Does your hospice use standing orders?

[Butterflyxx0621]

I work for a hospice that has always had standing orders for the carekit, bowel regimen, DME if needed, oxygen, and catheters. After a recent survey, we are now doing away with standing orders completely. All now require a call to the physician for a verbal order, including accessing the carekit. Does anyone work for an agency that does not have standing orders and if so what is it like? I'm not opposed to change but I am concerned that the patients will suffer for this... Let's say you go to a patient visit for shortness of breath that has worsened and they were previously not using morphine. Now, you cannot access the carekit for morphine or titrate their oxygen without first speaking to a physician and sometimes you don't hear back from them for hours or days at a time. In the mean time, that patient is still short of breath. They may not want to transfer to the inpatient unit, and quite honestly they don't always need it, the goal is to keep them comfortable in their own homes. How is this good patient care for someone to have to suffer until a return call is received from a physician?

[toomuchbaloney]

The agency should have a working policy which describes how quickly the physician or provider must respond to nursing calls for symptom management. If the managing physician/provider does not return the call within that standard the hospice medical director will generally be contacted and will provide the timely orders for additional care. The providers should be advised of the requirements and expectations for call back when they refer their patients to the agency.

There must be considerable confidence that the hospice nursing staff will be successful in obtaining pertinent orders quickly for a patient in transition and experiencing exacerbation of symptoms for the agency to adopt this protocol. That might not work well in some markets. I am thinking about the newish medical hospice in Fairbanks, AK. Those staff don't always even have cell phone coverage dependent upon where the patient is located.

[Butterflyxx0621]

The agency should have a working policy which describes how quickly the physician or provider must respond to nursing calls for symptom management. If the managing physician/provider does not return the call within that standard the hospice medical director will generally be contacted and will provide the timely orders for additional care. The providers should be advised of the requirements and expectations for call back when they refer their patients to the agency.

There must be considerable confidence that the hospice nursing staff will be successful in obtaining pertinent orders quickly for a patient in transition and experiencing exacerbation of symptoms for the agency to adopt this protocol. That might not work well in some markets. I am thinking about the newish medical hospice in Fairbanks, AK. Those staff don't always even have cell phone coverage dependent upon where the patient is located.

We actually do not have a policy for how long a physician has to respond so at times yes we do contact the medical director. The problem is, our medical director has his own practice outside of hospice and the NP's who cover are also out doing visits so sometimes they are hard to reach as well. Even with the medical directors/covering NP's sometimes we do not hear back from them for several hours, which is my biggest concern. Our medical directors' partners in his private practice are the physicians we contact on-call and weekends, so they take even more time to get back to you.

Having said all that, I really am concerned with how this is going to effect the patient care.

I hadn't even thought about cell phone coverage, but you are absolutely right. I live in a very rural farm area and while some houses have great reception, others get none.

I really hope that the patient's will not suffer because of the changes

[Butterflyxx0621]

I don't think it's a matter of whether they have confidence in this policy, so much as our hands are tied. Our continued JCO accreditation is dependent on quite a few necessary changes, and this was one of them.

[toomuchbaloney]

Joint Commission accredited hospices are not forbidden to use standing medical orders. A friend of mine started a new medical hospice in 2012 and they established Medical Standing orders that were not an issue for JC. The fact that your agency is changing this at the direction of JC suggests that there were some issues with scope of practice, perhaps.

I suspect that if this new practice of calling for EVERY medication POC change slows response times and patient pain treatment is delayed or adversely affected that your agency will again be on the sorry side of the JC.

My understanding is that regardless of the other responsibilities of the medical director, there is an obligation on his/her part to be immediately available to the hospice staff and patients. If this becomes too great a burden for the MD and his/her support providers they will have to take issue with the recommendation and/or requirements of JC.

Good luck.

[Butterflyxx0621]

Joint Commission accredited hospices are not forbidden to use standing medical orders. A friend of mine started a new medical hospice in 2012 and they established Medical Standing orders that were not an issue for JC. The fact that your agency is changing this at the direction of JC suggests that there were some issues with scope of practice, perhaps.

I suspect that if this new practice of calling for EVERY medication POC change slows response times and patient pain treatment is delayed or adversely affected that your agency will again be on the sorry side of the JC.

My understanding is that regardless of the other responsibilities of the medical director, there is an obligation on his/her part to be immediately available to the hospice staff and patients. If this becomes too great a burden for the MD and his/her support providers they will have to take issue with the recommendation and/or requirements of JC.

Good luck.

You are exactly right. Apparently standing orders are not "individualized" and hospice care is supposed to be individualized to the person. In my opinion, having the orders allows the nurse to use their discretion to individualize and tailor to the patients' immediate needs. They also do not anticipate this increasing workload or visit time at all, which clearly is not the case. Thanks for the luck, I think we will need it

[toomuchbaloney]

You are exactly right. Apparently standing orders are not "individualized" and hospice care is supposed to be individualized to the person. In my opinion, having the orders allows the nurse to use their discretion to individualize and tailor to the patients' immediate needs. They also do not anticipate this increasing workload or visit time at all, which clearly is not the case. Thanks for the luck, I think we will need it

I am familiear with that complaint from JC. To me that suggests that your management and medical director were not able to explain how standing orders allow them to quickly customize an appropriate and comprehensive POC for the patient. In my experience, this decision could have been avoided had the medical director and the director of nursing for your agency had interacted appropriately with the surveyor(s) and had focused ALL of their responses on the patient directed POC which includes ONLY enacted physican orders from the SOs as well as individualized orders. The standing orders are NOT a medication or medical plan of care. They are merely a tool agreed upon by the physician and nursing staff to provide coverage for the most commonly needed orders that depend almost exclusively upon the nursing assessment of the patient.