Can you give a lesser dose than prescribed without an order?

[Faith1234567]

The pt asked to receive 2/3 of the dose of celexa and when I asked the provider for an order he told me "the patient has the autonomy to take whatever dose if he wants too" and did not want to change the order. Just wondering if I can administer a lesser dose without an order.

Thanks

[Orion81RN]

It's frustrating when people don't understand our scope of practice. Sometimes I want to tell doctors, "Trust me, I'm just as annoyed, if not more, at having to make this call as you are receiving it."

[Jory, MSN, APRN, CNM]

Yes, the patient has the right to say "I don't want 8mg, I want 4mg." And in that case, you need to call the physician and see if you can get an order for 4. You can't just give the patient 4mg and document that and go on your way, because you are in fact practicing medicine without a license if you do that. TJC and CMS would come down on you on a hot second (and, even range doses "1-2 tabs q4h" are a big no-no).

I disagree, this highly depends on what the medication is for. If it's for pain, nausea, anything ordered PRN, nowhere does it say patient has to take the full dose, you document it and move on.

No, it is not practicing without a license. You are not adjusting the prescription, patient is refusing to take part of it. That is their right. If they were at home, they don't have to take the full dose. Nurses can't make them take their meds.

Now if it's an antibiotic, blood pressure medication, etc...something where it needs to be given over time, in a lesser dose the therapeutic goal is compromised and that is why the physician needs to be involved. In terms of 2/3 of a dose, even if the physician agreed to it, pharmacy would be giving instructions on how to cut that down because I don't see how you can give 2/3 of a tablet or even better, cutting it themselves.

TJC and CMS doesn't get involved in "nurses practicing without a license". That is what the Board of Nursing is for.

[Tenebrae, BSN, RN]

This is exactly the type of situation I was thinking of when I wrote in an earlier post that "nursing judgement" doses do happen. I work in a SNF, we don't have providers in the building and there is no way I am calling the primary MD or an on call every time a resident refuses a dose of stool softener or a Tylenol even though technically I am supposed to. Prescription meds are another matter though, any refusal or adjustment in dose does need the providers input.

I work in a LTC facility. We have an awesome inhouse GP who is avaliable alot of the time.

He is wonderfully patient, I suspect it would wear thin if we had to call him every single time a patient refused a laxsol, or paracetamol

We are also fortunate in that he is in the facility at least four times a week so its easy to follow up quickly if patients are refusing meds, or only taking partial doses

[klone, MSN, RN]

TJC and CMS doesn't get involved in "nurses practicing without a license". That is what the Board of Nursing is for.

You're wrong. They most certainly do get involved with "scope of practice" issues as they pertain to orders, how they're written, and how they're carried out. I'm not saying that they would get involved with disciplinary action for individual nurses, but the facility could certainly get cited.

[klone, MSN, RN]

TJC kind of touches on the topic here:

Medication Administration - Incorporating Patient Preference Into Medication Administration Practices

Are there circumstances when a provider may write PRN medication orders that allow variation in administration based on patient preference such as in the following examples ? Example 1: Orders are written to administer 'acetaminophen for mild pain' and 'hydromorphone for moderate pain'. However, due to the side effects of hydromorphone, the patient requests to take the acetaminophen even though pain was reported as 'moderate'. Example 2: A post-partum patient has PRN pain medications written as follows: morphine for severe pain, hydromorphone written for moderate pain and acetaminophen written for mild pain. New moms who report moderate or severe pain may request to take the acetaminophen as they do not want to take the other medications as they are breastfeeding.

The practice described may be acceptable as long as an organization has determined that:

1. That the medication order is written in a manner that supports deferring to patient preference when:

a. Requesting a lesser potent medication. (Potency should be established with an evidence based tool i.e. morphine equivalents).

b. Requesting a lesser prescribed dose in a range order.

c. Requesting a less intrusive route of administration if both routes are prescribed by the provider.

2. The medication is administered in accordance with orders from the Licensed Independent Practitioner (MM.05.01.07 EP 5).

3. The inclusion of patient preference into the medication order cannot subsequently create a therapeutic duplication with other prescribed medications.

4. The organization's medication management policy (see MM.04.01.01 EP 1) identifies this type of medication order as deemed acceptable, and defines all required elements of such orders.

5. The use of a protocol is not required. However if an organization chooses to utilize a protocol, the review and approval process must comply with the requirements found at MM.04.01.01 EP 15. The medical record must contain evidence of an order to implement the protocol as well as the protocol itself.

6. That implementing such orders or protocols is not outside of the RN scope of practice as defined by state law/regulation,

7. The medical record must accurately reflect that the lesser potent medication was administered based on patient preference (RC.02.01.01 EP 2). It is NEVER acceptable to administer a medication of stronger potency based on patient preference.

