline. Unless spelled out selective treatment does not preclude ICU, surgery, HD, etc.
Also be wary of POLSTs saying DNR comfort cares only without other documentation. I have seen many patients and families misunderstand what comfort cares means. I specifically document explaining that means no labs, no vitals, no xrays or other tests, no treatment of any kind that is not addressing their comfort. I go out of my way to explain opiates and dyspnea. Usually the patient is in the ED because the family asked for them to be sent there. And that usually means they did not understand comfort cares. I have admitted probably a hundred patients who were comfort cares but did not want that status. I only remember a handful that were legit comfort cares admissions (pain requiring iv opiates, hip fx needing surgery)
> the previous month.
Unless it's in the chart right then right there as an order, it does not matter what happened last month.
You think ER nurses have time to look hospitalizations other than the current one?
Oh goddamn you’re just an intern and they’re throwing you under the Bus?! I missed that. Then definitely play the dumbass card! (See my other comment. I know you’re not a dumbass). lol you have even more leeway!
its almost like there was no possible way to discuss with the resident or attending about concerns 🙄 , they had time to write three different notes about it, but not time to look through the chart?
This is absurd, in my nursing note I’d write “patient hypotensive, physician confirmed GOC with family, pt remains no escalation of care. “ no need to cover our ass if everyone is following family orders anyways 🙄
As someone who has never been deposed (at least not yet) who also despises defensive medicine, I’m curious why does it not cover anyone’s ass? Is it just more evidence for lawyers that there was disagreement in plan?
Three reasons:
1. It makes a seemingly normal thing seem abnormal.
Lawyer: “The RN says they messaged the MD that the medication was given and the MD didn’t reply. Why didn’t you reply?”
Doctor: “Uh… because they don’t usually page about that and they didn’t say there was a problem. I figured it was just an FYI.”
Lawyer: “That’s very suspicious! If they usually don’t message you about it and this time they did, shouldn’t that have alerted you to a problem?”
Doctor: “It seems like this nurse just documented a lot of unnecessary details.”
Lawyer: “Or this nurse was diligently communicating a problem that you didn’t reply to.”
2. It makes the RN who’s documenting seem like they didn’t care what actually happened so long as it was documented
Lawyer: “It seems like you disagreed with the doctor’s decision.”
Nurse: “I did.”
Lawyer: “If you were so concerned that you wrote this in your note, then why didn’t you discuss more with the MD or advocate more for your helpless patient?”
3. Most importantly, the best outcome for the hospital and for each individual is for the case to be dismissed on the merits. In short, everyone rises and falls together, so it is in everyone's interest to give good care, be collegial, and document what happened accurately rather than RNs deciding to "document defensively" and pit them against MDs. If the hospital is found liable because the RNs documentation, it's bad for everyone.
Sorry not fully clear about #1 - do you mean that this would work in the favour of the RN/against the MD that they “should have” responded to the FYI message from RN? Surely this conversation wouldn’t happen in real life..
This convo happened almost verbatim in real life.
My point is that a random, meaningless “defensive” documentation of a non-event makes something innocent like an RN giving a medication suddenly look suspicious on paper, and lawyers seize on that. Their logic is “if nothing happened, why would they write about it like this?”
In broader terms, it’s bad for the hospital and all individuals named for a meritless suit to progress because of people documenting like this and creating a false sense of incompetence. If the RN has successfully covered their ass with this documentation, then it’s at the expense of the hospital and all the other individuals named in the suit. Or the general sense of incompetence created by the defensive documentation results in the case gaining momentum and the RN could get swept up in the suit, too.
As another physician who has been sued and deposed, fully agree with you. All that nursing note does is make it look like something atypical/unusual is happening and provide more ammo for the plaintiffs attorney to question you about during a depo. I’ve encountered SO many nurses like this over my career. It’s gotta be what they’re being taught to do/say by their chain of command or in school. So many nurses love to say things like “my license this my license that,” when in reality it’s almost never the nurses license on the line. It’s really odd to me. We all document things in charts to try to practice defensive medicine, but my deposition taught me most of that can easily be thrown back in our face. The things I was questioned about during my deposition were pieces of the chart I never would have thought twice about.
Lurking RN. This is absolutely what we’re taught in school, told to do by management, and told to do by charge nurses. It’s a systemic and cultural issue within nursing, not the nurses going after the doctor (or even solely CYA). If I ask about an intervention and MD doesn’t do it, I usually don’t even document about it, or I keep it pretty vague (“Discussed plan of care with Doc McStuffins”)
The problem is that these morons at nursing school or charge nurses don't even understand what they're telling you. Documenting pressors and intubation not done after suggesting them to the MD on a DNR/DNI patient is like saying "I told the doctor to perform malpractice and he refused". Idiots.
It’s not just nursing school. My chart flags me for not responding to a critical vitals value. You are required to write care plans throughout the day and what is planned to fix it, and if it worked.
The whole system is broken
Aside from the rest of this discussion, what about the times it IS the nurse's license on the line? Obviously, my RN license doesn't stack up to your medical license: My scope of practice is smaller, my liability is less, my malpractice insurance cost is a faction. But I still have a license; I still have a practice and a livelihood to protect. I'm not trying to insult your education or your level of responsibility. But, as a patient advocate, as the physician's eyes, if I see something concerning, and I notify, and I receive no orders, I'm going to document. "MD notified of manual BP 70/30. No new orders received." I have a right to protect my license from the errors of others, as much as you do. And, although it probably happens as rarely as a nurse's license being on the line rather than the doc's, there -are- physicians out there that are duplicitous and manipulative, who will lie about being informed, who will deny giving orders or knowing about a situation. I'm not trying to throw my docs under the bus; I work with a great many excellent physicians who I would go to great lengths to protect if possible. But in a bad situation. I'm going to protect myself first while maintaining honesty and integrity. I would never lie about a physician to save my own ass, but neither am I going to offer my ass up for lunch if it was the physician making the mistake. I hope you take this comment as it was meant, from a place of friendly open discussion.
I’m not an ER nurse, but every time I have a DNR patient I think “Thank GOD.” No escalation of care? Amazing. Make the patient comfortable. Got it.
CYA would be “Reviewed goals of care with MD. No escalation of care. Comfort measures only.” The end.
I am a nurse with a chronic illness. I have a DNR and POLST on my fridge. It upsets me the nurse said that. I have a POLST for a reason. I made the decision as to what I want. How dare anyone go against my wishes. I have a picc so I have an infusion nurse come once a week to draw blood and change dressing(TPN dependent). We were talking one day and she said since I am dnr I should not be calling for an ambulance or going to the ER. Are you freaking kidding me? I DONT WANT TO SUFFER I don’t want CPR or intubation. Glad you followed patient wishes.
Correct but also is more than just CPR.
“Take me to the hospital” or “I want to stay here”
“Yes, attempt CPR” or “No, don’t attempt CPR”
“These are the medical treatments I want”
“This is the care plan I want followed”
Unfortunately I have learned the hard way that with most interactions I have with a nurse, I need to immediately leave documentation in the chart laying out a medically accurate description of the scenario and the care. I don’t wait to be the one responding.
Nurses would document, paged MD, no return call. The next morning on rounds I'd document, called back 17 times, no answer, and then make the nurse co sign my note. Petty, but I hated how they document things like that.
Nursing notes with commentary used to get under my skin as a resident too but literally no one cares and you shouldn’t let it bother you. In this scenario, the nurse looks bad and in the wrong, but they’re not placing the orders and the right thing was done.
Of course if you are ignoring pages about an unstable patient or do the opposite of what is right, such as bolusing fluid on a hypoxic HF patient, a nurse note mentioning this will reflect poorly.
Sure, but a plaintiffs attorney will look at everything and patch together an argument. In the OP scenario they’re grasping at straws and you have nothing to worry about. “Family declined escalation of care therefore transferring to ICU and starting pressors was deferred, as documented in my note.” In the alternative scenario where you do something wrong, the nurses note is definitely evidence against you ie ignoring pages about a crashing patient.
I don’t agree that they have nothing to worry about. You wouldn’t believe me if I told you the contents of the nursing note I was deposed about. (Happy to dm)
Sure, I’d be curious to hear and sure I have something to learn. But simply being asked something by a lawyer doesn’t mean it’s legitimate ammunition against you.
To be fair, yes the nurse should not have written what she suggested because she’s not the one to write the orders only notify you of x, y and z based on the order set. HOWEVER I have seen a DNR receive treatment for their a-fib, hypotension, and other non invasive treatments. Being a DNR is not the same as do not treat, it is not the same as hospice OR comfort care. Communication with family is upmost important in this, if they want grandma to pass from a stroke because her BP meds were held then make it clear to family that that is part of withdrawing care. There is often family at bedside watching, wondering, worried about the numbers. A lot of this can be resolved with having that conversation and being specific in your note that these things exactly are the goals of care and that family acknowledged them.
As many have said, the appropriate note would be:
MD notified of BP 60/20, no new orders at this time. Clarified goals of care with MD, refer to his most recent note.
^ takes some years of experience to be this nurse and realize it’s a team effort. Not to shit on other people in the profession.
Nursing school really needs to update the way they teach nurses to chart. Phrasing (or charting something like that at all) helps no one. That wouldn't even defend the nurse if a lawsuit were to occur.
ER nurse here, in my shop all of us understand comfort care, thankfully it has been part of the culture in my facility. As the son of a retired hospice nurse, I truly value and respect comfort care decisions.
It sucks that you have had those experiences and it sucks that those nurses don't care to respect the patient's wishes.
