Imagine the following scenario: You are a recent emergency medicine residency graduate practicing as an attending physician in a small army hospital. EMS calls en route with a middle-aged man who had just collapsed in the back of the ambulance after complaining of chest pain; CPR is in progress. They are approximately 12 minutes from your hospital with minimal capabilities and approximately 16 minutes from the nearest cardiac center that has PCI capabilities.

You decide this gentleman who just had a witnessed cardiac arrest has higher chances of survival and resuscitation at the cardiac center. You follow the latest evidence-based medicine recommendations by the American Heart Association for regionalized care of out-of-hospital cardiac arrest, and attempt to tell EMS via the radio to divert to the slightly farther away but more capable facility. (Circulation 2015;132[18/Suppl 2]:S313; http://bit.ly/2rAxnN4.)

Suddenly, a nurse who is at a higher rank than you prevents this from happening, stating it is protocol that EMS come to the nearest facility. After you attempt to tell the higher-ranking officer that he is wrong and you have the right to make these medical decisions as acting medical control per your institution's EMS standard operating procedure, he overrides your call based on rank. Later, you are reprimanded for refusing to take an order from a nurse who is a higher-ranking officer.

The word “order” has been used for many centuries, and the expression “doctor's orders” is one that is often used to denote a plan, care, or medical decision by a physician. The nurse-physician relationship has historically been one where the nurses not only work collaboratively with the physicians, but also do not assume the responsibility and decision-making authority of the physician.

The medical and nursing fields have different educational requirements, different licensing statutes, and different scopes of practices. Nurses are not expected to follow physicians' orders blindly, but they are expected to be part of the team with the goal of reaching the best possible outcomes for the patient. A nurse not only has a duty to the patient but also a duty to maintain competence and continued professional growth, according to the Code of Ethics for Nurses. (MedSurg Nursing 2015;24[4]:1; http://bit.ly/2rAjQoB.) This includes being fully aware of local standard operating procedures.

Respondeat Superior

Historically speaking and from a military standpoint, Article 90 of the U.S. Manual for Courts-Martial says that anyone who “willfully disobeys a lawful command of his superior commissioned officer shall be punished, if the offense is committed in time of war, by death or such other punishment as court-martial may direct.” (2016; IV-19; http://bit.ly/2rAsUK8.) It also states that “the commissioned officer issuing the order must have authority to give such an order. Authorization may be based on law, regulation, or custom of the service.”

This implies that a nurse does not have the authority despite rank to overrule a physician when it comes to medical decision-making. What is it that allows certain command structures to be so rigid that they allow a nurse to “oversee” a physician because of a higher military ranking? Is it the diminished legal accountability that individual physicians and nurses face? In the military, active-duty members are not allowed to bring a claim for malpractice, and civilians are only allowed to sue the government, not the individual.

Many courts will rule that a nurse is required to follow a physician's order if that order is reasonable, even though the nurse has an ethical duty to disregard orders that he believes are erroneous or dangerous. The doctrine of respondeat superior applies here: A hospital may be party to a lawsuit brought about by the negligent act of its nurse employees, including failure to follow a doctor's order. (Proc [Bayl Univ Med Cent] 2010;23[3]:313; South Med J 2002;95[5]:545.)

The American College of Emergency Physicians holds that the autonomy of the emergency physician in clinical decision-making ought to be respected and not restricted by rules and protocols. They emphasize that the physician must be allowed to do what she believes is in the patient's best interest. The college also states that physicians should not be subjected to reprimand when bringing to light deficiencies hindering high-quality care. (ACEP, October 2015; http://bit.ly/2rAmc6V.)

Physicians should not be limited in medical decision-making based on military ranking. The physician is considered the captain of the ship in the emergency department. Commanders and military supervisors, who are not always physicians, should keep in mind the nursing and physician's scope of practice and role in health care and how that differs from the military role.

The views expressed in this article are those of the author, and do not reflect the official policy of the Department of the Army, the Department of Defense, or the U.S. Government.

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