8. Each organization is responsible for determining how such orders are to be entered into the medical record. However, the following is an example for consideration:

Acetaminophen 325 mg 2 tablets po every 4 hours prn mild pain.

Hydromorphone 2 mg 1 tablet po every 4 hours prn moderate pain. May administer less potent prescribed medication based on patient request per the organization's medication management policy (MM.04.01.01).

The policy must be explicit in that such an order is ONLY for administration of a different (lesser) agent, not changing the dosage ordered of the same medication. If the policy allows a lower dose of the same medication than ordered, it would not be accepted as compliant.

[ruby_jane, BSN, RN]

The policy must be explicit in that such an order is ONLY for administration of a different (lesser) agent, not changing the dosage ordered of the same medication. If the policy allows a lower dose of the same medication than ordered, it would not be accepted as compliant.

Wow....ok, everything I learned just went out the window there...

[klone, MSN, RN]

Wow....ok, everything I learned just went out the window there...

Yep. Hundreds of hospitals all over the country are non-compliant on this medication management topic. Our facility is tightening up our order sets right now in order to get into compliance.

[beekee]

So if oxycodone is ordered for pain rated 5-7 and Tylenol for pain rated 1-4 (or whatever), and the patient rates his pain at 6 but wants Tylenol I'm suppose to get a new order?

[klone, MSN, RN]

So if oxycodone is ordered for pain rated 5-7 and Tylenol for pain rated 1-4 (or whatever), and the patient rates his pain at 6 but wants Tylenol I'm suppose to get a new order?

Officially, yes. Unless the order has the applicable wording from the post above:

May administer less potent prescribed medication based on patient request per the organization's medication management policy

[Jory, MSN, APRN, CNM]

You're wrong. They most certainly do get involved with "scope of practice" issues as they pertain to orders, how they're written, and how they're carried out. I'm not saying that they would get involved with disciplinary action for individual nurses, but the facility could certainly get cited.

But that isn't what you wrote. Your comment said that the TJC or CMS would come down on the OP, not the facility.

The TJC and CMS doesn't define the scope of practice for nurses, the State Boards of Nursing through whatever legislature is passed in that particular state does. All the TJC or CMS does is check to see if the facility is in compliance in accordance with state law, facility policy, reimbursement guidelines.

A patient has the legal right in every state to refuse any amount of medication they desire. This is where policy will most likely guide that nurse over scope of practice.

If the patient refused to take their blood pressure medication altogether, a nurse would hold it and notify the physician because the therapeutic goal has been compromised. We notify the physician, document the physician was notified, document the patient was educated but here is what we don't do: We don't get a new order for a patient skip this dose because they refused. I have never seen that done in my career.

So it's no different with a partial dose. Same documentation process. Notify physician, document what was given, you don't need a new order because you already have an order.

[klone, MSN, RN]

But that isn't what you wrote. Your comment said that the TJC or CMS would come down on the OP, not the facility.

The TJC and CMS doesn't define the scope of practice for nurses, the State Boards of Nursing through whatever legislature is passed in that particular state does. All the TJC or CMS does is check to see if the facility is in compliance in accordance with state law, facility policy, reimbursement guidelines.

A patient has the legal right in every state to refuse any amount of medication they desire. This is where policy will most likely guide that nurse over scope of practice.

If the patient refused to take their blood pressure medication altogether, a nurse would hold it and notify the physician because the therapeutic goal has been compromised. We notify the physician, document the physician was notified, document the patient was educated but here is what we don't do: We don't get a new order for a patient skip this dose because they refused. I have never seen that done in my career.

So it's no different with a partial dose. Same documentation process. Notify physician, document what was given, you don't need a new order because you already have an order.

We are not talking about holding a medication. We are talking about changing the medication dosage. You can't just choose to do that without an order. See what I copied above directly from TJC.

I'm sorry I was not clear when I wrote "TJC would come down on you in a hot second" - what I meant was that they would cite the facility, not an individual nurse. An individual nurse's actions can certainly result in a "finding" for a facility. But the most likely scenario is that if one nurse is doing it a certain way, then multiple nurses are as well.

[Kooky Korky, BSN, RN]

Yes, the patient has the right to say "I don't want 8mg, I want 4mg." And in that case, you need to call the physician and see if you can get an order for 4. You can't just give the patient 4mg and document that and go on your way, because you are in fact practicing medicine without a license if you do that. TJC and CMS would come down on you on a hot second (and, even range doses "1-2 tabs q4h" are a big no-no).

The dear doctor should know better. He or she should just write the right order, and take into account that it is pretty hard to give 2/3 of certain meds - like those that don't come in doses that are truly calculable, also what Pharmacy has available.