Just saying no to drugs.

[BlueDevil,DNP, DNP, RN]

What are your techniques for saying "no" when asked for inappropriate prescriptions patients have been given by other providers in the past? I am not referring only to narcotics.

I saw a Phys. Assist. (as a pt) the other day whom is transferring her care to me due to an insurance change. She asked me to write for a bottle of 100 tablets of doxy 100mg tabs to keep at home. She takes them prn. This has been her habit to ward off infection whenever she has a sniffle b/c "I have asthma and everything always goes to my chest." She just takes one or two, and Voilà, she doesn't get a life threatening pneumonia. Who knew?

This would not surprise me coming from Jane Citizen who read about it on her Mommy message board, but a PA? Yes, I'd expect her to know better. When I expressed hesitation, she told me her old provider, "a MD" (yes, with emphasis -the clear implication in her tone was that someone who is smarter and better educated than I am thought it was a great idea) did it for her all the time.

I told her that I am not familiar with any literature that supports this as a sound practice, and if she could find me any, I'd be happy to do it for her. I even gave gave her my work email address, which I would ordinarily never do for Jane Citizen, lol. She said she would probably not be making me her PCP since I wouldn't continue the plan of care that had been working for her up until now.

I don't feel bad when junkies get mad and leave threatening to go someplace else (I pray they actually will, they just seem to wait until after hours and try to pull one over on whomever is on call- as if they have never heard of EMRs, lol) but I did feel disappointed by this encounter. She seemed like a nice person, and normal in all other respects, and losing her means I probably lost her whole family as well, since they were all my schedule for next week.

How would you have handled it? I asked a doc I work with and he just shrugged and said he gives crazy nurses, docs, PAs and NPs whatever they want (as long as it isn't really dangerous) as part of the "cost of doing business." Do you think that's true? Are there different rules for colleagues?

[wowza]

How bad is her asthma- how bad are her PFTs ? There is literature in COPD that daily Azithro decreased hospitalizations so if the FEV1 showed true obstruction you could make a bit of a logical leap to maybe suppor this.

[Corey Narry, MSN, RN, NP]

i agree that the nhlbi guidelines for the diagnosis and management of asthma does not mention antibiotic therapy as a recommendation. however, there is a growing evidence in the literature that implicates atypical bacterial infections (mycoplasma pneumoniae and chlamydophila) and their role in triggering acute asthma exacerbations in adults and children. in this subset of asthmatics, the studies do appear to find some benefit in antibiotic therapy particulary macrolides and clarithromycin.

[MillieT]

I think the point is that she's not taking a full rx to treat infection, she's just taking one or two.

~Millie

[BlueDevil,DNP, DNP, RN]

Actually, my point was more about how you deal with people when you aren't going to give them what they are asking for, be it 100 doxycycline tablets to pop 1 or 2 whenever they sneeze, or 100 oxycodone tablets because it hurts when they sneeze. And further, are you more flexible if the patient is a health care provider?

[psychonaut]

Tough call, and clearly a far cry from someone wanting narcotics. I like your invitation to provide you with some supportive evidence. This is the example of going out of your way for a colleague moreso than just giving it would be. Even a small study with shaky foundations would give you some theoretical basis to work from.

In those times when I've wanted to propose an unconventional dosing or whatever to a new provider, I always come prepared knowing I'm asking for an "off-label" use and having evidence and rationale to offer them (and not an attitude, like with the "MD" comment).

[bsnanat2]

I think the posts are good but missing the OP's point: There is clearly no good reason to use Abx the way the PA is asking for them, especially with all the concern about resistance. That being said, I believe the OP's question is 'Would you still give the patient the script because they wanted it (and knowing it will probably not harm them)? Would the fact that the patient is a fellow professional influence that decision?' 'How do YOU handle it when a healthcare professional makes a clinically silly request? Does professional courtesy say that you should comply if it is harmless?'

OP, correct me if I am wrong. Good question.

[Sarah G]

Stick to your guns.

[BCgradnurse, MSN, RN, NP]

I would say no if you clearly feel there isn't an indication for the meds. Just say you're not comfortable doing it. If they argue, just stick to your guns.

[BlueDevil,DNP, DNP, RN]

I think the posts are good but missing the OP's point: There is clearly no good reason to use Abx the way the PA is asking for them, especially with all the concern about resistance. That being said, I believe the OP's question is 'Would you still give the patient the script because they wanted it (and knowing it will probably not harm them)? Would the fact that the patient is a fellow professional influence that decision?' 'How do YOU handle it when a healthcare professional makes a clinically silly request? Does professional courtesy say that you should comply if it is harmless?'

OP, correct me if I am wrong. Good question.

Nope, you got it. This is it exactly.

[BlueDevil,DNP, DNP, RN]

I would say no if you clearly feel there isn't an indication for the meds. Just say you're not comfortable doing it. If they argue, just stick to your guns.

As an aside, I was taught never to utter the words "I am not comfortable," with the rationale that it makes the speaker appear incompetent or to be lacking confidence. It reportedly does not inspire respect in the listener.

[delfin]

I think you handled it well. When I was in family practice I was constantly giving the talk about why abx were not needed for a virus, even if the patient was in the habit of picking up the phone anytime they had a sniffle and receiving a z-pak from their provider. I had a clinical preceptor whose background was infectious disease and drug resistance and I think his voice always stuck in my head about overprescribing abx.

I think it is hard to make decisions like that when the patient is in the healthcare field. But I guess the way I look at it is, I am okay if they do not want to have me as a provider. In all reality I wouldn't want to their patient either. :)