Ordering controlled meds, then refusing prescription?

[mystory, BSN, RN]

Hello,

I have witnessed a frustrating pattern that has gotten worse over the years. Doctors order a generous pain management regimen for patients in house, then send the patient home on Motrin or 3 days on Percocet. The patients understandably get upset, and since I am doing the discharge teaching I get the brunt of it. Most of the time, patients are not satisfied with my response and rationale. I then call the resident and ask if they can speak to the patient. At that point, they have already washed their hands of the patient, who by their own intents and purposes is or should be discharged. It's quite frustrating.

It gets worse when they add a benzo to the regimen, (first of all, IMHO anxiety while hospitalized is normal and adaptive, but some docs treat it like a problem to be extinguished.) The patients want that Ativan at home now too, and of course rinse and repeat..same scenario as the pain meds.

I am on the float pool and this is a huge problem in psych, with the docs snowing the patients and then refusing to send them home with prns or benzos.

Is this a problem where you work?

[NurseCard, ADN]

I guess my best advice would be, to advise the patient ahead of

time that they may not have as much medication when they

go home. Why are they getting so much pain medication in

the hospital and not to go home on? Many surgery patients,

for example, should begin to have pain relief naturally, after so

many days post op. After a little while, Motrin or something

similar should be sufficient.

"anxiety while hospitalized is normal and adaptive, but some docs

treat it like a problem to be extinguished". Okay... are the doctors

ordering round the clock Ativan, or PRN Ativan? You don't HAVE

to give an anxious patient Ativan if you feel like there are other

ways to alleviate that anxiety, like letting them talk and vent a

little bit.

[blondy2061h, MSN, RN]

By your own statement these people are anxious from being in the hospital. Why do they need to go home on benzos? If being in the hospital is causing their anxiety, going home should make it all better. How long are these hospitalizations that you have people getting so dependent?

[Jules A, MSN]

. How long are these hospitalizations that you have people getting so dependent?

That was my question and even so if the dc includes a few days of opiates or benzos in most cases that would be sufficient. I applaud your physicians for being judicious with the schedule 2 meds they are sending out but hope they don't order them in excess while the patient is hospitalized in an effort to avoid calls and then cut them down drastically. I agree that patient education, in advance of the time you are handing them their suitcase, about nonpharm coping skills is important. In my experience even a teetotaling grandmom can very quickly become enamoured by the delightful feeling of benzos and it can become a psychological crutch which then turns into a physical dependency. Good luck I know this is challenging but personally I have no problem saying NO to meds that aren't warranted. Hint for benzos in the geri population they are in fact largely contraindicated, I mention the words dementia, delirium and falls resulting in breaking a hip which often assists in getting the point across.

[HouTx, BSN, MSN, EdD]

All this back and forth coordination is a ton of work, especially for a float nurse. It appears to be an ongoing problem that probably affects a lot of patients. Can't you call in the Case Manager / DC planning folks to take this on?

[CoffeeRTC, BSN, RN]

...and I'm the nurse that gets those patients admitted to my SNF for rehab....minus the Ativan, minus the Ambien, minus the Dilaudid/ Percocet/ Vicodin.

Yep, they were on all of those in the morning and might have even got their prns that morning. Now it is 7pm and I'm in the middle of doing their admission. Try getting an order for any of those.

[Jules A, MSN]

All this back and forth coordination is a ton of work, especially for a float nurse. It appears to be an ongoing problem that probably affects a lot of patients.

Are there really that many people who after one procedure or hospitalization demand continued benzos or opiates?

I tend to become suspicious the more agitated or insistent they get. When I discuss the necessary taper with a patient and they immediately start arguing, threatening or crying... huge red flag and definite taper.

[LessValuableNinja]

I agree with involving the person involved with discharge planning.

I also agree that agitation at a taper can be a red flag.

However, in cases where the physician has been giving the patient IV Dilaudid with no taper or transition while inpatient and switches them to IBU or whatever at discharge with no discussion, I have no problem calling the physician and telling them they need to explain it to the patient.

[Jules A, MSN]

I agree with involving the person involved with discharge planning.

I also agree that agitation at a taper can be a red flag.

However, in cases where the physician has been giving the patient IV Dilaudid with no taper or transition while inpatient and switches them to IBU or whatever at discharge with no discussion, I have no problem calling the physician and telling them they need to explain it to the patient.

This sounds very reasonable however raises two questions for me. Exactly how long have they been getting IV dilaudid? There is an estimated time to dependence. Secondly how do these lay people even know there might be withdrawal symptoms? Or are they just seeking additional meds? Prior to becoming a nurse I would have had no clue that I needed to insist on receiving narcs or benzos after discharge. Then again I was raised to attempt only what is absolutely needed and would be glad the physician felt I was ready to downgrade to IBU or whatever.

[LessValuableNinja]

In my anecdotal and nonsciency experience, people who flip out are usually the patient's kids, or long term users. Sometimes though, the (not in either category) person's been there for weeks after surgery and there's a sudden change in their discharge orders that's fairly drastic, with no explanation to the patient or their MPOA.

[TheCommuter, BSN, RN]

Moved to the Nursing / Patient Medications forum.

[Orion81RN]

I tell my patients I am discharging that we're sending them home with 3 days of meds and that they need to f/u with their doctor and show him/her the discharge papers showing what meds they were on in our facility. I do get some disgruntled pple, but when I state it that way, it usually turns out ok as far as receiving attitude.