July 21, 2007, 5:10 am

For the Love of Strange Medicine


Every inducement to what?

Is the nurse holding coffee pots or metal urinals?

At first glance this ad appeared to be for some mighty sturdy urinals.

In reality, those are Thermos brand coffee pots.

What was I thinking?

If it confused me, imagine how the patients must have felt!

I hope nobody confused their coffee pot with their urinal.

That would be bad.


When did hospital administrations begin dictating what physicians will or will not do in the emergency department?

I’m not talking Joint Commission requirements, I’m talking the practice of medicine.

I’ll use this fictitious story to illustrate my point.

Sorry if it seems a bit over-the-top.


When a patient arrives in the emergency department, they are evaluated by the emergency physician. This occurs every time the patient presents, even if the patient is well known to the physician.

Even if it is the seventh time the patient has presented with the same complaint in four days.

The physician examines the patient. Based on their assessment and the patient’s history, a diagnosis and plan of treatment is prescribed.


Let’s say the patient expects a certain medication in a certain amount on every visit. Say the patient arrives in the department looking like they have already received a great deal of medication.

The physician on duty believes that administering this medication to the patient would not be prudent as the patient appears to be “dependent” on the medication.

Addiction is such a strong word, don’t you agree?

However, the physician has other treatment modalities (ie, medications) available for treating the patient. Given the nature of the complaint and the treatment requested by the patient, the physician discusses his concerns regarding “dependency” with the patient and explains why the requested medication will not be provided during this particular visit. They order something other than what the patient requests.

(For the sake of our story, let’s assume that the physician is seriously concerned about administering the amount of medication the patient insists on receiving. Withholding the requested medication is not a punitive decision.)

The patient is pissed. Excuse me, I mean the patient is experiencing anger at the unwillingness of the physician to administer what they want to be given.


The patient is so angry that they take it all the way up to the head administrator of the hospital.

In person.

The administrator is concerned. Although the Admin is neither an RN nor MD, they do see an unhappy patient/client/health care recipient who feels they were treated inappropriately.

This needs to be addressed.


A meeting is called to address the patient’s issues.

The bottom line: the patient gets what they want. Every time they come in, from anyone who happens to be on duty.

This message is relayed back to the ER and the physician who did not treat the patient per the patient’s request is reprimanded.

The patient is now given exactly what they ask for every time they come in by every doctor in the department.


Given this scenario, fictitious though it may be, a few questions come to mind:

1. What happens if the physician absolutely believes that the requested treatment will be hazardous to the patient, but is required to order the treatment or risk being reprimanded?

2. If the requested treatment is ordered and the nurse administers it, are the physician and the nurse now enablers of the addiction? What if the nurse says “no”?

3. Do you, as a health care provider, ever feel like a drug dealer/pusher/enabler/codependent? How do you handle those feelings?

4.  Where is the line between true concern and being judgmental?

Which brings us back to my initial question. When did hospital adminstrators begin dictating health care decisions by medical personnel?

If it is occurring in the real world, someone forgot to send me the memo….



  • TwinsX2

    July 21, 2007 at 7:32 am

    The doctor needs to get some on them shiny juevos (cahones, balls, whatever) that monkeygirl has talked about. In the ER, the customer is not always right. Ask if the hospital wants to be sued if a) the “patient” harms someone while medicated, b) the “patient” seeks treatement for his/her addiction and is advised that the ER enabled it or c) the patient dies. I can’t imagine a lawsuit where a plaintiff states that he didn’t get his drugs and therfore couldn’t get stoned. Even the slimiest attorney wouldn’t take such a case.

  • ERMurse

    July 21, 2007 at 8:29 am

    This is an unfortunate consequence of the excessive weight placed on patient satisfaction scores. Just a few negative surveys can skew your results which get published in the paper and are promoted to the public as some kind of barometer of how good or bad a hospital is. We know that is a load of BS. I agree, testicles are in order here. In the ED’s I work, contract groups live daily in fear that they will be replaced by another group so testicles are definitely lacking.

  • MyOwnWoman

    July 21, 2007 at 8:50 am

    Hmmmm…..that scenario reminds me of a patient I took care of yesterday…and the day before… and the day before…..