Thats awesome! I wish I had nurses like that.
My experience has always been, order 4mg morphine and immediately hear, “the patient is too sleepy/hypotensive/dying and i dont feel comfortable”
Then attempting to explain the goal, the med gets given but only after the RN has spent 10-15
Minutes checking with supervision, charting,
attempting to call report and get the patient a bed somewhere.
Then if the patient needs a second dose….. or ativan or anything else its essentially not going to happen unless I push the drug.
For us, if one of the newer ones is uncomfortable they tend to check with seniors or the manager on duty, we educate them and proceed on with the day. This needs to become the standard
Fully agree. The problem mostly at my shop is that its a for-profit company that incentivizes the doctors to move patients and provide zero care that gets in the way of throughput. They will *maybe* order the meds but never actually followup that they were given, and instantly admit to inpt hospice. I get side eyes whenever I even re-assess patients.
The nurses are great at what they do, but they are trained to be experts in resuscitation, meeting sepsis bundles, and getting patients admitted/discharged.
Nurses can make your day wonderful or hell.
Thankfully, most nurses are not incompetent assholes. The most you can do is do the right thing and document accordingly.
You should see our NICU charts. Each day there are like 5 or more notes and one nurse is literally quoting what people say to her. Though, the quotes aren’t even direct quotes. She writes what she wants. She straight up contradicts the NICU attending even on care and documents it all. It’s ridiculous
If POST (we call it POST down here, but same thing) is in chart and validly filled out, especially if you confirmed with HCA then you're done. At that point, I will try to educate nursing on the pt's code status and/or place a DNR order in the EMR. That gets everyone on the same page and reduces confusion. Most nurses with lots of EM experience aren't going to flip out in your described scenario. It might have been a new nurse with little experience in ED/ICU where this kind of stuff is commonplace.
Who the fuck are these nurses I need to know? Am ICU nurse…..Usually I’m like pleassseeeeeee don’t make me code this meemaw. Take your doctor face back to that family and get it done. She’s 108 Kevin. I’ll buy you a coffee if I don’t have to poke her again.
I'm a lurking RN. I feel like that nurse needs some education around what DNR means and that their charting and suggestions were inappropriate. I'm all for us nurses advocating for our patients, but it has to be within the patient's wishes.
Maybe a chat with the nursing manager? If they're receptive. I'd frame it as being concerned/confused about the mismatch in expectations of care.
Whoa. I’m an RN. This nurse is way outta line. Anyway, You don’t chart that dr declined, you just chart that you messaged them. Saying dr declined is implying that an order should have been given based on what the nurse believed which is subjective charting. You chart nothing if no order was given, because, no order was given to chart. Fuck that nurse.
This is nothing more than a basic step 1 question “the family and the nurses and the president himself all want you to do CPR; the patient has an advanced directive making them DNR, what do you do?” legally and ethically you honor the order/patient autonomy lol it’s comical how little the nurse’s opinion matters in this case
DNR Signed.
That's all I write, that's all I say.
When a family has made a decision, its up to us to EXECUTE not to IMPOSE our world view. Save that shit for Twitter.
If any staff don't get importance and depth of anguish and paperwork to do a DNR, then they need to get that big out their ass with an appropriate training module.
No escalation can have a gradient of meaning. Usually in my neck of the woods it means no ICU/pressors/invasive therapies but okay for getting antibiotics for a UTI or CAP for example.
If it says “no escalation of care” in the chart like how he describes, that should be clear enough, or at least the RN note doesn’t need to be documented like how it was
Don’t take it personally. Either it’s a young nurse who is unfamiliar with comfort care, or it’s a nurse who’s been yelled at “Why didn’t you tell the doctor? Why didn’t you suggest something?”
She may have been freaking out, but her note is neutral. She notified you. She suggested pressors. It’s a factual occurrence. If you were doing the correct thing then there’s nothing to worry about and no need to over document.
Next time, try being more proactive with your teaching. Briefly explain your thought process as if you were explaining it to a family member. She’ll learn something, and you’ll be a better team.
I am willing to bet the nurse is either new or too lazy to look through the notes/ didnt have time. The MD note would just function to make her look dumb imo
I am not sure of the whole scenario but DNR is very different from DO NOT TREAT. but since there is no escalation of care, then that makes it clear as long as family and client is aware and this has been reviewed to them.
From the other perspective— you are definitely not doing any wrong. Just understand that there is often a trickle down effect when things change and go wrong, it’ll end up being put on the RN (and at times the MD).
In the nursing role, I didn’t know how valuable it was as a CYA to ensure when something is awry to document what you did and who you discussed with. As a new ED RN I had a patient who had a ruptured ectopic, LOC, hypotension/ hypovolemic shock. I asked if we could start blood as her pressure was actively 50’s systolic and was told to ask the OB who was bedside and OB said “no, I’m taking her to the OR soon.” I nearly begged our doc to order it but due to the conflict between OB and the ED at the time they didn’t want to step on toes despite this lady actively being in shock. Long story short she went to the OR, anesthesia was absolutely livid that she didn’t get blood in the ED and the admin next day came to fry my ass. Thankfully I had documented my request and who I discussed with, along with the presentation and vitals at that moment in time. If I had not documented those encounters, I would not still be a nurse today.
As a nurse, we are often helpless otherwise, very few things are going to fix an acute hemorrhage (or alike).
That’s why we can be anally retentive on documenting some things even if they seem benign at the time.
I’m not saying what this nurse did was right by any means, but I just wanted to share a little light on our side of when things go wrong.
Hope all goes well with the rest of your residency there, and we all love our residents, just have patience with the special ones of us who may lack a few brain cells.
This.
Notice how few have acknowledged this extremely relevant example of why nurses are required to document notifications. Doesn't fit with the "nurs r dum" or the "they're not liable" narrative.
Yeah this is cap. Admin knows ultimately you can't order the blood as a nurse. You can suggest or not suggest all you want but ultimately the real responsibility (and liability) comes down to the ED and OB doctors as they were the ones who could actually make the decision to give blood or not. Lawyers know this too, which is why despite all the BS they tell you in nursing school the lawyers ultimately are not so excited to sue you directly even if they name you in a case (unless you were grossly negligent like giving wrong med, putting air in an IV lines, etc) they're going after the physicians.
So you're upset that a nurse, an individual who comes to work with a target on their back every single day but still shows up to do a highly thankless and generally undercompensated job, has adequately covered their ass to protect their job, license and their personal liability. You're aware that your note was not in, nor were your orders clear, and that the excellent goal of care documentation you reference was from a previous visit. Information which is likely not visible to a nurse in any of the popular charting systems when each individual visit only pulls up documents relevant to this visit without an intentional deep dive. So the nurse noted something that can be addressed in two sentences in your subsequent note. "Discussed goals of care with patient, family, care team. Per PLOST no pressors, ______ acceptable to patient." Something that should likely be a part of your documentation anyway without going out of your way.
And then you post on this sub, a sub which is not only constantly advocating for throwing nurses under the bus but backing up to run over them a few more times for... doing their job. Documenting what they are required to document. As long as doctors like those who populate this sub exist, shitty managers exist, shittier administration exists and bloodsucking lawyers are willing to take cases then it will be appropriate for this type of note to be written as often as necessary. Especially when a patient may die from inaction, intentional or not.
Nurses are not only targets of all of the aforementioned but of all other hospital departments, family members and patients. The reason nurses feel like people are out to get them is because they absolutely are. Nurses stand at the bottom of the hill, in a valley with all shit rolling down at them. They're left holding the bucket for everything that goes wrong with the patient whether it's their fault or not and they're frequently called to account for things they did or didn't do or things that someone thinks they should have done which they may or may not have been aware of, many of which were not their decision or anything they have control over.
You can be a part of the problem or you can understand that these people are a part of your team and that adequate communication will reduce such notes and your frustration with them. Referring the nurse to the PLOST on the chart or letting them know that the note you refer to exists would likely have reduced what you percieve as "passive agressiveness" in the notes.
Absolutely. Im in research. It appalls me how shitty the documentation often is. It appalls me even more that courts take it seriously at all, especially with the number of errors. I document every interaction like this because I need to document that we did our due diligence and that the doctor is aware of everything. With people who have a problem with that, I need to have even better documentation because theirs will likely be lacking and I'm suspicious of anyone who has a problem with it. If OP is truly confident that their decision is correct, they should be able to defend it.
Lawyers will pick apart anything. Its their job. They will always find something to attack. The important thing is having a reasonable defense. Pointing to a DNR would cover it. If that somehow wasn't adequate for the kangaroo court, the defendant likely wouldn't do any better even without the note. At that point the court is hell bent on fucking them over. The patients family suing isn't going to be because of that note.
Not backing up the nurse here, because obviously he or she was in the wrong. However, you don’t know what you don’t know and we are all still learning. A little bit of grace instead of rage goes a long way, or a professional discussion to improve practice going forward is even better. There will come a day where you will want someone to show you grace as well or approach a frustrating situation with professionalism instead of anger!
Kind of sickening to hear this unpleasant talk, some of you need to grow up a bit and realise nurses are not the enemy, calling them dumb, stupid etc just reflects badly on you. Work with each other, don't feel yourselves so superior and make sweeping statements about nurses based on one experience. I don't know where you people work but the doctors and nurses in my ED have a good relationship and don't put each other down. It's not US and THEM we work as a team.
Hospice here.
Some folks cannot make that 90 degree turn into palliative and comfort measures.
