Need Opinion of Smart Hospice Type Nurses

Specialties Hospice

Published

Hello Hospice Nices,

I have a dilemma and need opinions on it.

Picture: New hospice, low census, skeleton staff, I'm an RN wearing many hats to control costs and help out as much as possible ...

It seems there is some confusion on what meds are covered in Hospice but I've always used the 'related to the symptom management of the admitting Dx' and a good dose of common sense as a guide on what to provide. Well that blew up in my face today over the cost of some breathing meds.

Case: New patient referral, released from hospital with a minimum of information. Dx: "Lung Cancer". Pt is not well off financially. Pt is at home and calling for us, I get there and find him in a pain crisis, discover he was on Fentanyl and scheduled Oxycodone for Arthritis and both are out. On top of this, the pt is on 5l O2 by mask and has a Hx COPD with nebs and puffer med use. The pt is a current smoker and can hardly speak due to SOB and pain.

Well the referral source wrote scripts for new respiratory meds, steroids by inhilation and PO, as well as antibiotics for Pneumonia and no pain meds or direction for pain management.

Question: What meds should the Hospice cover here?

Thanks,

Looking forward to any opinions.

Specializes in hospice.

At our hospice, the medicines would depend on our pharmacy formulary. We would supply all comfort and lung medicines. If the meds he is on was not on the formulary, we would change them. We do not cover oxcodone or duragesic so we would switch him to MSER and roxanol. Some of the puffers we do not cover like spiriva, advair. We do cover albuterol and atrovent.

If the doctor is unwilling to change his medications, we have to get approval and order them anyway.

Specializes in Hospice, Palliative Care, OB/GYN, Peds,.

I am under the impression that meds for symptom management, comfort and the terminal disease are covered by Hospice. Shortness of breath is a symptom of lung cancer whether or not there is an underlying COPD. I always consult with my pharmacist to determine which meds that we cover before I inform the patient. In this situation it might be more difficult to determine, but pain and symptom control are the basics that we should cover. Our hospice covers all of the pain meds including neuropathic, bone, etc. If I were to make the determination I would cover the breathing meds, hoe would we know which disease was causing the symptom. Just a thought.:typing

Specializes in Hospice, Palliative Care, Gero, dementia.
At our hospice, the medicines would depend on our pharmacy formulary. We would supply all comfort and lung medicines. If the meds he is on was not on the formulary, we would change them. We do not cover oxcodone or duragesic so we would switch him to MSER and roxanol. Some of the puffers we do not cover like spiriva, advair. We do cover albuterol and atrovent.

If the doctor is unwilling to change his medications, we have to get approval and order them anyway.

So, you're saying your only opiate is morphine? What is someone cannot tolerate morphine, or has developed issues that require an opiate rotation?

Specializes in hospice.
So, you're saying your only opiate is morphine? What is someone cannot tolerate morphine, or has developed issues that require an opiate rotation?

I was using that as an example, we also use dilaudid, lortab, and whatever else is on our formulary, but if someone was allergic to everything we had, a non-formulary pain med would be approved. sorry for the confusion.

in your nsg dx, you may want to change pain r/t arthritis, to pain r/t lung ca...

just so everyone's on the same page.

and while certain meds may not be covered, the classifications and indications, certainly are.

bronchodilators, analgesics, antiinflammatories, etc.

if it's documented that certain meds didn't work, then hospice will cover other ones.

but they want you to try what's on the formulary first.

leslie

It looks like the POC has to include these meds as if we don't provide them, they will not be sourced by the family and we'll loose the pt.

Management wants to know what meds we will cover for any Dx so I guess I'll have to get a formulary and Med Use Guideline started. I may have to create a Policy using drug classifications with examples, by each med will be impossible.

We all know though, that if a med is ordered, and the MD wants it given, then we give it irregardless of the policy and cost.

Thanks for the replies, very helpful to know I'm not totally off here.

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Just Thinking out loud. Technically, for a pt that has an Admitting Dx of Lung Ca, Hx COPD, Smoking and Arthritis with opiate Tx. It looks like these pain meds are not hospice provided as tehy are not truely related. (But try telling that to an MD that the pt goes to see about pain while in a Hospice and see how that goes over.)

And there is a case to be made that the previous COPD maintenance meds are not the hospices' responsibility. (Again, try telling that to an ER doc when your Lung Ca pt is in the ER for SOB.)

But, as I can't seem to make anyone truely understand, these are related and the referring MD could just as easily have offered all these Dx as why they are appropriate for Hospice and then they would be all ours no matter what, if we took the pt, as if we would refuse to care for him over this.

Personally though, as a clinician, I can't remove the time component from the equation. Those same health issues that were unrelated to the actual Cancer, are now co-morbidities going to exacerbate the Cancer symptoms and impede comfort. Also .. what Shrinky said. How are you to separate the Lung cancer SS from the COPD SS from admit onwards? The prudent thing is to include these complicating Dx and meds into the POC for the patients sake.

[/stopping thinking outloud]

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Thanks!

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