Giving PRN at family request

Specialties Geriatric

Published

Specializes in ICU.

I am have been a nurse for two years and work in a LTC facility. I have had several " run in's" with family requesting PRN medication for the resident( residents who are not oriented). I go and assess the resident and determine that they do not need the prn medication. When I try to educate the family about the medication they insist. I had a man phone his wife so she could speak to me and insist that " mama" needs an ativan. I spoke with an experianced ltc nurse who says " give them what ever the family is requesting or they will have you written up." I want to know is this true? Should I save my breath? I had a resident who was not alart, resp 10 with family demanding she needs morphine. When I tried to educate them on resp depression they looked at me like I was the devil and then complained to the social worker. I need help. Should I shut up and give what ever they want? Should I keep trying to educate? I feel so inadequate. The family just talks me in circles until I am exhausted and even I don't know what I am saying.

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Ugh. Are these new families or have you developed some trust with them? If it is absolutly going to harm them then I put my foot down and say sorry, that isn't what the drug is for. If it is ever a question of pain, then yes, I might give it or maybe educate the family on non pharm pain interventions and comfort care or maybe a tylenol with help? Def report it to the DON and get the IDT team involved with this family since they probably have issues.

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Specializes in Geri-psych, corrections, wound care, MDS.

I had the same sort of issue with a Hospice volunteer. My resident was resting comfortably with an undeniably peaceful expression, and I'd just come back from talking to her family, who were all on the verge of a meltdown already. The volunteer apparently spoke with them about the fact that "she (their mother) needed a dose of Roxanol", and proceeded to bring them to the nurses' station to explain this to me. (I have to add here, my mother has done hospice for 12 years and I am a HUGE hospice advocate, in addition to the fact that I generally tend to err on the side of pain control in terms of PRN administration!)

I'm stuck trying to calmly explain my rationale for NOT giving MSO4 then (resps = 10, no grimacing, no signs of anything other than a potentially nice dream), with the volunteer condescendingly talking to me/them like I'm an idiot. And then she asks, "Well, what is the actual order?", to which I reply "0.25mL SL q 2 PRN".....Her response? "Oh. Ok...what does PRN mean?"

So I feel you. And although families can make your life hellish at times, always trust your judgement, even if it means calling MDs, asking someone more experienced, etc. Families have patients best interests at heart, but they sometimes think with emotions and don't understand the consequences of some of the things that they're asking for. :)

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Specializes in Medical Surgical Orthopedic.

I do give the family's request some weight, but I wouldn't administer anything that is likely to be unsafe.

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I had the same sort of issue with a Hospice volunteer. My resident was resting comfortably with an undeniably peaceful expression, and I'd just come back from talking to her family, who were all on the verge of a meltdown already. The volunteer apparently spoke with them about the fact that "she (their mother) needed a dose of Roxanol", and proceeded to bring them to the nurses' station to explain this to me. (I have to add here, my mother has done hospice for 12 years and I am a HUGE hospice advocate, in addition to the fact that I generally tend to err on the side of pain control in terms of PRN administration!)

I'm stuck trying to calmly explain my rationale for NOT giving MSO4 then (resps = 10, no grimacing, no signs of anything other than a potentially nice dream), with the volunteer condescendingly talking to me/them like I'm an idiot. And then she asks, "Well, what is the actual order?", to which I reply "0.25mL SL q 2 PRN".....Her response? "Oh. Ok...what does PRN mean?"

So I feel you. And although families can make your life hellish at times, always trust your judgement, even if it means calling MDs, asking someone more experienced, etc. Families have patients best interests at heart, but they sometimes think with emotions and don't understand the consequences of some of the things that they're asking for. :)

That volunteer should be reported to the company for stepping way over her boundaries. A volunteer does not need to know a pt's med orders. It may even be a HIPAA violation for her to know them. A volunteer has no say in nursing decision making, no right to give the family any medical advice or opinion on anything medical or nursing related.

I am incredulous at that volunteer's behavior.

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Specializes in Gerontology, Med surg, Home Health.

YOU are the one with the license and assessment skills...not the family. You did the right thing by educating them. I would never write up a nurse for not giving a PRN on a family request if her assessment showed the resident was in no distress.

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Hi. First, look in a res. med. record. Find out if they are a code or no code. Then, find out if they have a durable power of attorney for health care, and/or an advanced directive. If the res.has a legal representative then you are legally responsible for discussing the residents care and treatment options with them. They are acting in behalf of the resident and can request and refuse medication that is ordered by the doctor. If you do not agree with a request then you need to call the MD and let the MD make the final decision. If they disagree with the MD's decision then the issue is between the family member and the MD.

As far as pain is concerned. If a res. has been ordered something as strong as morphine for pain then the res. has a legitimate need for it. If the need for pain med has been resolved as in the res. has been cured of a diagnoses related to pain then the MD needs to be called the order needs to be discontinued and the family notified. Just because a res. is no longer able to verbalize their needs, is not alert does not mean that they do not feel pain and do not deserve or need to have their pain relieved. If you noticed that the res. resp. are below normal then by law you need to contact the MD and ask if it is still OK to give morphine.

If an MD has an order to give the res. something for pain, and the res. has a legal representative making decisions, you could be found guilty of violating a residents rights, failure to follow a doctors order, failing to notify the MD about the res. abnormal resp. , failing to follow the residents advance directive, failing to keep the res. comfortable, etc.

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You could find the volunteers job description and write her up for not following it. Since a volunteer is not directly responsible for a res. care I believe it would be a HIPPA violation to discuss any matter concerning a res. with them and would excuse them from a conversation even if they did bring family members to the desk.

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Specializes in Gerontology, Med surg, Home Health.

Code status has NO place in this discussion and frankly, neither does a HCP,Guardian, DPA or anything else. It is the NURSE'S assessment skills that determine the need for a pain medicine. You can't really 'cure' pain at the end of life so your suggestion to dc the order is ill advised.

Nurses advocate for the residents. If it were me and I had the med cart, I would NOT give any resident pain medication if in my assessment they did not need it.

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Specializes in LTC,Hospice/palliative care,acute care.

quote

Exactly-and the department of health dinged us a few years ago in a similar situauion.We had a family member refusing/requesting various treatments all contrary to nursing judgement. We were told we MUST consider the resident's needs ahead of the family's demand.

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Specializes in ER, ICU.

Look at it this way, if you overdose a patient that you felt did not need the med, will the family repay your salary and represent you to management and defend you in court? They can complain, you might get flak for it, but you will never lose your license over it. They might just want nana out of the way so they can collect her inheritance, you have no idea what their motivation is. Your patient's safety is your job, your job is important, your license is more important. I've been in that situation and the family complaining has gotten me removed from that patient's care, which was a huge relief that I couldn't have been happier about. I didn't miss them.

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Specializes in ER/ICU/STICU.

Absolutely not. The families are probably not medical professionals. Even if they are they don't have any privileges where you work. If you don't feel the patient needs the med and they cannot communicate the need for it, then it is up to your clinical judgment.

I can imagine a scenario if you were to "just give them what they want" and the patient were to code (such as giving the morphine and having their respirations go down to 2) the family would be up in arms and wanting you fired, sued, etc. And "just give them what they want" is not a defense that will hold up in court. The family should be incorporated into nursing care, but the patient takes priority over family.

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