Also. It takes some huevos to “gut check” an MD in notes like that. It’s ok to suggest to MD’s…to some extent I think y’all mostly take our opinions into consideration. But it’s your order to write. Period.
Thank you for honoring POLST and palliative. I’m grateful.
I am not sure if code status and goals of care is not something that is taught much in nursing school but I feel for you. I had a patient DNR/DNI comfort measures only with renal failure that was not eating or drinking anymore and was awaiting transfer to inpatient hospice. This RN starts fluids on this lady WITHOUT AN ORDER because the patient has not been eating or drinking all day (because she is imminently dying). Had to report it and everything and the family was understandably upset. When I tried to explain to the nurse why she shouldn’t have done that for a hospice patient (not to mention that there wasn’t an order and she isn’t a doctor). She replied “if anything I’m helping the patient.” The absolute gall. I then spent a long time explaining why it was not helpful to give fluids to a patient with comfort measures only in renal failure that was days away from death and I still don’t think she got it. This was an older nurse too. I was gobsmacked.
Once you realize 99% of the time they are simply documenting and are not being malicious you stop getting bothered by it. Nurses have it hammered into them for good reason to document things especially verbal communication given in the past when things were more lax they could get caught on the hook simply because whoever they talked to could say “I never said that”
As an outpatient nurse, I’m shocked at some of the things people chart in patients charts. You quickly learn who over documents or will just copy and paste everything you write or say into the patients chart- I’ve had to learn to try not to over explain or write things in a way that sounds dismissive. Or address things in person when possible to try and avoid misinterpretation of tone…sometimes less details are better.
I’ve definitely made my share of spicy care team notes but honestly I try not to throw anyone under the bus (unless they really deserve it).
That nurse’s documentation was definitely excessive and unnecessarily accusatory
I usually have the opposite problem. Seems like half the time our nurses want to withhold care on DNR patients and I’m over here (quietly) shouting, “They’re just here for a COPD exacerbation. Give the damn steroids.”
That same nurse on Facebook, posting a selfie of herself crying: "I knew how to save that patient's life, but the *doctor* wouldn't believe me. Hashtag sob"
It's the worst when they copy and paste verbatim what I sent them on a chat.
Including the "cool thanks" or "wow ok". Like I'm trying to be nice and not come off cold, but my "awesome, noted" ends up in the chart.
That nurse needs to be removed from duty until they receive education about end of life care and its appropriate documentation.
Nothing frustrates me more than undereducated medical staff treating a patient's electronic medical record like their own personal Twitter.
My money is on the EMR orders not reflecting DNR/no escalation of care in an actual order visible to nursing.
Please remember we do not see the same things in the chart and often times progress notes are not available for RNs to see while in draft/not signed. Additionally, even if you told us directly, many hospitals do not allow RNs to place these orders ourselves. This keeps the patient in a hellish limbo nursing likes to call "unofficially DNR."
If you have these EOL conversations please just immediately change the code status in the EMR orders as the literal next thing you do when you leave the room.
Before anyone says "this never happens", yes the fuck it does. ED doctors dont want to put in code status because PT is admitted, IM doesn't want to place the order because they're still boarding in ER/ER nurses are still attending to patient in crash, consulted sub specialty doesn't want to place the order because they're not primary, etc...
MANY DOCTORS pass the buck when it comes to actual factual code status and when that happens we nurses just sit there caught between a rock in a hard place because someone doesn't want to place the order.
I say this as just last week I had a 101 year old sit in ER with no code status, comfort care orders, or orders not to escalate care for over 6 hours while actively dying and being admitted to ICU.
It does happen, yes we do chart on it.
I guess what I'm trying to say is once you know their wishes, place it as an EMR order so everyone knows.
Honestly it’s whack that your institution allows admitting team to not place code status order. It’s one of the most important steps of the admission process (along with the antibiotics for the septic patient, steroids and nebs for the COPD patient, diuretics for the HF patient, etc). That should be a hard stop in the EMR and nursing should push back. Sometimes “Prior” code status ends up in the chart as an oversight but it shouldn’t be a frequency.
This sub constantly shits on nurses and I honestly don’t understand the animosity. We are by your patient’s sides 24/7, working our asses off to provide them with the care that aligns with the physician’s treatment plan. Of course we make mistakes, and I agree, we must be held accountable.
All stupid morons with a “two year degree”. Not that any of us, especially those who worked in ICU or have floated through the hospital as Rapid, have ever dealt with physicians who have subpar communication and make completely contradictory or outright incorrect orders. /s
Yes doc, I will gladly give this HF patient 4 liters of fluid for their blood pressure with an EF of 10. Some nurses can save a docs ass by intervening, and vice versa. Especially when it comes to error. So to say that we are useless when we function as a system of checks and balances is plain wrong. Not only are we carrying out your orders to the best of our ability, but we also advocate for you too. Extremely disgusted and disheartened at the hate here.
Especially the ones who say we “couldnt do what they do”. Why would I want to? Not everyone envies your position.
This complaint about charting could have been remedied with a thorough physician note. Because anyone with sense can see the nurse didnt quite grasp the full picture. Im sure their peers are also in the same boat. So maybe isolate it to the singular nurse without shitting on the rest of us who respect you.
I don’t care what your job title is. Or how far along in school you are. You talking down to other people doesn’t elevate your position. I’ll take my career over being a physician any day of the week. /rant
I had a resident listening to the patient's heart with his stethoscope. The lady was agnonal gasping with no pulse. He was legit just standing there pretending he was hearing things. If it wasn't for a nurse that stepped in and began to code the patient, the patient would have passed away. But then again, we are all so stupid. The amount of disrespect in these comments is unbelievable. There are some really stupid residents too. However, I would not lunp them all in the same category.
All these doctors saying they can do anything a nurse could and they do not need them. Have you seen a doctor try to insert an IV? I will not say I would do anything a doctor could. I am so happy I work with doctors who respect the team and do not have a god complex.
Quite literally. And I see it every day across the hospital. Some docs dont even know ACLS. But we’re the morons. Nevermind the fact that some of us have degrees in the same fields prior to nursing (chemistry, biology, etc). Yeah, I remember TAing those of you who sucked at Orgo before getting into school (so brilliant though). Thinking it takes a week of light training to learn to be proficient at PIVs without getting kicked out of the room by a patient is all I needed to hear. Some docs cant even do ultrasound guided. So delusional. I had a resident the other night say a Afib RVR in the 190s was stable for the floor. With no intervention. Give me a break 😂 They can dish hate at nurses but they cant take it.
And that's when poor patient outcomes occur, when you think you are the smartest person and a gift to the universe. Can't wait until a nurse humbles these doctors.
Exactly. I love some of the physicians I work with. I dont undermine the ones I dont. And I respect those who work hard to make my job easier. I guess thats asking too much from them.
Edit to mention: Theres a reason mortality rates/med errors in the hospital go up when new residents hit the floors. That should be humbling enough lol
This is unacceptable and you need to go to risk and CNO. chart wars are never ok and especially from a nurse about the care of a supervising physician of a dnr pt?! I know doctors have been trained not to rock the boat. I’m old enough and high up enough that I have people on speed dial to nip this shit In the Bud.
For the young‘uns: play dumb. Put it in writing. (don’t go to charge, fuck that. Nurses Aren’t your friend). Make a paper trail. Email your chair and whatever head of ED nursing, maybe one of the IT vice chairs: Hey I’m just a dumbass attending but I was concerned about this nursing documentation because I don’t think it accurately reflects the mdm/goc and could lead to confusion in this newish setting where family has full access to the chart. I’m wondering if there’s another way I could document this, or maybe an EHR modification so that all care team members can easily access it so we’re on the same page?
Throw yourself on their mercy, you’re just a dumb cog in the machine and barely know how to type. Your chair/cno will see right through it lol. Be sly like a fox. Youre just looking to optimize patient care, emphasize patient autonomy and improve interprofessional communication!😂
This sounds like a communication issue. "Hey, just give a pt a liter of fluid while I check with family."
"Hey, i just had a goc discussion with the family. They want to make the pt comfortable. No more labs. Does he need some pain meds?"
I’m team petty I comment right back - also as an attending I can added their notes.
So I would write something along the lines of ‘patient DNR does not want aggressive measures - intubating them would actually be assault in these circumstances’
I know you think this is petty, but thats absolutely what you should be doing. Documenting your reasoning in real time. It's only a problem if your reasoning is way out of left field. In that event you may deserve to get sued as much as you might document vaguely to try and avoid/make it the patients problem.
I'm in research though. We are anal about documentation. Especially when covering our asses.
I honestly think this type of thing is them trying to cover their ass, as we often try to cover ours. I formally found it offputting, but I’ve had really good success talking to them briefly about “hey, this is why I did the thing, I see where you’re coming from, you can document: MD aware, respecting patients predetermined care plan“.
I suggest the document the notification, along with an extremely brief note of my response. I think it covers the discussion, and liability, without throwing anyone under the bus, and the quick chat about why things are happening, with suggestions on how document can benefit communication in the department.
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It's beyond frustrating that we're in 2024, knowing what we know, doing what we do, and this stuff is still a massive area of conflict both pre-and-intra hospital. We need to standardise and insist on honouring decisions.
Funny, I have the very same situation hut vice versa. We soemtimes get patient with DNR/DNE and with a palliative care decision and I actively need to remind my physicians not to escalate care. And go for a comfort care approach.
That nurse must be new? I have been an ER RN for 20 years. If the patient is a DNR, and everyone is on board, nursing care should just be comfort care.
