Is this a confusing MAR order? And moral dilemma

[Cclm, LPN]

Administer  6.25mg(1/4 tab) to 12.5 mg (1/2tab) seroquel PRN PO b.I.d for agitation. 

I understand it as....

Admin 6.25mg or 12.5mg twice a day . Meaning the total daily dose can be 12.5 (if admin 6.25 x 2) or 25 mg (if admin 12.5 x 2). 

Also it gives a dose range. I've always had the understanding that a nurse can choose the dose based on the patient, assessments and prior PRN effectiveness and clinical judgment. 

If I have a patient where all non pharmaceutical intervention have been tried, that I have admin the lower dose previously and other nurses previously, have found that the lower dose is not effective. Therefore a clinical judgment can be made to admin the higher dose. Agree or not? 

I understand the clinical phrase start low, go slow but this is typically in the case of opiods and benzos. (Have a few issues with this but thats a different topic). 

In this case the start low go slow has already been done. 

I feel I should be able to admin the higher dose as it is in the Dr. Order, my assessments have been made, my personally experience and the PRN documented effectiveness has been evaluated. 

Also I rationalize that all meds have a risk factor. Why would you want to admin a lower dose that is ineffective instead of a higher effective dose?. In a sense introducing a medication with all it risks and no therapeutic effect in a smaller dose is redundant. Like admin a med with risk and no benefit. 

Not to mention the patient verbally requesting a higher dose and is obviously not meeting except able relief from the lower dose. 

Obviously I'm having a personal dilemma. My supervisor says I have to always start at the lower dose. Which I agree and have already done. It doesn't make sense to me to admin a med at a dose too low to do any therapeutic benefit. 

In most situations I would do what my supervisors says. However I am conflicted. I feel it's my duty to advocate for my patient. It is obviousl this person needs a over all med review but until then, they are suffering horribly. This is terrible anxiety this person is experiencing and it's awful.  I have admin the higher dose with it being effective. I do not see why they need to suffer when I have a intervention that will help them. Apparently. SBAR the Dr. to clarify order by stating a total daily dose and/or suggesting additional med or increased dose of meds is not appropriate either.(Assisted living). 

I am also new to my position. I chart everything and have documentation backing everything I said, but we know how some nurse culture is like and fear if I advocate for this person ill get put in the "not fitting in file" and it will become a power struggle all the while the patient suffers. Then I get out casted. 

My patient is my most important concern and feel I will advocate for them even if it risks what I mentioned above. (Being outed). 

I thank you in advanced for any contribution.! 

[MunoRN, RN]

This seems to be the never-ending argument between nurses, but the answer I've gotten directly from my licensing board, is that as nurses we are expected to interpret the order as the Prescribing Provider expected us to interpret the order.

So if the provider intended you to understand that given a certain level of "agitation", that it had already been determined that 12.5mg is the appropriate dose, then not, you should not first give 6.25mg.  And technically, if that's the prescriber's expectation then you are actually practicing outside of your scope by giving only 6.25 mg.

 

[JKL33]

On 11/24/2021 at 4:43 PM, Cclm said:

My supervisor says I have to always start at the lower dose.

Well...whether your supervisor likes it or not, that is not what the order says. There are ways to write the order if they want to make sure you start at the lower dose and have the freedom to repeat it if not effective. But they did not write the order that way, they wrote what they wrote and your interpretation of it is correct.

Whenever you have questions or there is a disagreement in interpreting an order the best answer is to ask the person who wrote it. You could also contact the prescriber and see about having the order changed to just 12.5 BID PRN based on your assessments.

 

[Cclm, LPN]

On 11/24/2021 at 10:25 PM, MunoRN said:

This seems to be the never-ending argument between nurses, but the answer I've gotten directly from my licensing board, is that as nurses we are expected to interpret the order as the Prescribing Provider expected us to interpret the order.

So if the provider intended you to understand that given a certain level of "agitation", that it had already been determined that 12.5mg is the appropriate dose, then not, you should not first give 6.25mg.  And technically, if that's the prescriber's expectation then you are actually practicing outside of your scope by giving only 6.25 mg.

Thank you. That's what I thought! 

