Medication administration vs Patients wants

[Notmarvin]

I am a brand new RN of two weeks and have run into an issue I cannot get a clear answer on. I work on a very challenging Med-Surg unit and have had one day of orientation with a preceptor and am now pretty much on my own. I have a pt who has been admitted for many months and waiting placement. My MAR shows she has dozen of meds scheduled between 0800 - 1100. I have worked with her for the last two days and each am she refuses all meds and demands to take them around 1030. I have been charting refusals and have dispensed the meds as 'patient request' at the later times. Other RNs on the unit say this is how she does them, they leave them bedside and she takes them as she pleases. I am uncomfortable with this as that I cannot keep track of when she takes them. I can recite the medication admin rights in my sleep but does patient desires trump those rules? Should I omit the am meds and refuse to give them when she asks for them late am, or give them when she will take them? Hoping to keep my license long enough to pay off my student loans I would love any help!

[toomuchbaloney]

Come on, people, take back your turf-- or at least recognize that it's yours. Notice that in the following I very purposefully do not use the word "order," because we are not in the military and the physicians are not our superiors.

This is not part of medical standard of care, and a physician cannot prescribe it because it is unsafe. Well, a physician can prescribe it, but no nurse is obligated to implement that in the plan of care.

This is because of a radical concept: Nursing standard of care is what rules over this sort of issue. It's not a matter of drug dose, route, indication, or frequency (those are medical), but a matter of safe administration of oral medications to an awake and competent patient. That and its associated safety issues fall under the purview of nursing, not medicine. Physicians are not trained or experienced in the administration of medications in the way nurses very explicitly are.

If a nurse can negotiate with a patient to handle medications safely/get them rescheduled to suit patient preference as described above, then fine. Otherwise, it's, "Sorry, I can't just leave them here," take them away and chart as refused.

As a recap: A physician can prescribe meds to be left at bedside for the patient to take whenever he damn well pleases, but the nurse is under no obligation to follow that prescription because it is unsafe and against nursing standard of practice for medication administration. The nurse should go up the chain of command to get that prescription changed or modified, or to have the physician explain to the patient why these medications will no longer be prescribed while he's in the hospital if he refuses to take them properly. People get discharged from the hospital for declining to participate in their plans of care (medical and nursing) all the time.

When a hospice patient is hospitalized for a condition unrelated to the hospice terminal diagnosis it is common practice for the physician to order that home medications may be at bedside and taken per patient/family schedule.

Since the nurse is not administering the medications, there is no implied liability. The prescribing provider has assumed responsibility for the practice with their 'orders' and notes reflecting the plan of care. If the nurse has a concern about patient safety based upon a critical observation of the patient, that observation and concern should be communicated to the provider and/or other relevant individuals.

[nurseprnRN, BSN, RN]

When a hospice patient is hospitalized for a condition unrelated to the hospice terminal diagnosis it is common practice for the physician to order that home medications may be at bedside and taken per patient/family schedule.

Since the nurse is not administering the medications, there is no implied liability. The prescribing provider has assumed responsibility for the practice with their 'orders' and notes reflecting the plan of care. If the nurse has a concern about patient safety based upon a critical observation of the patient, that observation and concern should be communicated to the provider and/or other relevant individuals.

This is completely correct. This is because:

1) This is at home, not in a hospital

2) The nurse will still communicate difficulties to the prescribing physician based on professional nursing assessment and judgment

[psu_213, BSN, RN]

2. Obviously the pt has been doing this( I would see it as manipulative, because I'm sure you aren't the first staff who has tried to insist pt take meds at assigned time) for a long time.

4. with electronic charting- it is marked as a med error if not given on time or refused.

2. As previously suggested by someone else, there might be a whole lot more to it than the pt just being manipulative. Perhaps, after a month in the hospital, the pt is just trying to have even the smallest measure of control over her situation.

4. I'm not sure how it works everywhere, but our EMR allows RNs to change the administration time(s) on just about any med when the doc has not specified a specific time in his/her order.

[MunoRN, RN]

This is completely correct. This is because:

1) This is at home, not in a hospital

2) The nurse will still communicate difficulties to the prescribing physician based on professional nursing assessment and judgment

While I applaud you pointing out that we aren't expected to follow MD orders that go against our judgement, I don't agree that leaving meds at the bedside goes against a standard of care. There are circumstances where it's very appropriate.

[SoldierNurse22, BSN, RN]

Come on, people, take back your turf-- or at least recognize that it's yours. Notice that in the following I very purposefully do not use the word "order," because we are not in the military and the physicians are not our superiors.