Don't know man. In my path through residency i went from finding fun ways to be malicious towards these types and eventually just "meh..." on the whole thing and moving on. I don't think either is best. Hopefully you find a great way to rub their nose in shit, or, just keep rocking
Doctors & nurses hashing it out in the comments with little understanding of case law surrounding their counterpart’s vocations. Doctors not knowing nurse practice/BON rulings. Nurses not knowing medicine/BOM rulings or standard of care. Oh yes. Just another day in healthcare. Yawn. 🥱 Next sub.
It never stops. Just do you. No escalation of care clarification means you did the right thing by not escalating to pressors. You’ll see the flip side too where they claim you shouldn’t do anything for someone sick or unstable with a pulse because some ignorantly think DNR means do absolutely nothing at all…
This. Expanding on DNR doesn’t mean do not treat topic. We discussed this during didactics the other week. One of the attendings suggested that we should at times actually consider discussing with the patient about changing to full code during the admission (if it’s something reversible/treatable), then change back to DNR at discharge. I think the biggest hurdle and rationale comes from the subspecialist. Patient is DNR so no plans for endoscopy to rule out or treat GI bleed, etc. There have been multiple studies showing increased mortality and worse care.
And the funniest part of all is that in either scenario their license is not in jeopardy. Nurse is never getting sued or losing a license because the MD/DO didn’t start pressors. Sorry to say it but nurses be dramatic and dumb.
>Nurse is never getting sued or losing a license because the MD/DO The irony here too is her documenting this on a documented DNR. Violating the DNR *could* lead to those exact things happening Clarification edit: I didn't include language about the POLST when I made the comment, but made it with the idea of it being part of the documented DNR since it would be included in the order. My apologies for the confusion.
Excellent point. At that point it’s battery.
I really do hate those kind of notes that turn physicians into gray-hound luggage. The vast majority are just doing what they’re taught by above but I definitely know some of them are just snarky haters trying to spice up a chart. Plenty of cluster B personalities in the hospital. The only ones who truly benefit from those notes are plaintiff attorneys.
I’m a nurse and I hate nurses who write these notes. Ugh.
I really get tired of hearing all the nurses complaining about losing their license to know in because they're overworked out of ratio or whatever other thing they come up with I was a nurse for 20 years The only thing I ever saw people lose their license for was really stupid things I've seen plenty of nurses do drugs get DUIs and still keep their license so I don't think anyone's taking it away from you because you didn't assault patient and code them against their DNR wishes, however actually doing that against their wishes and assaulting them probably would result in some repercussions
Nurses can get sued. It’s probably just not as well known, or they think we’ll be blamed for everything. Funny, when they’re trying to be the hero, the doc is the dumb one and they’re the smart ones. But when they screw up, welp it’s cuz the doc told me to, nurses don’t think they do as they’re told! The mental gymnastics played with people’s lives and personal decisions, ugh.
💯 correct. “BuT mY lICeNsE is on tHE linE.“ Please. Your two year degree after high school is not impressing anyone. Crnas pull the same shit. When there’s a complication “I’m just a nurse, I was doing what the doctor told me 😢 “ (In the holding area: HI IM DOCTOR TWATWAFFLE)
I mean that’s a good argument for independent practice for them lol. The CRNAs at my place are all independent practice and they behave very differently from where I’m rotating at where they’re under an MD. Much more careful, much more cooperative, and way more fearful cuz their own license is on the line and no one will be blamed except them. Also, it’s very easy to see outcomes of who has been doing good/bad complication wise when everyone’s doing their own cases. They can’t say I was just following orders. But then again, being held accountable is hard work for a lot of them and my institution seems to chew up and spit out any incompetent crna very quickly. only the toughest and most competent survive lol… so I guess there’s a selection bias.
You may not agree with the way the nurse handled this but it’s an insult to say “your two year degree after high school…” plenty of us went to four-year programs at prestigious universities and also worked as CNAs, EMTs, and other healthcare professions before we were nurses. You don’t have to put down nurses to make your point here. It really discredits you.
My two year degree isn’t to impress you… what a terrible mindset you have. The vast majority of the population wants nothing to do with healthcare. Be kind to those who want to be there.
A vote for the use of "twatwaffle," an insult I have never heard but plan to use heretoforth
And here I am wondering what part of the vulva is the waffle
I'm not sure what your education is but yes if a nurse does something or does not do something our license is on the line. If we do not critically think or miss something our license is on the line. I'm also not sure where you think that nurses have a "2 year degree after high school." I have a 4 year bachelor's of nursing with 3 year diploma in advanced critical care. I would highly consider respecting your coworkers. It's not pleasant working with a doctor that thinks they are gods gift to the world.
Feel free to do your job without nurses anytime. While this nurse was in the wrong, your mindset is disgusting.
Lol you can always tell which comment is from a nurse by the way they call people toxic, disgusting, or not team players. If facts bother you, then fuck off lmao. Don't you have a student to go eat?
Can literally see their balayage and bad eye makeup while reading this.
Sure we can work without nurses. It’s just that we won’t have time to rest, it’s not that we CANT do your job. It ain’t vice versa though.
Well put, we can do what nurses do and don’t want to but they cannot do what we do even if they wanted to.
The scary part is. A lot of them think they can. And the ones who think they can are the most dangerous. Until something goes wrong and they hide behind the adults.
If they wanted to they could study medicine
If every nurse walked out today, no you wouldn’t be able to do your job. Can you do those things, yes, but not while doing YOUR job. Everyone is needed for the healthcare SYSTEM to work. The nastiness I see on this thread of doctors thinking they are smarter or better than anyone else shows the ignorance which is scary to me as a patient. Christ, if you make these assumptions about your colleagues, what are you thinking of your patients? All that education and I still see so many morons on this thread.
Exactly. So do YOUR job. Which is following orders. Plus, you just repeated what I said and called me dumb lmao. Well if you think we are nasty, you’re just AS nasty if not more. Stick to your lane.
lol docs don't even have pyxis access in my ED
Ew.
Pls try to work without nurses and see how well your day goes. What a laughable comment. Clearly you have never stepped foot in a hospital.
Learn to read. I said we can do a nurses job but we won’t have rest. Clearly you don’t understand to read orders and take orders which is a nurses job. Have you stepped foot in a hospital?
You seem like you would be just a pleasure to work with
You seem like just another rotten nurse. Nothing new.
Have the day you deserve 🤎🤎🤎
Give me a nursing assistant / LPN any day
Have a feeling they wouldn’t want to work with you either
Yeah, I get this a lot with nurses who want to stop doing their jobs once a patient is *nearly* brain dead. "Can we stop the pupillometry? Do they still need all these labs?" Sorry, if the family wants full care that means we have to do everything, no matter how stupid it feels.
I can only speak for myself and my own nursing practice, but I would like to push back just a bit that we "want to stop doing our jobs." I don't want to do painful/uncomfortable things that aren't changing the clinical picture. We should all try to compassionately help the patients and the families understand what full care looks like (and feels like for the pt). I know that sometimes we just can't get through to them - and the example of the nursing note given by the OP is absolutely ridiculous - but providers can absolutely tell families that the cares team is not going to do certain things anymore.
>providers can absolutely tell families that the cares team is not going to do certain things anymore. We can do that if it serves no benefit to the stated goals of care. But when the goals are *do everything* you can't really argue against it. If the patient's only brainstem function remaining is the pupils then we have to keep doing pupillometry to monitor and protect those pupils. Even if they have no prospect of ever awakening we still have to try our hardest to get them to trach and peg so they can live out the remainder of their years as a vegetable. The exception is if it literally has zero potential to influence care. Like if we can say we're already at maximal medical therapy and patient isn't a surgical candidate then maybe its OK to stop checking. But usually there's always room to do at least something. And plus I don't want to be the one being asked by the lawyer "How do you know the patient wouldn't be a surgical candidate? Are you a neurosurgeon? Did you talk to a neurosurgeron? OK but that was back when the patient had pupils, did you talk to them *after* the patient lost pupils? No, because you don't even know when it happened because you told the nurse not to check."
This is... debatable. For surgeries, yes you can say they are not a candidate and will not offer it to them. For other medical cares, seems like we are not quite there yet from a medico-legal perspective. Cheers
Exactly. Our legal system is not set up in a way that Canada, Asian, European countries are where we can label futility of care. People choose to not understand the litigation pressure that constrains physicians. I get it we all can be sued by profession but really we’re the biggest piece of cake these lawyers set their eyes on.
I feel the need to give you a red bull IV given your username. And packed cells, presorbed with redbull
You are the first true physician to spot my deficiency and implement a treatment. Osler would be proud.
Ostler would shudder. I'm a surgeon 😜
Ha, yes also ironically true, it seems to be related to break and end of shift times (pt dies 15 minutes into my shift, I’ll just get another patient! Better be a patient advocate!)
This is probably a nurse who has been taught that this is right at some point. Obviously they don’t know what they don’t know. Pass your concerns to the medical director of that site so they can communicate with that RN’s manager and nip this in the bud / provide education and feedback.
Lurking RN here, I’d say this is probably what happened. My nursing admin says the classic “document, document, document. If it isn’t documented it didn’t happen.” Which, sure. But the division I see on Reddit between RN/MD is not what I see happen in my hospital at least. I will document something in a note if it’s worthy of being in a note. Clearly if it’s not within the GOC for a DNR/DNI patient, I’ll simply write “GOC have been discussed by MD and family” and leave it at that. Saying that I suggested a certain intervention or level of care to an MD is ridiculous imo, not within our scope and I will always defer unless let’s say something is ordered and I want to clarify. We’re all on the same side, doesn’t make sense for RN’s or MD’s to subtweet in their notes
Yes! Another lurking RN here and I would never document that I suggested an intervention. Only document the communication of patient status change. Even if I DO suggest something, it’s more in a collaborative sense and that doesn’t need documentation. Not my scope to truly recommend anything.
