Posted On: October 16, 2010 by Patrick A. Malone

When doctors and nurses disagree about a patient, who decides?

Doctors and nurses bring different values, different training, and different snapshots of patients to the process of care, so it's no wonder they can disagree. Often the disagreements are not about technical issues but about basic human values where there is no clear right and wrong.

Theresa Brown, R.N., has an excellent column in the New York Times about how she agonized when a terminal cancer patient cried out in protest against the painful chemotherapy treatments he was getting. The doctor pushed the patient to carry on the treatment, and so the patient agreed, only to die shortly later with extra pain from bleeding in his bladder that the aggressive treatment had caused.

When she was criticized by another physician for speaking out against what she saw as unnecessary and unwise care, here is how she responded:

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.

I agree that there has to be a conversation. But I think the central actor in the conversation is the patient, or if the patient is incompetent, then the family. We lawyers call this "informed consent." But it's really about the fundamental human right to determine what is done to our own bodies.

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