I backed down. I put in a one time order. Clinical RPh followed up the chain of command in the AM with physician cardiology section chair. Who of course wanted nothing to do with it. The Clin RPh documented not only in an I-vent (EPIC) but on the eMAR chart itself, but did indeed verify the order.
Thoughts?
We are only as heroic as our physicians allow us to be.
Advise, persuade, document as much as possible when rebuffed (get it into the legal chart record), and then eventually verify it. If possible, a little game to play is to time the order such that there's at least a delay on the administration time. I've found that physicians will tell you no no no 'til the cows come home and once they're off the phone with you, they'll take every recommendation you made.
I don't think I've ever come across a situation where I'll refuse to dispense the drug (like PCN + previous documented anaphylactic reaction, something epic like that).
But as I follow your transcript, I would have changed the way I phrased the first part of the conversation to better elicit a "yes go ahead" response from the physician. You kind of left it hanging, as if you were saying, "He's on dialysis...........you know this, right?" That kind of sets you up for failure later down the line. I would have probably done this:
"Hi Dr. Harry Pants, thanks for the call back. Your patient awvall's mom in 325-2 on dialysis, sotalol and xarelto are actually contraindicated/not recommended in dialysis patients, did you want to switch over to another agent? (alternatively: which substitute agents would you like to use? alternatively: would you like to start ______ and ______ instead? bonus: i can take a verbal order now if you'd like."
Here's what I did:
1) Like sakigt said, I get my priority issues out of the way first. Interest tends to fall after a few seconds.
2) Didn't rely on the physician to make the connection between ESRD and sotalol + xarelto; if he did initially, we wouldn't be having this conversation now.
3) Made the initial question a positive....it makes people feel good and seem in control.
If I gave you the choice of ordering vanilla ice cream vs. chocolate ice cream for the department because it's a hot day, you'll feel pretty good about giving everyone a treat. If I told you it's a hot day, you didn't say anything, then I suggested you buy ice cream for everyone....you're going to feel pretty crummy for not thinking of it in the first place. It's a saving face measure, it doesn't work every time, but it keeps you from lingering on the negative (that the physician forgot about renal issues).
Additional note: giving physicians specific choices may work, depending on personality. Using the ice cream analogy, some people respond better to being given the choice of vanilla vs. chocolate, others want 3-4 choices, others want an open ended question.
4) Made the immediacy subtle -- By pressing the question of what agent to use, or to give a recommendation, it requires a bigger hurdle for the physician to say "no" and to reverse course and blow you off ("I'll look at it later.")
5) Worked as the physician's advocate -- Verbal orders are generally a no-no in the CPOE world unless the doc is at home or something, so I further lower the resistance by making it seem like I'm doing him a favor by entering it and obviating the need for the physician to get to a computer and put it in themselves.
