Free Reign for Hospice Orders?

[SoCalRN1970]

I have worked at a few hospice agencies. Most Medical Directors will allow some basic ok's without orders. For example increasing roxanol from 10 to 20 mg. Inititating atropine etc.

I recently was spoken to because I wrote orders on a Crisis Care patient that was in support of the reason for having staff there 24 hours daily.

I changed orders for Roxanol for pain to same frequency, smaller dosing and specific to respiratory distress. This is what the patient was on for. The PCP knew this pateint was on CC, she gave the ok to go ahead with this. SHe was upset because I tweeked the orders to fit the Respiratory Distress need of the patient's CC diagnosis. ( I did not call her ) I was not initiating new meds. Just different dosing, and purpose. ( patient was comatose and no pain, but respirations were 40-50 a minute! )

I got "spoken" too by my manager. She threatend to write me up. She said I was practicing medication without a license. Ok. I see how this agency plays. I have called the MD for everything I mean everything... Today I was asked. Why are you calling me with all these orders?

Excuse me. Damned if I do, Damned if I don't. I actually told my MD that I was told I had to call for even barrier ointment and app mattresses. So, I suggest she speak to my manager if she feels my calls are too much.

OMG what am I to do?

[hospicernsrgr8t]

Do you have signed symptom management orders?? That is what we use to initiate/change medications per our facility policy.

For example, we always start with lowest dose of roxanol, 2 mg po/sl q 1 hour prn. Usually if it is a dyspnea at rest/pain issue,we will also have the same dose at schedule times q 4 hours. We increase only according to total daily dose at the next visit (i.e. 2 mg X 15 doses = 30mg/day. We divide this into q 4 hour dosing= 5mg q 4 hours and 10% of total daily dose for breakthrough = 3mg. We adjust according to use for comfort, and only according to the scope of the symptom management orders. If we exceed or get close to the top of that titration, we will ask for another titrate to comfort order. We always collaborate with another RN in clinical support if the adjusted dose is a big jump, are rotating opioids or if we feel uncomfortable.

If there are no signed/approved symptom management orders then we need to call/fax for orders.

So, the answer is No....we don't have free reign on Hospice orders at all. Nurses still follow doctor's orders, always.

[SoCalRN1970]

I just find it bizarre that there is such a response to me calling for everything like I was told to do. But I also was told that the MD was upset because I didn't call to clarify roxanol orders for respiratory distress. I have NO idea what I can do that won't cause a complaint anymore. I have only been at this office for 2 weeks and it seems like I can't go a day without my manager calling me to ask me if I did something or there is a complaint. Today she asked if I left a note int he pateints home chart saying the family isn't coping and has trust issues within. I have been a HOSPICE RN 8 years.. I know better than that.. everything is fallin on me it seems like. I may of made a mistaike. ( BTW the note was written by an after hours nurse.. but hey... lets blame NOEY67 she is the newest person.. and doesn't know what the hell she is doing.

[caliotter3]

Once the doctor signs the order, or gives the telephone order and follows up by signing the hard copy, you are covered, so I don't know what this person's beef with you is. You should be getting praised for showing initiative in attending to the patient's medication needs.

[SoCalRN1970]

I feel the same way. Caloitter. I will say that I will give this agency no reason to question me at least. I have written pages of communication notes.. if for any reason to cya. The person with the beef issues per se' is the manager who Freaking Hired me!

[caliotter3]

I think you need to start looking again. This person's insecurities or borderline personality issues seem to be placing handwriting on the wall that is not in your best interests. I'll bet you aren't the first person she has run off.

[SoCalRN1970]

I have no idea why this person has an agenda. But they do. Supervisors that act like this are enough to make one bonkers and scared out of their wits if they cough they can be termed.

[AtlantaRN, RN]

That is such a bunch of crap.......i wouldn't have called the doc to change the order to from pain to respiratory distress....

frankly, a doc that wants to be called for every little change, has no business being inhospice. hospice patients change, and a good nurse reponds to the changes. and that is exactly what you did.....

[tewdles, RN]

What are you to do?

Begin looking for another job...it sounds like there is an adversarial relationship between management and field professionals and this is not likely to change unless you get new management.

CYA at every turn. Your job is not to make the MD happy but to take care of your patients while functioning within your scope of practice. So, if you need to call the doc for every butt cream or duoderm you apply...well, so be it.

Having said that, try to come to an understanding with the MDs so that they can be your partner in investigating improvements to the standing order sets that your agency is using.

Good luck!

[SoCalRN1970]

I am frustrated. My manager has never worked hospice before. Has done home health. There is another person acting as a manager, but is clueless. LIke I said. I wasn't necessarily accused of leaving inappriate notes behind in someone's home chart calling them untrusting... BUT I WAS THE FIRST ONE THEY THOUGHT OF WHO MIGHT OF DONE IT. Touche' it was the admissions RN and well.. not my prob.

[Irisheyessmilin]

Hi Noey. You did what you thought was best for your patient-GOOD for you!! I agree with the others CYA! and keep doing what you feel is right for your pts!

[ErinS, BSN, RN]

Oh my goodness it sounds like you are in a crappy agency! Our MD gives us very liberal orders and does not get upset when we change orders within a range. I don't have to tell him that I am using haldol for nausea instead of agitation, or that we are using 1 mg instead of 0.5 or 2 mg. I am so thankful everyday for our amazing MD who fully supports us and our patients. Good Luck!