Saturday, August 14, 2010

Don't Think

I read a missive from hospital administration recently, posted on the wall in the physicians work area at one of the hospitals. The message read something along these lines:

“Per JCAHO* regulations physicians should refrain from writing orders allowing for a range of medication to be administered. Specifically, pain medication orders should not say:

Dilaudid 1-2 mg IV Q3h prn pain

Instead such orders should be written:

Dilaudid 1 mg IV Q3h prn moderate pain
Dilaudid 2 mg IV q3h prn severe pain

Orders written in the former manner, allowing for a range of dosage allow the nurse administering the medication to make independent judgment decisions. Such decision making is not permitted under the nursing licensure.”

My reaction to this directive was that the lunatics are in charge of the asylum and everyone should run for cover. Nurses are to become robots, methodically passing out meds and dutifully charting when the patient last belched, while ignoring their patients overall wellbeing. I asked several of the nurses in various hospitals their opinion of this rule. I pointed out that, to me, there wasn’t any difference between the two orders. What they said was a bit disconcerting. The nurse is supposed to ask the patient about the severity of their pain and then medicate accordingly. So, if the patient responds that he is feeling severe pain he is given the higher dose, no questions asked.

Now, I’ve been in practice for over twenty years and I can tell you that pain; its intensity, quality, severity and every other aspect is the most subjective of clinical symptoms. I’ve had patients, who have undergone a very minor procedure, tell me the pain is the most excruciating they’ve ever felt, while others, who have just undergone a major abdominal surgery with a stem to stern incision, report only mild discomfort.
There are patients who appear nearly comatose after surgery, barely arousable, but will state that their pain is severe and will request their medication every three hours on the dot. In this situation, what is the nurse to do? Blindly administer the higher dose prescribed for severe pain or actually think that the patient’s pain may not be as severe as reported and give the lower dose, and/ or call the doctor to have the medication adjusted.

No matter what, a good nurse has to use her best judgment to care for her patient in the most compassionate, but also clinically appropriate, manner possible. Patients, who are human, have widely varying ideas of what the hospital experience should be, particularly when it comes to pain. For some, pain relief means completely numb from head to toe; for others it means just enough medication to have the edge taken off. Most are somewhere in the middle. The nurse serves as the doctor’s eyes, learns to make a proper judgment and provides a continuous image that complements the snapshot the doctor receives on daily rounds.

The idea that nurses not be allowed to think echoes the words of one of my medical school instructors, Dr. John Adams. In the early 1980’s I was at the University of Rochester Medical School in upstate New York. Dr. Adams was the classic curmudgeonly surgeon. Loud, intolerant of ignorance or incompetence by subordinates, he often chastised the residents on his service for writing orders with a dosage range in the way that is now prohibited. He must be working for the JCAHO, because his exact words were:

“Don’t write Demerol 50-75 mg IM q3h. That allows the nurse to think; we don’t want the nurses to think. Their job is to do what they are told to do.”

Who would have thought chauvinistic Dr. Adams was such a visionary?

Actually, I don’t think that he had such a low opinion of nurses, rather, I believe, he was trying to drive home a message to the residents and students: orders should be clear and specific. Such clarity allows the nurse to perform her task efficiently and provide the patient with the best care possible. Doctors and nurses are a team, working together to help an individual who is sick or injured recover and return to a normal life.

Years ago I read a study on factors affecting outcomes on critically ill patients. I don’t remember which journal it was in, but the study looked at ICU patients and a number of variables that could have an effect on the patient’s recovery. The only variable that made any difference was the quality of nursing care.

This makes perfect sense to me. The critically ill patient requires continuous monitoring. Most of the time it is the nurse that is at the bedside checking vital signs, urine output, oxygenation and every other parameter that may be indicative of the patients well-being. The best ICU nurses will pick up on subtle changes that could be harbingers of impending deterioration in the patient’s clinical condition. If such nurses are shackled by the “don’t think and don’t make judgment” rules, these critically ill patients will suffer.

Besides acting as physician’s eyes, nurses also provide a level of protection for the patient. If an order is written or a medication prescribed that seems to be in error the nurse is there to question it. Despite what some doctors may believe, we physicians are not perfect and sometimes errors are made. A vigilant nurse often picks up on this, questioning the order; calling the doctor for a “clarification” (correction). Sometimes it is an omission that needs to be brought to the doctor’s attention. In all situations the nurse is the patient’s advocate, doing his or her best to smooth the often bumpy road to recovery.

Doctor’s, by necessity, approach patient care from a very different angle than nurses. Medical School and residency teach us the underlying pathophysiology and the clinical manifestations of various diseases and medical conditions. We take this information and establish a diagnosis and institute a therapeutic plan. Our primary purpose is to see that the disease process is properly treated and see the patient to a complete recovery or at least keep chronic diseases under control.

Nurses share in this goal, but along the way they are often called upon to provide comfort, counseling and to allay fears. The nature of their profession allows nurses to do this in a way doctors cannot. The best nurses always seem to find the time to sit with their patients, provide reassurance and still manage to do all the ridiculous charting and filling out of seemingly endless forms that generate reams of paper that no one ever looks at.

In the middle of these essential activities the nurse often have their carefully planned schedule disturbed by a million other tasks, usually accommodating the interruption with a smile and a shrug of the shoulders. I know that when I have asked nurses to help with a bedside procedure they are only eager to help and always insist on finishing up all the cleaning and reordering of the patient room when I am finished. I sometimes wonder if it is eagerness to do all they can to help or if they really want to be sure that the patient’s room is properly returned to an orderly state.

Nurses are truly amazing in their ability to calm anxiety, inform ignorance, allay fear, provide comfort, stroke egos (especially OR nurses), see us all at our worst moments and invade our most intimate places and do it all with a smile and a wink that says “I know you don’t feel well now, but just give us a little time and you’ll back home with your loved ones before you know it.

I may be a bit biased towards nurses. After all, I married one; Laura, my wonderful, beautiful, intelligent wife of twenty five years, the cutest little nurse I had ever seen, always took the time to talk to her patients, share their feelings and make sure that all their treatment was delivered in the best, most professional manner. When we first met I think I used to exasperate her by my asking for patients’ vital signs and her appraisal of their condition. But, we shared our concern for the patients’ well being and have continued to share for twenty five years.

Nurses and doctors, along with surgical technicians, respiratory therapists, physical therapists, occupational therapists, speech pathologists, patient care aids and all the other allied health personnel, share a common goal; that is to treat the sick and injured and allow them to return to happy, healthy, productive lives. The doctor provides the diagnosis and overall therapeutic plan, institutes the plan’s delivery and makes alterations and interventions when necessary. The nurse provides the monitoring, the immediate delivery of therapy, nurturing, comforting and compassion on a continuous basis. If our nurses are not allowed to “think” our patients will end up suffering, with longer stays in the hospital and some, I am sure, will never leave the hospital.

It is something for all of us to think about.

*Joint Commission on accreditation of Healthcare Organizations