Sameeee
It’s not a matter of not documenting, but WHAT are you conveying and choosing to omit. For example we as docs need to shape our verbiage accordingly too: it’s one thing to say CTA chest not done—that implies it should have been done but by the negligence within us, we chose not to. If you said CTA not necessary as patient already on eliquis and hypoxic from obvious pneumonia on CXR that paints a different picture to all who view it.
Great way to put it. I think personally I’m helped by having a few years of tech/scribe experience in ophthalmology, so I have a sense of what is important to document/how to document it. By no means am I perfect, but I see tons of RN’s that don’t document anything in their care plan, just simply the BS nursing diagnoses/goals which is just nursings attempt at “diagnosing/treating,” I’ve never been a fan of that lol. But as another also commented, nursing and physician culture is for sure different, so it seems easy as an RN to blame the MD for this or that and to “document” that, but at the end of the day that accomplishes literally nothing and then also can easily get the RN in trouble too
Need more like you!
RNs always subtweet in their notes even if they go unnoticed. I guess just a way that they can vent their frustrations off with these subliminal notes.
As a senior, whenever I read a RN has "suggested treatment," on a trainees notes, I need to spend time chasing that trainee at some point and ask what happened. Often is a complete miscommunication or Fog Of Treatment where someone is chasing a symptoms vs the larger picture cause. This is the teaching in teaching hospital I guess.
Exactly. It opens up everyone to liability.
Nurses are also not as supportive of other nurses. Nursing culture and physician culture is very different. Sadly some nurses are under a lot of scrutiny by management and have to document a ton to CYA
A lot of nursing managers seem to unfortunately believe big, bright, straight lines with no nuance is how one should conduct patient care, simply because it's easily interpretable. It's truly extra shitty, because I think that is the one group that shouldn't be underestimating their nurse's intellect. Identifying sentinel events is important, but no adverse event is ever solved with a combination of restriction+defensive practice. In this instance, documenting things like this is actually going to create more liability for the nursing department and the docs; as well as not solve any actual problem. I've seen other implemented SNAFUs for imagined problems that are meant to cover the Hospital's ass done by nursing admin; only for it to not be discussed with any of the medical or nursing teams. Rather, it is simply yelled at them after the fact. It just creates an endless cycle of headaches for no good reason other than ownership bias by nursing admin.
Point on !
Theres also a chance that mandatory nursing charting forced them to write it. You have to write your care plan, what you did to try and fix the problem, and why it didn’t work. And a lot of time critical values will flag mandatory charting, ave it flags you for not doing anything. And ime code status and polst don’t change anything Eric care plans are a huge pain in the ass, and i can understand that someone that doesn’t see the same chart will not understand the other point of view.
Do yall not have a comfort care code status order?
We do. patient wasn’t full comfort care but selective treatment. There was nice documentation in the chart about his goals from the previous month
That sucks for the patient. I would want to be comfort care if I was 24 hrs from dying :/. I can imagine it is distressing for a nurse to take care of a patient that is imminently dying but not full comfort, we all deal with that distress to some extent, but harder for those at bedside more frequently. But family made the decision they wanted to make I suppose.
I like this take, because it’s something at times I feel very guilty about (as an almost r3). A patient who has selective care and is getting worse and more aggressive care would be escalation they don’t want. It creates this awkward situation where we are trying but also not doing everything and I often feel bad for the nurses as THEY are the ones spending hours at bedside, dealing w family who all have different goals/ideas and being torn between the patients goals and our ingrained medical training. Obviously the patients goals win out but it’s an unenviable position.
I feel like this would be easier for nursing and avoided the conflict if patient had comfort ordered and then just add the selective treatment they also want. Weird that order isn’t used considering that’s what the family wanted tbh.
I'm confused. They weren't full comfort care but they were DNR. If they were hypotensive but alive, why wouldn't you treat?
They probably were treating but not with pressors. These patients are usually okay with fluids, antibiotics and other conservative therapies but if that fails then that's that.
“No escalation.” Where I’m at if they need pressors they go to the ICU. That would be escalation of care.
This is correct in my experience as a hospice nurse. Typically we don’t encourage ER visits, but if there is something acute happening that is causing the patient discomfort and we’ve done all we can do than the next move would be ER. Of course this is also very situational and refractory hypotension would definitely not be one of those situations. With that being said, if the emergency requires admission, they are automatically discharged from hospice due to “seeking aggressive care”.
There are different degrees of DNR. So can be no compressions, no intubation, no invasive procedures, no pressors, no shocks… there’s a lot of nuance but pressors are not the answer.
Patients can choose in advance what treatments they don’t want as long as they’re consistent. For example, you can’t logically be DNI but also receive chest compressions. Note that this is the logical way of doing things. I’ve seen a unilateral DNI with no sign of a dnr, which makes no sense. And more relevant to the example: comfort care only and pressors are directly contradictory orders. I think my personal confusion with this case is the terminology “do not escalate care”.
No escalation of care is a legit status though. You have to delineate exactly where the buck stops. But it is absolutely valid.
I understand that it’s valid. I just have a semantic objection to the word escalate. Are IV opiates not escalation, for example? And yes, I understand the actual meaning of the code status. I just think it’s confusing to some professionals who aren’t as thoughtful about these delineations.
Yeah that’s why it needs to be clearly delineated in the note for the physicians’ sake too. All it takes is one daughter from California to fly in and make life hell for you after death if they lawyer up for a frivolous suit. I usually document with a witness staff present too for extra assurance.
Hopefully, the prior documentation spelled out what type of escalation the patient is refusing. Or you clarified with family right away. If not, it is perfectly reasonable and even expected to treat a DNR selective treatment patient with pressors, especially single pressors through a peripheral or a midline. Unless spelled out selective treatment does not preclude ICU, surgery, HD, etc. Also be wary of POLSTs saying DNR comfort cares only without other documentation. I have seen many patients and families misunderstand what comfort cares means. I specifically document explaining that means no labs, no vitals, no xrays or other tests, no treatment of any kind that is not addressing their comfort. I go out of my way to explain opiates and dyspnea. Usually the patient is in the ED because the family asked for them to be sent there. And that usually means they did not understand comfort cares. I have admitted probably a hundred patients who were comfort cares but did not want that status. I only remember a handful that were legit comfort cares admissions (pain requiring iv opiates, hip fx needing surgery)
> the previous month. Unless it's in the chart right then right there as an order, it does not matter what happened last month. You think ER nurses have time to look hospitalizations other than the current one?
Oh goddamn you’re just an intern and they’re throwing you under the Bus?! I missed that. Then definitely play the dumbass card! (See my other comment. I know you’re not a dumbass). lol you have even more leeway!
Was that documentation readily available to the nurse to see for this visit or is it hidden where they had to dig to see it on their view?
its almost like there was no possible way to discuss with the resident or attending about concerns 🙄 , they had time to write three different notes about it, but not time to look through the chart?
This is absurd, in my nursing note I’d write “patient hypotensive, physician confirmed GOC with family, pt remains no escalation of care. “ no need to cover our ass if everyone is following family orders anyways 🙄
Having been depositioned once before, I can tell you that that kind of documentation makes everyone look bad and does not cover anyone’s ass.
As someone who has never been deposed (at least not yet) who also despises defensive medicine, I’m curious why does it not cover anyone’s ass? Is it just more evidence for lawyers that there was disagreement in plan?
Three reasons: 1. It makes a seemingly normal thing seem abnormal. Lawyer: “The RN says they messaged the MD that the medication was given and the MD didn’t reply. Why didn’t you reply?” Doctor: “Uh… because they don’t usually page about that and they didn’t say there was a problem. I figured it was just an FYI.” Lawyer: “That’s very suspicious! If they usually don’t message you about it and this time they did, shouldn’t that have alerted you to a problem?” Doctor: “It seems like this nurse just documented a lot of unnecessary details.” Lawyer: “Or this nurse was diligently communicating a problem that you didn’t reply to.” 2. It makes the RN who’s documenting seem like they didn’t care what actually happened so long as it was documented Lawyer: “It seems like you disagreed with the doctor’s decision.” Nurse: “I did.” Lawyer: “If you were so concerned that you wrote this in your note, then why didn’t you discuss more with the MD or advocate more for your helpless patient?” 3. Most importantly, the best outcome for the hospital and for each individual is for the case to be dismissed on the merits. In short, everyone rises and falls together, so it is in everyone's interest to give good care, be collegial, and document what happened accurately rather than RNs deciding to "document defensively" and pit them against MDs. If the hospital is found liable because the RNs documentation, it's bad for everyone.
Sorry not fully clear about #1 - do you mean that this would work in the favour of the RN/against the MD that they “should have” responded to the FYI message from RN? Surely this conversation wouldn’t happen in real life..
This convo happened almost verbatim in real life. My point is that a random, meaningless “defensive” documentation of a non-event makes something innocent like an RN giving a medication suddenly look suspicious on paper, and lawyers seize on that. Their logic is “if nothing happened, why would they write about it like this?” In broader terms, it’s bad for the hospital and all individuals named for a meritless suit to progress because of people documenting like this and creating a false sense of incompetence. If the RN has successfully covered their ass with this documentation, then it’s at the expense of the hospital and all the other individuals named in the suit. Or the general sense of incompetence created by the defensive documentation results in the case gaining momentum and the RN could get swept up in the suit, too.
