What would you do?

[Guest219794]

What would you do?

24 y/o male, kidney stones, pain.

Ms 4 mg as 1930.

Fentanyl 100 mcg at 2000

At 2200, pt is still comfy, and ready to go home, with some Percocet to go. I explain that he will need a ride. He tells me this will be difficult. I explain to him that it won't be as difficult as getting arrested for operating under the influence of narcotics, or worse, killing somebody.

He agrees that he will get a ride. Looked me in the face, was sincere. I could tell from the timing of his discharge to how fast he left the ER, he never even tried for a ride. I followed him out to the parking lot, and when he got into his car, waved him over. Told him he could come back in with me, or I could call his tags to PD, and he would most likely go to jail, where they won't let him eat Percocet.

I don't generally follow my patients out the door. In this case, I was initially just watching to see if he was going to use the lobby phone. I am not too keen about people driving on narcotics, and was really ticked that he lied to my face. Not that I expect much from people, but I actually made his pain my priority, and did a good job taking care of him. The little craphead.

So, I present this to the Doc, and ask what kind of time frame we might be looking at. The truth is, that this kid looked totally solid on discharge. Clear speech, intact reasoning, steady gait, etc. since 2100, at least. The Doc was really not sure the best way to handle it, but suggested 4 hrs from the ms. Since he had seemed perfectly sober, this seems reasonable. At some point, you have to put a number on this, whether it's 1 hr, 4 hrs, or 12 hrs.

Now, we have incurred some responsibility for his driving. We said he was sober. Contrast this to my other choice: I could have ignored the fact that it was obvious he was going to drive, and documented to cover my butt. I would have knowingly let him on the road, but removed myself from any responsibility.

Unlike alcohol, which has set numbers, narcotics don't. It is not illegal, as far as I know, to drive on narcotics. It is illegal to drive while impaired.

So, two questions:

Does your facility have a policy to deal with this?

What would you do?

[Lunah, MSN, RN]

Before I give anyone narcotics (unless they are obviously accompanied by a spouse/friend, and writhing in pain), I ask how they're getting home. As I'm giving their meds, I tell them they cannot drive home, and the person with them must drive. If they are unable to get a ride, they often won't get narcotics. There are some repeaters that we see often enough that they know we must see the whites of the eyes of the person giving them a ride before we'll give them narcs. Otherwise, it's Tylenol/Motrin/Toradol/something non-narcotic.

In the case you mentioned, it's tough -- when they look like they might be steadier on their feet than I am after a 12-hour day. I get the doc involved. We have taxi vouchers, but are necessarily stingy with them. But we are strict about not letting people drive under the influence, to the point where the police have been called. We'd rather let them camp out in a bed (as long as we're not slammed at the time) than to put them on the road where they can hurt themselves, or someone else.

[parablue]

We also DO NOT give narc's if the pt. does not have a ride or is not going to be an admit, It is amazing how quickly someone can get a ride when you tell them "I have a order for (whatever narc) but can not give it till you have a ride home, We can not even call a cab because of the liabilty of putting an impared person in a taxi???? Why they can go with a friend/family member I do not know.

[miss81, BSN, RN]

We have forms that the person has to sign before we give narcs, usually only use it if they are alone. It states that they understand that they cannot drive after the narc and that we have explained the reasons why and they understand them. I'm not sure if there is a time limit on them... I'll have to take a look.

[Larry77, RN]

I agree that we should address this issue before we give the narcs...I do not recommend following anyone out to the parking lot where you put yourself in danger. I can see far too many scenarios where staff could get hurt.

I know that people drive all the time on chronic px meds but they have a tolerance and would not be considered "impaired" but you are talking about an acute situation I sign these people out to someone else, until I see the whites of their eyes they do not get discharged.

[LilgirlRN, ADN, RN]

We make sure there is someone with them before narcotics.

[Miss Mab]

I had a very similar situation I posted about on the ER threads--it was a while ago--and most of the responses were a variation on the theme that others would NEVER give certain meds w/out a DD in place, keep them in dept., etc.... Due respect, int he real world rarely a one size fits all dilemma..

That said, I think you'll find that this is one of those tricky practice issues that almost never is officially addressed in any unit or facility P/P exactly because 'they' don't want hard and fast rules written down about it. Too much liability for a wrong call one way or another-(vagaries re. not adequating treating pain/holding against will/driving while impaired and on) MY belief.

We all know what should be done and you can only do your best to see that it is done, ideally in concert w/physician treating and much CYA documentation.

Unless and until more facilities actually officially address this issue instead of existing in the realm of"everyone knows that you do" then this is just another grey'ish area that reminds one to maintain their own Liability Insurance.

Sadly.

ETA: Reading another thread reminded me....Getting consents--this is also one of those everyday practice areas where everyone KNOWS how it should be done but darn it if there is ever any written P/P. More rope to hang and all that.

[Guest219794]

I generally do discuss the transportation thing before giving narcs. in this case, the kid was in such pain, I had to drag him out of the bathroom to medicate him. No real chance for a conversation.

[back2bRN]

I hand them the phone and say that due to P&P they will need a ride home following the med. I stay to listen to the conversation and sometimes will dial the number. If they don't have a ride I talk with the MD/NP prior to giving the med to find out other options. We do actually have a P&P for keeping pts for 4 hrs following admin of a narcotic or other altering drug, or ensuring they have a ride home. I also document that the pt was advised, and has agreed to get a ride or stay. Now if they are in pain+++, I give the med and then address the ride home when they are more comfortable.

[canoehead, BSN, RN]

I document that I have discussed sedation effects with them, and that includes that they cannot drive/fall risk if they get up on their own. When they leave I look for the driver, or if there is no driver I let them know that if they drive themselves we will be calling the police. We cannot hold anyone against their will, and don't have the beds to do so. Usually they come up with someone.