Calling Doctor to START end of life Med.

I believe its a federal regulation that states the facility may have emergent kits but once accessed the physician must be notified/thus yes needing an additional order.

Whenever I do an admission, I make sure to tell the family that we order a comfort kit for every patient (removing any meds that the patient is allergic to or cannot take for a medical reason) which will be delivered in the next day or so. All admission orders include the comfort kit and these orders are signed for by the patients doc on admission...so there you have an order and can begin them whenever the patient needs them. I shutter to think of having to wait for a doc to call you at 2am when a patient is SOB with secretions and you cannot give the meds because the doc has not called!
And since we have a very good admission coordinator, we usually know if the patient is critical or actively dying at admission and can get scripts and have them filled before we go in to do the admission.

Most hospices that I am aware of work with algorythms in the form of standing orders which allow the nurse to initiate care, including medications, without notifying the MD in advance. This format for care delivery insures that the care we can provide is rapidly responsive to the dying person's needs. The use of "comfort kits or packs" containing the typical constellation of symptom management meds is pretty widespread now and is probably close to being considered standard of care. Delivery of that kit should, ideally, be the day of admission to the hospice. Some hospices arrange to have the "comfort meds" provided through the discharging hospital when the people are leaving rather than using an outside pharmacy. No matter how it is accomplished the presence of the pharmacologic "tools" in the home is crucial to the timely response to the changing needs of dying people. AT any rate, the confident hospice nurse sees a symptom, initiates the proper hospice action, educates the patient and family, and notifies the team (which includes the MD).