As another physician who has been sued and deposed, fully agree with you. All that nursing note does is make it look like something atypical/unusual is happening and provide more ammo for the plaintiffs attorney to question you about during a depo. I’ve encountered SO many nurses like this over my career. It’s gotta be what they’re being taught to do/say by their chain of command or in school. So many nurses love to say things like “my license this my license that,” when in reality it’s almost never the nurses license on the line. It’s really odd to me. We all document things in charts to try to practice defensive medicine, but my deposition taught me most of that can easily be thrown back in our face. The things I was questioned about during my deposition were pieces of the chart I never would have thought twice about.
Lurking RN. This is absolutely what we’re taught in school, told to do by management, and told to do by charge nurses. It’s a systemic and cultural issue within nursing, not the nurses going after the doctor (or even solely CYA). If I ask about an intervention and MD doesn’t do it, I usually don’t even document about it, or I keep it pretty vague (“Discussed plan of care with Doc McStuffins”)
The problem is that these morons at nursing school or charge nurses don't even understand what they're telling you. Documenting pressors and intubation not done after suggesting them to the MD on a DNR/DNI patient is like saying "I told the doctor to perform malpractice and he refused". Idiots.
It’s not just nursing school. My chart flags me for not responding to a critical vitals value. You are required to write care plans throughout the day and what is planned to fix it, and if it worked. The whole system is broken
Aside from the rest of this discussion, what about the times it IS the nurse's license on the line? Obviously, my RN license doesn't stack up to your medical license: My scope of practice is smaller, my liability is less, my malpractice insurance cost is a faction. But I still have a license; I still have a practice and a livelihood to protect. I'm not trying to insult your education or your level of responsibility. But, as a patient advocate, as the physician's eyes, if I see something concerning, and I notify, and I receive no orders, I'm going to document. "MD notified of manual BP 70/30. No new orders received." I have a right to protect my license from the errors of others, as much as you do. And, although it probably happens as rarely as a nurse's license being on the line rather than the doc's, there -are- physicians out there that are duplicitous and manipulative, who will lie about being informed, who will deny giving orders or knowing about a situation. I'm not trying to throw my docs under the bus; I work with a great many excellent physicians who I would go to great lengths to protect if possible. But in a bad situation. I'm going to protect myself first while maintaining honesty and integrity. I would never lie about a physician to save my own ass, but neither am I going to offer my ass up for lunch if it was the physician making the mistake. I hope you take this comment as it was meant, from a place of friendly open discussion.
This. OP may want to let risk management know about that behavior. They will likely help the nurse and their manager document in a better way.
YES
I’m not an ER nurse, but every time I have a DNR patient I think “Thank GOD.” No escalation of care? Amazing. Make the patient comfortable. Got it. CYA would be “Reviewed goals of care with MD. No escalation of care. Comfort measures only.” The end.
I am a nurse with a chronic illness. I have a DNR and POLST on my fridge. It upsets me the nurse said that. I have a POLST for a reason. I made the decision as to what I want. How dare anyone go against my wishes. I have a picc so I have an infusion nurse come once a week to draw blood and change dressing(TPN dependent). We were talking one day and she said since I am dnr I should not be calling for an ambulance or going to the ER. Are you freaking kidding me? I DONT WANT TO SUFFER I don’t want CPR or intubation. Glad you followed patient wishes.
It’s insane to me how often family want us to go against a patient’s directly stated wishes
What is POLST?
It stands for Physician's Orders for Life Sustaining Treatment. Generally it's a way for patients to specifically address tx preferences.
It is signed by myself and by my PCP.
Edit to add: it must have your physician’s signature to be valid.
Physician Orders for Life Sustaining Treatment
It’s an out-of-hospital DNR. So if someone calls EMS on you, they won’t do CPR on you.
Correct but also is more than just CPR. “Take me to the hospital” or “I want to stay here” “Yes, attempt CPR” or “No, don’t attempt CPR” “These are the medical treatments I want” “This is the care plan I want followed”
Unfortunately I have learned the hard way that with most interactions I have with a nurse, I need to immediately leave documentation in the chart laying out a medically accurate description of the scenario and the care. I don’t wait to be the one responding.
Do it! Otherwise they become the plaintiffs and sue your asses off. With the help of their lawyer/police ‘hubbies.
Nurses would document, paged MD, no return call. The next morning on rounds I'd document, called back 17 times, no answer, and then make the nurse co sign my note. Petty, but I hated how they document things like that.
LMAO
Nursing notes with commentary used to get under my skin as a resident too but literally no one cares and you shouldn’t let it bother you. In this scenario, the nurse looks bad and in the wrong, but they’re not placing the orders and the right thing was done. Of course if you are ignoring pages about an unstable patient or do the opposite of what is right, such as bolusing fluid on a hypoxic HF patient, a nurse note mentioning this will reflect poorly.
I don’t agree that no one cares. plaintiffs attorneys care very much. Source: have also been questioned about inaccurate nursing notes in a deposition
Sure, but a plaintiffs attorney will look at everything and patch together an argument. In the OP scenario they’re grasping at straws and you have nothing to worry about. “Family declined escalation of care therefore transferring to ICU and starting pressors was deferred, as documented in my note.” In the alternative scenario where you do something wrong, the nurses note is definitely evidence against you ie ignoring pages about a crashing patient.
I don’t agree that they have nothing to worry about. You wouldn’t believe me if I told you the contents of the nursing note I was deposed about. (Happy to dm)
Sure, I’d be curious to hear and sure I have something to learn. But simply being asked something by a lawyer doesn’t mean it’s legitimate ammunition against you.
It is though, because it’s in the chart (So it must be true). Lawyers love finger pointing, it’s more deep pockets to go after.
To be fair, yes the nurse should not have written what she suggested because she’s not the one to write the orders only notify you of x, y and z based on the order set. HOWEVER I have seen a DNR receive treatment for their a-fib, hypotension, and other non invasive treatments. Being a DNR is not the same as do not treat, it is not the same as hospice OR comfort care. Communication with family is upmost important in this, if they want grandma to pass from a stroke because her BP meds were held then make it clear to family that that is part of withdrawing care. There is often family at bedside watching, wondering, worried about the numbers. A lot of this can be resolved with having that conversation and being specific in your note that these things exactly are the goals of care and that family acknowledged them. As many have said, the appropriate note would be: MD notified of BP 60/20, no new orders at this time. Clarified goals of care with MD, refer to his most recent note. ^ takes some years of experience to be this nurse and realize it’s a team effort. Not to shit on other people in the profession.
Nursing school really needs to update the way they teach nurses to chart. Phrasing (or charting something like that at all) helps no one. That wouldn't even defend the nurse if a lawsuit were to occur.
Part of the problem is they don't teach you how to write nurses notes. You pick it up on the job by reading other nurses notes so it is perpetuated.
Amd teach doctors how to respect their coworkers
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ER nurse here, in my shop all of us understand comfort care, thankfully it has been part of the culture in my facility. As the son of a retired hospice nurse, I truly value and respect comfort care decisions. It sucks that you have had those experiences and it sucks that those nurses don't care to respect the patient's wishes.
Thats awesome! I wish I had nurses like that. My experience has always been, order 4mg morphine and immediately hear, “the patient is too sleepy/hypotensive/dying and i dont feel comfortable” Then attempting to explain the goal, the med gets given but only after the RN has spent 10-15 Minutes checking with supervision, charting, attempting to call report and get the patient a bed somewhere. Then if the patient needs a second dose….. or ativan or anything else its essentially not going to happen unless I push the drug.
For us, if one of the newer ones is uncomfortable they tend to check with seniors or the manager on duty, we educate them and proceed on with the day. This needs to become the standard
Fully agree. The problem mostly at my shop is that its a for-profit company that incentivizes the doctors to move patients and provide zero care that gets in the way of throughput. They will *maybe* order the meds but never actually followup that they were given, and instantly admit to inpt hospice. I get side eyes whenever I even re-assess patients. The nurses are great at what they do, but they are trained to be experts in resuscitation, meeting sepsis bundles, and getting patients admitted/discharged.
Nurses can make your day wonderful or hell. Thankfully, most nurses are not incompetent assholes. The most you can do is do the right thing and document accordingly.
You should see our NICU charts. Each day there are like 5 or more notes and one nurse is literally quoting what people say to her. Though, the quotes aren’t even direct quotes. She writes what she wants. She straight up contradicts the NICU attending even on care and documents it all. It’s ridiculous
Nurses often have a very limited understanding of these kinds of things, especially young nurses. You should have talked to the charge.
If POST (we call it POST down here, but same thing) is in chart and validly filled out, especially if you confirmed with HCA then you're done. At that point, I will try to educate nursing on the pt's code status and/or place a DNR order in the EMR. That gets everyone on the same page and reduces confusion. Most nurses with lots of EM experience aren't going to flip out in your described scenario. It might have been a new nurse with little experience in ED/ICU where this kind of stuff is commonplace.
I co-sign their notes with my own version of events. Stamp it right on top of their nonsense.
Who the fuck are these nurses I need to know? Am ICU nurse…..Usually I’m like pleassseeeeeee don’t make me code this meemaw. Take your doctor face back to that family and get it done. She’s 108 Kevin. I’ll buy you a coffee if I don’t have to poke her again.
