Dilaudid for self-driving patient.

[thecode]

Few days ago, one of the nurses held Dilaudid from patient until she (the nurse) sees the person who will drive this patient home because patient drove herself to our ER. Patient did not have any problems with it and was willing to wait, however, our manager told her to give Dilaudid now and that she is not suppose to hold the pain medicine or any treatment just to see the responsible driver physically.

That separated our nurses in two groups here:

Group 1: "I will not give this patient Dilaudid until I see the driver because I do not want to put my license at risk when this person elopes after Dilaudid and runs over a bus full of nunns. I do not want to go to court and have it on me for the rest of my life that I contributed to killing of innocent people. My preceptor told me when I was a young nurse to always wait until I can see reponsible driver in person because many patients will lie to you that someone is coming but what truly ends up happening is that they get discharged and drive off in their own car!"

Group 2: "You cannot hold Dilaudid from patient who told you that someone is coming to get them. You have to exercise a certain element of trust to what patient tells you. It is the same with drinking and driving, police officer exercises a certain element of trust that when you go to the bar, you won't get illegally drunk and can drive yourself home. If patient told you ride is coming, you can give it to them. All you can do to be a prudent nurse is to WARN this patient that she/he cannot drive home, that medicine inhibits your reaction, and DOCUMENT that you told them. Also document that patient verbalized understanding and has made arrangements for someone to come and get him/her. That is it. It is wrong to hold the medicine just because you don't trust this person and want to see the driver physically. And then how far do you go? The person may come to the room but they can still drive in separate cars (pissed at you and complaining to your manager the next day because they told you ride is coming but you have trust issues). To insure that they don't run over the bus full of nunns you either have to give it to them at their house and stay with them for 4 hrs or at the ER and then make them lay in bed for four hrs. Seeing someone in the room who says they gonna drive them does not mean your patient will not get in her car on the parking lot. And are you going to the parking lot too to make sure they get in one car?!!"

Is there any policy that can back one or another point of view state wide? I work for HCA and there is no specific policy for that.

[BloomNurseRN, ASN, BSN, RN]

I don't have a policy I can point to but I know at the clinic I used to work at, we had to confirm a driver for Dilaudid or Phenergan before administering. Our docs and NPs all followed that even though it wasn't an actual written policy. It just made good sense.

[thecode]

BloomNurseRN,

Clinic is different. You could have your own policy if you are privately owned and and the board of directors can establish that rule. What about statewide... that's my question. Another issue rises, in a lot of statistics, they watch for proper and timely medication of patients, longer you don't give medicine, worse it looks..... it also doesn't look good on Press Ganey, that's from management standpoint. So, your manager incourages you to give it, and it is not that he is not concerned about nunns, it is that he wants that patient to get pain medicine and control her pain. She already told you that ride is coming, what more do you want? she is in pain and needs Dilaudid.

[BloomNurseRN, ASN, BSN, RN]

BloomNurseRN,

Clinic is different. You could have your own policy if you are privately owned and and the board of directors can establish that rule. What about statewide... that's my question. Another issue rises, in a lot of statistics, they watch for proper and timely medication of patients, longer you don't give medicine, worse it looks..... it also doesn't look good on Press Ganey, that's from management standpoint. So, your manager incourages you to give it, and it is not that he is not concerned about nunns, it is that he wants that patient to get pain medicine and control her pain. She already told you that ride is coming, what more do you want? she is in pain and needs Dilaudid.

I understand that, that's why I qualified it by saying I couldn't offer law. I was also specific to state that it was not a policy but that the physicians and NPs I worked with chose to have a higher standard of care. I sincerely doubt you're going to find case law regarding this specific issue, I was just giving an example.

[ebrooks1013]

I believe we are divided at our facility as well. I will give the medication but I will not discharge them until their ride arrives or they sit for four hours. I have seen other nurses wait until they set eyes on their ride especially when they know they will get discharged soon.

[Ruby Vee, BSN]

Interesting question. I think you should have put a poll in -- perhaps you still can.

Yes, you have to trust a patient to a certain extent, but patients lie. If you actually SEE the driver, you have TWO people telling you that the patient has a ride home, not just one (potentially desperate for dilaudid) person telling you so. If the bartender who refuses to serve a patron unless he sees the "designated driver" who comes to pick him up ever has to testify in court, he will testify that the patron SAID he had a ride home and wouldn't be driving. And that he actually laid eyes on the driver. Same thing for the clinic nurse who medicates a patient. If they later decide that the medicated patient will drive home after all, that's on them, not the clinic nurse.

I've had cancer, two joint replacements and a CSF leak. I've had some dilaudid in the past -- IV, IM and PO. Since I had the cancer and the joint replacements over about a year and a half, I developed a bit of a tolerance to dilaudid. (Which I hope passes, since I don't want to be viewed as a "drug seeker" if I subsequently have another health issue that requires pain medication.) Even though I had significant pain and a tolerance, I would NEVER have taken dilaudid and gotten behind the wheel. Which meant that my poor husband had to drive me to ALL of my physical therapy appointments, since there's no way I could have done the therapy I needed to do without it.

Put me down for "No narcotics without a designated driver." Or benzos or muscle relaxers or . . . .

[caliotter3]

Whenever I got pain meds in the ER and there was some question about my ability to get home, I was asked about how I would get home but nobody followed me outside to see who got behind the wheel of what car. In another case, after a procedure, I was not allowed to leave without my driver checking in to the front desk, as this was all explained to me when I made the appointment. They must have been emphatic because I remember them asking more than once and I seem to remember signing a special form attesting to the fact that I was not driving myself home. Another time I took a taxi but did not have to bring the taxi driver inside!

[SubSippi]

I believe we are divided at our facility as well. I will give the medication but I will not discharge them until their ride arrives or they sit for four hours. I have seen other nurses wait until they set eyes on their ride especially when they know they will get discharged soon.

This is the answer...give the medication, but let the patient know that he/she won't be discharged until a driver has arrived or the medication has worn off. Then document this conversation.

Some people might not think it's up to us to make sure a patient isn't driving while impaired, but if that patient got in a car accident I seriously doubt this wouldn't somehow come back to bite that nurse in the butt.

And it is part of our job to make sure our patients are discharged safely.

[Swellz]

This is a really interesting topic and I'm glad it's not something I've come across. I'm really interested to keep hearing how people have handled this in the past.

[OCNRN63, RN]

When I worked in the ED (2000s), we would not give pain meds until the patient had a designated driver present. Patients do lie. We had one of our FFs who came in for something or other, but needed pain medication. The nurse asked her if she had a driver, and she said "Oh, yes! He's out in the lobby." The nurse didn't look for the driver, just took the patient at her word.

Another nurse saw that patient a little bit later getting into her car and informed the ED physician. The ED phys. called the cops, and they went after the patient. IDK what the outcome was, but I remember after that we gave patients needing pain meds a handout informing them of our policy regarding having a DD.

[That Guy, BSN, RN, EMT-B]

Give the narcs but the driver for them has to come into the ER to get them. Simple as that. Our state has a law that shows what the timeframe is for a person to leave and be considered "sober".

[caliotter3]

This reminds me of a bartender being held responsible for refusing to serve an obviously impaired customer.