Emergency Nurses as Advocates

Nurses are the patient's advocate. But when a nurse disagrees with a doctor, how far should they go on behalf of their patient? Where do you draw the line? This is a recent article from the New York Times. 

A recent conversation with a physician at my hospital was laced with tension about the different roles of doctors and nurses.

“When you get down to it,” he told me, “Patients come to me for care, Theresa, not you.”

Both of us were called away before we could talk more, but his words have been ringing in my head ever since.

Jeff Swensen for The New York TimesTheresa Brown, R.N.

I couldn’t believe that this doctor, who had always worked well with the nurses on my floor, had just suggested, at least in my mind, that a nurse’s opinion on patient care matters less because patients don’t directly make appointments with us.

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

It all began after the doctor read a story I had written about a leukemia patient in his 70s. The doctor had not been involved in the case, but he was troubled by my role in it. Due to the patient’s existing health problems, I was concerned that giving him chemotherapy would cause more harm than good.

During the course of the treatment, the patient complained in agony, telling me “I can’t take it,” and I relayed his misgivings to the patient’s care team. A more aggressive lament from the patient — “What the hell are you doing to me?” — also got communicated to the team. I was the patient’s nurse and his advocate, and I worried that it was not ethical to subject him to more chemotherapy when he was clearly having a hard time with the treatment. The chemo we had given him before this latest round had already sent him into permanent renal failure and caused congestive heart failure.

Other members of the team shared these concerns, but the man’s doctor did not. He checked in with the patient to see if he wanted to continue treatment. After some gentle prodding by the doctor (“You want to keep going, right? Right?”), the patient agreed.

I recounted that story with great sadness, as it had been agonizing to watch my patient suffer through treatments that I believed he would not have chosen had he known the harm they could cause and the unlikeliness of being cured.

He eventually was admitted to hospice and died, but only after the chemo had left him with unstoppable and painful bleeding in his bladder, robbing him of a more peaceful and more comfortable end to his life.

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

I understood his point, but I also felt he was too quickly dismissing the observations of oncology nurses, who intimately confront the suffering sometimes caused by well intentioned treatment.

And that’s when the conversation became tense.

Obviously, doctors and nurses have different roles in the hospital. Our training is different, and so are our responsibilities. It’s also true that patients choose their doctor and only end up with a particular nurse through the luck of the draw. But when a doctor and a nurse disagree over patient care, should the doctor always prevail?

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

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

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

And while my physician colleague said that nurses only see a snapshot, that picture is often one the doctor does not see.

Later, I had another chance to talk to the doctor who raised this issue in the first place. I told him that I was planning to write about our discussion of the role of doctors and nurses. “Yes,’’ he said. “We never got to finish our conversation.”

So we finished it. He shared difficulties he’d had with nurses criticizing treatment decisions when they had only known the patient for a few hours. I nodded. Then I said that physicians can have blinders on, too, and he nodded as well.

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

But when in doubt, I will err on the side of aggressive advocacy for my patients. Nurses have a professional obligation to make sure that patients receive the best care possible and to insure that all care given in hospitals is safe. For better or for worse, patients who come into our hospital are the responsibility of the nurses, even if the patient has been admitted by a doctor of her own choosing. A good nurse will share his or her opinions with the medical staff — sometimes loudly — because that’s part of our job, even if we ruffle a few feathers in the process.