Published Aug 2, 2009
caroladybelle, BSN, RN
What exactly do you mean?
We start medications when they have been ordered for the conditions that they have been ordered....it does not matter whether they are "end of life" meds or not end of life meds.
Now, often the nurse has to ascertain via calling the MD whether the patient is being still treated for a condition that is easily reversible, or if they are strictly comfort measures only. Given that in some areas, a hospice pt may still be a Fullcode or undergoing some limited treatments, sometimes a call is necessary to clarify acceptable treatments. In some areas, the pt may still be given treatments (blood transfusions) or limiting certain comfort measures to live longer but not in a curative manner...thus they may be "hospice" but not getting certain "end stage " meds necessarily. If they pt has had such changes in physical status, that a change is needed, the nurse in many places does need to notify the MD, to order "end of life" care/protocols.
Whispera, MSN, RN
In my hospice, the doctor orders meds on admission, both scheduled and prn, as part of "standing orders." The doctor doesn't have to be notified when we start the meds, because it's assumed we will, since they're ordered. A call would only be needed if a change is needed.
It seemed to me that I've read y'all have the "end of life med order's ie atropine/ativan/oms etc. on admission and alot have written that they notify the Dr. before starting them. (when the pt. is at the end of their life.) I wasn't sure if this was a Law. I'm not talking about prn's or scheduled meds. Thanks for your input
In my hospice we don't notify the doctor before starting the meds, but tell him or her the next time we talk. The end of life meds are part of the standing orders and are there so we can start them when we need to (they're prns).
Thank you, I do know there PRN's :) It just seemed that every post I read called the Dr. 1st. We never do it,so I wanted input. Take care
you need an order before any treatment can begin. Sometimes if its the weekend and I know that the MD will not be around to sign all the papers then I will page and get numerous medications started or at least given the order to go ahead and start if needed. But yes, an order before any meds are started.
On admission, if the patient is already having difficulty swallowing, we order a comfort kit with liquid morphine drops, compazine suppositories, phenergan tablets, ativan tablets, ABH (ativan, benadryl, haldol), atropine 1% drops (to dry up secretions), tylenol suppositories. This is on the initial plan of care that the physician signs once we have a chance to turn in the paperwork. I can call our medical director and get a verbal order to obtain a comfort kit. We contract with a compounding pharmacy and they can dispense, without a signed MD order, a 72 hour supply of these medications. This is a Godsend because alot of times, a patient has been in the hospital setting for days and days, and FINALLY you have the DME sent to the house; and if you have done your homework, and you know patients allergies and have met the family already; you can head to the compounding pharmacy with the patients MR# and show up for the ADMISSION with the comfort kit. NOTHING IS WORSE THAN GOING TO ADMIT A PATIENT AND FIND THEM IN PAIN OR IN CRISIS FROM THE AMBULANCE RIDE. Now, the cost of a comfort kit is $43 and our manager does ask us to only "order what you need," but honestly $43 is a small cost for the company to incur vs sending a nurse out after hours to evaluate a patient, just to call in to the local pharmacy for phenergan. Our comfort kits usually have 4-6 tablets of each med, or 2-4 suppositories. Again, its worth every penny for the family to have what they need in the home. My philosophy is it's better to have it and not need it, than to need it and not have it.....
My agency has standing orders for Atropine, with a nurse's assessment, but starting Roxanol, Ativan, Haldol takes a TC to the Dr, and an order.
If the Pt is actively dying, or close to it at admission, the admit orders usually will have these meds w/o need for additional orders.
I do my share of waking docs up at 0230, and the smart ones figure out to give some flexibility in their orders so they don't have me back on the phone at 0430.
Seems like this has been covered pretty well. Hospices practice a bit differently from agency to agency and state to state. I have worked for agencies that require the RNs to carry emergency meds in their trunks (PR, PO, SQ/IM/IV) including Morphine and Dilaudid, and I have worked for agencies that want you to carry no meds. The bottom line is really your standing orders. We are all aware that we cannot initiate a medication POC without a physician order... so it hinges on your standing orders. Beyond that, the working relationship between the RNs and the medical director(s), the community MDs, and agency policies will dictate how quickly you must notify the managing physician of a change in the POC. I have worked for agencies in which the RNs had considerable autonomy in changing the medication plan prior to notification of the MD/med dir including significant adjustments in opioid dosing. My current hospice prefers that the physicians provide specific direction beyond the first level increases during pain crisis. All hospices that I am aware of provide standing orders which allow initiation of the "comfort pak" with same day notification of MD. In other words, you are covered to start the Roxanol if needed, and don't need to call doc in middle of noc if effective at S.O. doses, but do need to advise of change in condition and POC in the A.M. Do Not ever be afraid to wake a doc up. If you are unsure if you are exceeding the scope of your practice ... call. If the S.O. are not clear or you are uncertain what the next step is...call. Better safe than sorry when it comes to your license.
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.
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