[Cclm, LPN]

On 11/26/2021 at 9:43 AM, JKL33 said:

Well...whether your supervisor likes it or not, that is not what the order says. There are ways to write the order if they want to make sure you start at the lower dose and have the freedom to repeat it if not effective. But they did not write the order that way, they wrote what they wrote and your interpretation of it is correct.

Whenever you have questions or there is a disagreement in interpreting an order the best answer is to ask the person who wrote it. You could also contact the prescriber and see about having the order changed to just 12.5 BID PRN based on your assessments.

Well. I had the family take her to the Dr. The Dr. Decided(brand new Dr ou of med school, thinking in terms of by the book with little acquired lived practice experience)decided to d/c the Seroquel all together. Tolld her daughter that if this patient is anxious, agitated etc to call an ambulance!! Not to mention she has been on scheduled Seiquel for over a year as well. 

Now I understand the consideration of the risk of prescribing antiphycotics with seniors I also understand it is a collective decision based on many factors. I also understand that stopping a antiphycotic abruptly is not safe. 

New dilemma. I want to suggest to the daughter they get a second opinion before they take the new order to pharmacy. 

Is this okay or not for me to do? 

[Cclm, LPN]

On 11/26/2021 at 4:53 PM, Cclm said:

Well. I had the family take her to the Dr. The Dr. Decided(brand new Dr ou of med school, thinking in terms of by the book with little acquired lived practice experience)decided to d/c the Seroquel all together. Tolld her daughter that if this patient is anxious, agitated etc to call an ambulance!! Not to mention she has been on scheduled Seiquel for over a year as well. 

Now I understand the consideration of the risk of prescribing antiphycotics with seniors I also understand it is a collective decision based on many factors. I also understand that stopping a antiphycotic abruptly is not safe. 

New dilemma. I want to suggest to the daughter they get a second opinion before they take the new order to pharmacy. 

Is this okay or not for me to do? 

Or is it inappropriate to get a verification on the d/c order in relation to stopping antiphyc abruptly? 

[Cclm, LPN]

Not to mention. We have one lpn on duty, we are assisted living. It takes upto 2 or more hours for an ambulance to get here. Also this is a senior facility and sending them to hospital is risky because of covid. The Dr wants us to call an ambulance when she is experiencing anxiety. This does not seem rational to me. A

[londonflo]

1 hour ago, Cclm said:

This does not seem rational to me. 

Actually it seems cruel to take her away from her surroundings into an ER. 

Hopefully you and your DON can talk to the MD to explain this.

[PoodleBreath]

The Dr. wants the daughter to call the ambulance if the patient is agitated? What is his rationale to send an agitated elderly patient to the ER in the middle of a pandemic, where she will be stuck in a busy and cold ER, powerless, for hours, and dump her care onto them, when he could just prescribe an appropriate med.

Who is going to pay for that extremely expensive and unnecessary intervention that may have lasting and terrible long-term emotional consequences? And if the ER decides she needs the Seroquel, what is his next thought on that?

The patient has been on Seroquel for more than a year and will predictably suffer a lot of agitation if it is just withdrawn. This is beyond cruel, to take a medication away from a patient that is helping her and then send her to the ER rather than just give her a med in house to help her.

Other options for him would be to prescribe the needed med or possibly something like lorazepam if he wants to go the PRN route, although I know that most facilities will only keep a PRN active for 14 days and then it needs to be reevaluated. This is what I hate about the nursing home industry and their regulations.

Hopefully, you can get the DON on board to help family put their foot down and advocate for the patient against this doctor's orders.

[Alnitak7]

On 11/24/2021 at 4:43 PM, Cclm said:

 

I am also new to my position. I chart everything and have documentation backing everything I said, but we know how some nurse culture is like and fear if I advocate for this person ill get put in the "not fitting in file" and it will become a power struggle all the while the patient suffers. Then I get out casted. 

My patient is my most important concern and feel I will advocate for them even if it risks what I mentioned above. (Being outed). 

I thank you in advanced for any contribution.! 

This is similar to my situation at present.  I'm protecting my patient.  I have communicated my concerns to the doctors.  I'm involved in a power struggle for protecting my patient.   I have listed my reasoning in extensive detail and am getting nowhere.