Well, I'm in the military. :)

Even in the military, physicians may at times outrank you, but there is still a nursing chain of command. Military nurses (with very little exception) directly report to other nurses, not physicians.

Also, regardless of who's above you in the chain of command, you retain the professional and ethical duty to refuse an order of any kind if it is unsafe/unlawful/unethical.

Just to clarify!

[toomuchbaloney]

This is completely correct. This is because:

1) This is at home, not in a hospital

2) The nurse will still communicate difficulties to the prescribing physician based on professional nursing assessment and judgment

Have you never taken care of a hospice patient in the hospital for an unrelated health condition?

That is but one specific example of a situation where the provider may provide a medication plan of care that deviates from the 'standard' acute care POC.

Nursing judgment is nursing judgement.

[martymoose, BSN, RN]

4. I'm not sure how it works everywhere, but our EMR allows RNs to change the administration time(s) on just about any med when the doc has not specified a specific time in his/her order.

Hmmm. We are able to send a request to pharmacy to change times for routine daily meds. The pharmacist is the one who enters the times. Nurse has no control over that.

In regards to home meds- our pharmacy policy is that the meds must be in original prescribed container, must be sent down to be identified, and must have a barcode label added to be scanned.The MD must have an order for pt to use own meds. All meds must be scanned. Managers can pull up histories of what meds are late, etc. Last I knew, a late med was a med error, no?

Also, say the patient "forgot "to take, oh, say, plavix that day. There's no record of them getting it( unless you are signing the med off illegally as given), and guess what. They end up with a blockage/restenosis. I have seen that happen with skipping one day. Not a liability I would want to be dealing with.

[jadelpn, LPN, EMT-B]

Don't ever leave meds at bedside. At 0800, ask said patient if she would like to take her medications now, or could she make a time? If she says 10:30, have a discussion with charge nurse about discussing with the MD changing all of her morning meds to 10a. Then is she refuses some of them, you can document same. You could also have MD discuss with patient the need or not of some of the meds. If she is never taking her multi-vitamin, then why are we getting all stressed about it for instance--can we just pare down a little? Of course there are some meds that are no discussion--like lasix or insulins--so if she is refusing those, the MD really has to have conversation about that with her.

Waiting for placement makes some patients anxious. That anxiety can manifest itself as a loss of control. So the patient controls what they feel they can. Which is in the taking (or not) of medications for a lot of patients.

[BluegrassRN]

In general, don't leave meds at the bedside. There are exceptions to this rule, of course. In our hospital, you can get a physician's order that the med can be left at bedside. We do this primarily with cough lozenges, inserts for nicotine inhalers, tums, etc. Even these meds can have untoward side effects, so get an order for it. If the pt wants all meds left at the bedside, just briefly explain why that can't be done. Scanning, professional responsibility, or even just "You know how the powers-that-be are; I don't want to lose my job over that, you know how it is." Most people are understanding of that.

If a med is not time sensitive, there is no reason to give 10 different meds at different times between 7am and 10 am. If a pt wants them all at 9, given them all at 9. Our emar has a functionality where we just shoot a message off to pharmacy, and they change it. No physician's order needed.

[amygarside]

I agree. Don't leave the meds at the bedside.

[nurseprnRN, BSN, RN]

While I applaud you pointing out that we aren't expected to follow MD orders that go against our judgement, I don't agree that leaving meds at the bedside goes against a standard of care. There are circumstances where it's very appropriate.

And hospice is one of them. Hospitals and other care areas where more than one person may have access to meds left parked on a bedside table, or where the opportunities for diversion or abuse, or where the possibility of aspiration or other mishaps exist (in an ongoing care milieu, not at home per hospice) are not.

Also, RN scope and standards of practice require us to follow safe med administration practices, including "right route," and there is ample evidence to suggest that this means you watch the patient swallow the meds you have poured.

There may be workarounds, as described above, but convenience for the nurse does not equal an imprimatur for unsafe or unprofessional practice.

[ParkerBC,MSN,RN, PhD, RN]

These are really good answers. The only concern I have is whether or not the nurse could get into trouble of “falsifying documentation?” You can’t chart something that was not done. In my opinion, leaving medications at the bedside is NOT medication administration. Suppose the patient was refusing an important medication…Keppra by throwing it away. Lab values will indicate the patient is not taking the medication although it is charted as such. If I have a patient who tells me that they want their medications at 10:30AM, that is the time I will administer them (watching them take them). Hospice I can understand as we are providing comfort measures. If I am passing medications per a patient’s request, the charge is aware and I purposely chart them late with a narrative.