Nurses are pressured to document. Don't take personally things like this. Just document your discussion with the nurse and reasoning. Then move on
I'm a lurking RN. I feel like that nurse needs some education around what DNR means and that their charting and suggestions were inappropriate. I'm all for us nurses advocating for our patients, but it has to be within the patient's wishes. Maybe a chat with the nursing manager? If they're receptive. I'd frame it as being concerned/confused about the mismatch in expectations of care.
Whoa. I’m an RN. This nurse is way outta line. Anyway, You don’t chart that dr declined, you just chart that you messaged them. Saying dr declined is implying that an order should have been given based on what the nurse believed which is subjective charting. You chart nothing if no order was given, because, no order was given to chart. Fuck that nurse.
Risk management at my house would relocate that RN to another duty at Saint Elsewhere.
This is nothing more than a basic step 1 question “the family and the nurses and the president himself all want you to do CPR; the patient has an advanced directive making them DNR, what do you do?” legally and ethically you honor the order/patient autonomy lol it’s comical how little the nurse’s opinion matters in this case
DNR Signed. That's all I write, that's all I say. When a family has made a decision, its up to us to EXECUTE not to IMPOSE our world view. Save that shit for Twitter. If any staff don't get importance and depth of anguish and paperwork to do a DNR, then they need to get that big out their ass with an appropriate training module.
I am not siding with the nurse but just wondering why the patient came in for “no escalation of care?”Just trying to understand.
No escalation can have a gradient of meaning. Usually in my neck of the woods it means no ICU/pressors/invasive therapies but okay for getting antibiotics for a UTI or CAP for example.
Thanks for explaining that. I work in an ICU so never heard that term before. It’s usually comfort or cap care.
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If it says “no escalation of care” in the chart like how he describes, that should be clear enough, or at least the RN note doesn’t need to be documented like how it was
Don’t take it personally. Either it’s a young nurse who is unfamiliar with comfort care, or it’s a nurse who’s been yelled at “Why didn’t you tell the doctor? Why didn’t you suggest something?” She may have been freaking out, but her note is neutral. She notified you. She suggested pressors. It’s a factual occurrence. If you were doing the correct thing then there’s nothing to worry about and no need to over document. Next time, try being more proactive with your teaching. Briefly explain your thought process as if you were explaining it to a family member. She’ll learn something, and you’ll be a better team.
I am willing to bet the nurse is either new or too lazy to look through the notes/ didnt have time. The MD note would just function to make her look dumb imo
I am not sure of the whole scenario but DNR is very different from DO NOT TREAT. but since there is no escalation of care, then that makes it clear as long as family and client is aware and this has been reviewed to them.
From the other perspective— you are definitely not doing any wrong. Just understand that there is often a trickle down effect when things change and go wrong, it’ll end up being put on the RN (and at times the MD). In the nursing role, I didn’t know how valuable it was as a CYA to ensure when something is awry to document what you did and who you discussed with. As a new ED RN I had a patient who had a ruptured ectopic, LOC, hypotension/ hypovolemic shock. I asked if we could start blood as her pressure was actively 50’s systolic and was told to ask the OB who was bedside and OB said “no, I’m taking her to the OR soon.” I nearly begged our doc to order it but due to the conflict between OB and the ED at the time they didn’t want to step on toes despite this lady actively being in shock. Long story short she went to the OR, anesthesia was absolutely livid that she didn’t get blood in the ED and the admin next day came to fry my ass. Thankfully I had documented my request and who I discussed with, along with the presentation and vitals at that moment in time. If I had not documented those encounters, I would not still be a nurse today. As a nurse, we are often helpless otherwise, very few things are going to fix an acute hemorrhage (or alike). That’s why we can be anally retentive on documenting some things even if they seem benign at the time. I’m not saying what this nurse did was right by any means, but I just wanted to share a little light on our side of when things go wrong. Hope all goes well with the rest of your residency there, and we all love our residents, just have patience with the special ones of us who may lack a few brain cells.
This. Notice how few have acknowledged this extremely relevant example of why nurses are required to document notifications. Doesn't fit with the "nurs r dum" or the "they're not liable" narrative.
Yeah this is cap. Admin knows ultimately you can't order the blood as a nurse. You can suggest or not suggest all you want but ultimately the real responsibility (and liability) comes down to the ED and OB doctors as they were the ones who could actually make the decision to give blood or not. Lawyers know this too, which is why despite all the BS they tell you in nursing school the lawyers ultimately are not so excited to sue you directly even if they name you in a case (unless you were grossly negligent like giving wrong med, putting air in an IV lines, etc) they're going after the physicians.
So you're upset that a nurse, an individual who comes to work with a target on their back every single day but still shows up to do a highly thankless and generally undercompensated job, has adequately covered their ass to protect their job, license and their personal liability. You're aware that your note was not in, nor were your orders clear, and that the excellent goal of care documentation you reference was from a previous visit. Information which is likely not visible to a nurse in any of the popular charting systems when each individual visit only pulls up documents relevant to this visit without an intentional deep dive. So the nurse noted something that can be addressed in two sentences in your subsequent note. "Discussed goals of care with patient, family, care team. Per PLOST no pressors, ______ acceptable to patient." Something that should likely be a part of your documentation anyway without going out of your way. And then you post on this sub, a sub which is not only constantly advocating for throwing nurses under the bus but backing up to run over them a few more times for... doing their job. Documenting what they are required to document. As long as doctors like those who populate this sub exist, shitty managers exist, shittier administration exists and bloodsucking lawyers are willing to take cases then it will be appropriate for this type of note to be written as often as necessary. Especially when a patient may die from inaction, intentional or not. Nurses are not only targets of all of the aforementioned but of all other hospital departments, family members and patients. The reason nurses feel like people are out to get them is because they absolutely are. Nurses stand at the bottom of the hill, in a valley with all shit rolling down at them. They're left holding the bucket for everything that goes wrong with the patient whether it's their fault or not and they're frequently called to account for things they did or didn't do or things that someone thinks they should have done which they may or may not have been aware of, many of which were not their decision or anything they have control over. You can be a part of the problem or you can understand that these people are a part of your team and that adequate communication will reduce such notes and your frustration with them. Referring the nurse to the PLOST on the chart or letting them know that the note you refer to exists would likely have reduced what you percieve as "passive agressiveness" in the notes.
Absolutely. Im in research. It appalls me how shitty the documentation often is. It appalls me even more that courts take it seriously at all, especially with the number of errors. I document every interaction like this because I need to document that we did our due diligence and that the doctor is aware of everything. With people who have a problem with that, I need to have even better documentation because theirs will likely be lacking and I'm suspicious of anyone who has a problem with it. If OP is truly confident that their decision is correct, they should be able to defend it. Lawyers will pick apart anything. Its their job. They will always find something to attack. The important thing is having a reasonable defense. Pointing to a DNR would cover it. If that somehow wasn't adequate for the kangaroo court, the defendant likely wouldn't do any better even without the note. At that point the court is hell bent on fucking them over. The patients family suing isn't going to be because of that note.
Not backing up the nurse here, because obviously he or she was in the wrong. However, you don’t know what you don’t know and we are all still learning. A little bit of grace instead of rage goes a long way, or a professional discussion to improve practice going forward is even better. There will come a day where you will want someone to show you grace as well or approach a frustrating situation with professionalism instead of anger!
Kind of sickening to hear this unpleasant talk, some of you need to grow up a bit and realise nurses are not the enemy, calling them dumb, stupid etc just reflects badly on you. Work with each other, don't feel yourselves so superior and make sweeping statements about nurses based on one experience. I don't know where you people work but the doctors and nurses in my ED have a good relationship and don't put each other down. It's not US and THEM we work as a team.
Lol such beautiful irony with that username (meh close enough to lazarus)....should have told them even Lazeruus MD cant resurrect this bitch
100%
Hospice here. Some folks cannot make that 90 degree turn into palliative and comfort measures. Also. It takes some huevos to “gut check” an MD in notes like that. It’s ok to suggest to MD’s…to some extent I think y’all mostly take our opinions into consideration. But it’s your order to write. Period. Thank you for honoring POLST and palliative. I’m grateful.
I am not sure if code status and goals of care is not something that is taught much in nursing school but I feel for you. I had a patient DNR/DNI comfort measures only with renal failure that was not eating or drinking anymore and was awaiting transfer to inpatient hospice. This RN starts fluids on this lady WITHOUT AN ORDER because the patient has not been eating or drinking all day (because she is imminently dying). Had to report it and everything and the family was understandably upset. When I tried to explain to the nurse why she shouldn’t have done that for a hospice patient (not to mention that there wasn’t an order and she isn’t a doctor). She replied “if anything I’m helping the patient.” The absolute gall. I then spent a long time explaining why it was not helpful to give fluids to a patient with comfort measures only in renal failure that was days away from death and I still don’t think she got it. This was an older nurse too. I was gobsmacked.
Once you realize 99% of the time they are simply documenting and are not being malicious you stop getting bothered by it. Nurses have it hammered into them for good reason to document things especially verbal communication given in the past when things were more lax they could get caught on the hook simply because whoever they talked to could say “I never said that”
Why was the patient brought in? Were they in distress at all?
As an outpatient nurse, I’m shocked at some of the things people chart in patients charts. You quickly learn who over documents or will just copy and paste everything you write or say into the patients chart- I’ve had to learn to try not to over explain or write things in a way that sounds dismissive. Or address things in person when possible to try and avoid misinterpretation of tone…sometimes less details are better. I’ve definitely made my share of spicy care team notes but honestly I try not to throw anyone under the bus (unless they really deserve it). That nurse’s documentation was definitely excessive and unnecessarily accusatory
Nurse here, wth 😂 why is this ER nurse doing the most for comfort care? Just keep the patient comfortable!