  • Terry

    July 21, 2007 at 9:30 am

    I would not be able to practice at said institution if said policy was in place. That being said, why do these physicians continue to practice like that?

  • Annemiek

    July 21, 2007 at 10:03 am

    Yeah, Dilaudid for everyone! Anti-biotics for any cold! Let’s keep those patient satisfaction scores up! Forget about all the problems we create.
    Well, I think administration needs to stand behind the docs a bit more, and trust their judgement.

  • Nurse K

    July 21, 2007 at 1:14 pm

    Well, this is what happens at our institution:

    Percocet for everyone!

  • Nurse K

    July 21, 2007 at 1:32 pm

    BTW, I’ll bet the coffee pots are signaling an inducement to, er, have a BM. Coffee is good for movin’ the bowels; although, the word ‘inducement’ implies something more forceful, like a cup of coffee followed by a finger up the bum or something.

  • Onehealthpro

    July 21, 2007 at 4:52 pm

    All of us with a license and a code of ethics are subject to fulfilling not just the letter of the law in our codes, but the spirit of the law in our codes. Could it cost someone their job if they lift up issues and concerns about appropriate medical judgement being dictated by administration. Absolutely. However, it is not administration with the license to practice having agreed to abide by a code that governs professional practice. No easy choices. And all choices have consequences.

  • Mother Jones RN

    July 21, 2007 at 5:54 pm

    This happens all of the time at my hospital. The doctors have 2 basic responses to the hospital administrator’s demands:

    Whimp doctors cave in and give the patient whatever their little heart desires. They tell the patient that they are sorry for being so inconsiderate to their needs.

    The doctors with balls of steel tell hospital administration to buzz off. They also say a lot of other things that I won’t go into, but you get my point.

    I’m not happy when I have to give a junkie their medications that they feel entitled to receive, but what can we do?

    As a side note, if anyone sees one of those coffee pots in a thrift store, please pick it up for me. I love those things!


  • NPs Save Lives

    July 21, 2007 at 8:12 pm

    There is no way I would practice in a hospital that would enable drug seekers. Their patient satisfaction scores would surely drop if someone left the ER with a high and killed someone on the road. I have no problem taking care of people who are in pain and we all know it’s a subjective thing. Enabling people is a bad thing.

  • Sheepish

    July 22, 2007 at 6:21 am

    Clearly your doctors need to firstly grow some balls, and secondly find a good lawyer.

    What they are doing is illegal, and what hospital administration is doing is illegal. The patient is a patient, not a client, whatever the business managers may say. No matter what the financial arrangements, a doctor’s duty of care is to the patient, and they cannot in good conscience act against the health interests of that patient.

    If your ED were a chronic pain clinic that would be a different matter, but it is not.

    Perhaps someone should print out this web page and put it on the staff noticeboard.



  • AlisonH

    July 24, 2007 at 12:18 pm

    Wow, Sheepish. That page is beyond belief.

  • Roy from Shrink Rap

    July 24, 2007 at 6:44 pm

    #1: Document your rationale for withholding the medication and accept the reprimand.

    #2: The nurse has the right to say No, but also accepts the risk of sanction. Declaring one an “enabler” is a judgment call. It can indeed be difficult to determine if the best course of action is to withhold the pain med vs give it to treat pain. This is a judgment call, and — as long as you have documented your rationale in the record — you must accept this as an appropriate exercise of clinical judgment.

    #3: No. I always feel like I am making the best judgment I can to treat someone who is suffering. If I ever felt like a drug pusher, than that should be a clue that I am making a wrong decision in that particular case.

    #4: The line between making a good call and being judgmental… that is a question we should all ask ourselves. Judgmentalism should have NO place in the practice of medicine (IMHO). People do not always make the decisions that I would like them to make. Giving them the option to be “wrong” is necessary if you want them to come back and have another chance at “getting it right.”

About Me

My name is Kim, and I'm a nurse in the San Francisco Bay area. I've been a nurse for 33 years; I graduated in 1978 with my ADN. My experience is predominately Emergency and Critical Care, and I have also worked in Psychiatry and Pediatrics. I made the decision to be a nurse back in 1966 at the age of nine...

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