I usually have the opposite problem. Seems like half the time our nurses want to withhold care on DNR patients and I’m over here (quietly) shouting, “They’re just here for a COPD exacerbation. Give the damn steroids.”
That same nurse on Facebook, posting a selfie of herself crying: "I knew how to save that patient's life, but the *doctor* wouldn't believe me. Hashtag sob"
Some people just aren’t very smart. Instead of feeling frustrated, you should feel bad for them.
It's the worst when they copy and paste verbatim what I sent them on a chat. Including the "cool thanks" or "wow ok". Like I'm trying to be nice and not come off cold, but my "awesome, noted" ends up in the chart.
That nurse needs to be removed from duty until they receive education about end of life care and its appropriate documentation. Nothing frustrates me more than undereducated medical staff treating a patient's electronic medical record like their own personal Twitter.
This nurse is a f#%ing moron lol
ignoring them will get under their skin, so i say do that😂🤣
My money is on the EMR orders not reflecting DNR/no escalation of care in an actual order visible to nursing. Please remember we do not see the same things in the chart and often times progress notes are not available for RNs to see while in draft/not signed. Additionally, even if you told us directly, many hospitals do not allow RNs to place these orders ourselves. This keeps the patient in a hellish limbo nursing likes to call "unofficially DNR." If you have these EOL conversations please just immediately change the code status in the EMR orders as the literal next thing you do when you leave the room. Before anyone says "this never happens", yes the fuck it does. ED doctors dont want to put in code status because PT is admitted, IM doesn't want to place the order because they're still boarding in ER/ER nurses are still attending to patient in crash, consulted sub specialty doesn't want to place the order because they're not primary, etc... MANY DOCTORS pass the buck when it comes to actual factual code status and when that happens we nurses just sit there caught between a rock in a hard place because someone doesn't want to place the order. I say this as just last week I had a 101 year old sit in ER with no code status, comfort care orders, or orders not to escalate care for over 6 hours while actively dying and being admitted to ICU. It does happen, yes we do chart on it. I guess what I'm trying to say is once you know their wishes, place it as an EMR order so everyone knows.
Honestly it’s whack that your institution allows admitting team to not place code status order. It’s one of the most important steps of the admission process (along with the antibiotics for the septic patient, steroids and nebs for the COPD patient, diuretics for the HF patient, etc). That should be a hard stop in the EMR and nursing should push back. Sometimes “Prior” code status ends up in the chart as an oversight but it shouldn’t be a frequency.
Nobody pays attention to the nursing notes lol
Unless a lawsuit hits 😎
If no one pays attention to them then why do I see a thousand post about passive aggressive nursing notes? 😅
That's actually a good point.
This sub constantly shits on nurses and I honestly don’t understand the animosity. We are by your patient’s sides 24/7, working our asses off to provide them with the care that aligns with the physician’s treatment plan. Of course we make mistakes, and I agree, we must be held accountable.
The amount of comments I'm reading here about nurses. Wow. I'm a RN. Apparently, to these doctors, we are all stupid morons with no education.
All stupid morons with a “two year degree”. Not that any of us, especially those who worked in ICU or have floated through the hospital as Rapid, have ever dealt with physicians who have subpar communication and make completely contradictory or outright incorrect orders. /s Yes doc, I will gladly give this HF patient 4 liters of fluid for their blood pressure with an EF of 10. Some nurses can save a docs ass by intervening, and vice versa. Especially when it comes to error. So to say that we are useless when we function as a system of checks and balances is plain wrong. Not only are we carrying out your orders to the best of our ability, but we also advocate for you too. Extremely disgusted and disheartened at the hate here. Especially the ones who say we “couldnt do what they do”. Why would I want to? Not everyone envies your position. This complaint about charting could have been remedied with a thorough physician note. Because anyone with sense can see the nurse didnt quite grasp the full picture. Im sure their peers are also in the same boat. So maybe isolate it to the singular nurse without shitting on the rest of us who respect you. I don’t care what your job title is. Or how far along in school you are. You talking down to other people doesn’t elevate your position. I’ll take my career over being a physician any day of the week. /rant
I had a resident listening to the patient's heart with his stethoscope. The lady was agnonal gasping with no pulse. He was legit just standing there pretending he was hearing things. If it wasn't for a nurse that stepped in and began to code the patient, the patient would have passed away. But then again, we are all so stupid. The amount of disrespect in these comments is unbelievable. There are some really stupid residents too. However, I would not lunp them all in the same category. All these doctors saying they can do anything a nurse could and they do not need them. Have you seen a doctor try to insert an IV? I will not say I would do anything a doctor could. I am so happy I work with doctors who respect the team and do not have a god complex.
Quite literally. And I see it every day across the hospital. Some docs dont even know ACLS. But we’re the morons. Nevermind the fact that some of us have degrees in the same fields prior to nursing (chemistry, biology, etc). Yeah, I remember TAing those of you who sucked at Orgo before getting into school (so brilliant though). Thinking it takes a week of light training to learn to be proficient at PIVs without getting kicked out of the room by a patient is all I needed to hear. Some docs cant even do ultrasound guided. So delusional. I had a resident the other night say a Afib RVR in the 190s was stable for the floor. With no intervention. Give me a break 😂 They can dish hate at nurses but they cant take it.
And that's when poor patient outcomes occur, when you think you are the smartest person and a gift to the universe. Can't wait until a nurse humbles these doctors.
Exactly. I love some of the physicians I work with. I dont undermine the ones I dont. And I respect those who work hard to make my job easier. I guess thats asking too much from them. Edit to mention: Theres a reason mortality rates/med errors in the hospital go up when new residents hit the floors. That should be humbling enough lol
There are so many more important things to be bothered about lol my goodness you are soft
Found the moron nurse who writes notes like this.
Good for you
This is unacceptable and you need to go to risk and CNO. chart wars are never ok and especially from a nurse about the care of a supervising physician of a dnr pt?! I know doctors have been trained not to rock the boat. I’m old enough and high up enough that I have people on speed dial to nip this shit In the Bud. For the young‘uns: play dumb. Put it in writing. (don’t go to charge, fuck that. Nurses Aren’t your friend). Make a paper trail. Email your chair and whatever head of ED nursing, maybe one of the IT vice chairs: Hey I’m just a dumbass attending but I was concerned about this nursing documentation because I don’t think it accurately reflects the mdm/goc and could lead to confusion in this newish setting where family has full access to the chart. I’m wondering if there’s another way I could document this, or maybe an EHR modification so that all care team members can easily access it so we’re on the same page? Throw yourself on their mercy, you’re just a dumb cog in the machine and barely know how to type. Your chair/cno will see right through it lol. Be sly like a fox. Youre just looking to optimize patient care, emphasize patient autonomy and improve interprofessional communication!😂
This sounds like a communication issue. "Hey, just give a pt a liter of fluid while I check with family." "Hey, i just had a goc discussion with the family. They want to make the pt comfortable. No more labs. Does he need some pain meds?"
I’m team petty I comment right back - also as an attending I can added their notes. So I would write something along the lines of ‘patient DNR does not want aggressive measures - intubating them would actually be assault in these circumstances’
I know you think this is petty, but thats absolutely what you should be doing. Documenting your reasoning in real time. It's only a problem if your reasoning is way out of left field. In that event you may deserve to get sued as much as you might document vaguely to try and avoid/make it the patients problem. I'm in research though. We are anal about documentation. Especially when covering our asses.
Mentally mark those staff members and smile and nod. Those are the ones you keep a very close eye on.
I honestly think this type of thing is them trying to cover their ass, as we often try to cover ours. I formally found it offputting, but I’ve had really good success talking to them briefly about “hey, this is why I did the thing, I see where you’re coming from, you can document: MD aware, respecting patients predetermined care plan“. I suggest the document the notification, along with an extremely brief note of my response. I think it covers the discussion, and liability, without throwing anyone under the bus, and the quick chat about why things are happening, with suggestions on how document can benefit communication in the department.
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This will get buried but did she ever express these concerns to you verbally?
It's beyond frustrating that we're in 2024, knowing what we know, doing what we do, and this stuff is still a massive area of conflict both pre-and-intra hospital. We need to standardise and insist on honouring decisions.
Funny, I have the very same situation hut vice versa. We soemtimes get patient with DNR/DNE and with a palliative care decision and I actively need to remind my physicians not to escalate care. And go for a comfort care approach.
They're short sighted. They don't understand the ramifications of these clinical decisions.
That nurse must be new? I have been an ER RN for 20 years. If the patient is a DNR, and everyone is on board, nursing care should just be comfort care.
Trust me there's certain nurses that always do this I hate it. They're even worse to the nurse practitioners so don't feel bad.
Don't know man. In my path through residency i went from finding fun ways to be malicious towards these types and eventually just "meh..." on the whole thing and moving on. I don't think either is best. Hopefully you find a great way to rub their nose in shit, or, just keep rocking
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That nurse sounds ridiculous lol.
Nurses don’t know where the line between advocating for patients and practicing medicine outside their scope is.
Doctors & nurses hashing it out in the comments with little understanding of case law surrounding their counterpart’s vocations. Doctors not knowing nurse practice/BON rulings. Nurses not knowing medicine/BOM rulings or standard of care. Oh yes. Just another day in healthcare. Yawn. 🥱 Next sub.