medicine without a license

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hello, I am new to this but there seem to be some intelligent people here. I have a question about LPN changing insulin dosing without a MD order? This is a nursing home, patient said he only wanted X amount of units, nurse granted request. I am looking for some verbage or legal document stating that this is practicing medicine without a license. We are in Georgia

HELP!:nono:

Specializes in Med Surg, Tele, PH, CM.
yes, but where can I find some type of OFFICIAL verbage to post. I am new DON to this facility and apparently the old one told them it was"OK"

You should have a copy of the Georgia BON Nurse Practice Act for reference, as well a one available for the staff. Dull reading, but a good reference for finding the rules.

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Georga Nurse.....I totally get where you are coming from.

My take is that she just wants to stop this practice or make it legal aka...do is the right way and honnor the pt wishes. Yes the pt always has the right to do what ever they want. Doctors orders change with the pts needs/ wants. The way to make this practice correct is for that nurse to call the doc when the pt wants a different dose. A verbal order and nurses note needs written. That is the bottom line.

I get the whole "we've always done it this way" mentality in LTC.

Plain and simple, that nurse is wrong and they just need to change their practice. Inservice all nursing staff and go from there.

What dose the ordering doc think of all of this?

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Specializes in Spinal Cord injuries, Emergency+EMS.
Pt has a right to refuse a med but not a right to change a dose.[/size']

so what do you do when you hand a competent patient 2 paracetamols and the patient decides to throw one in the trash or down the sink and take the other ?

you've 'changed a dose' there

In TX what she did was illegal because she changed a dr.'s order.

did she amend the 'direction to administer' i.e. the prescription chart? or simply give the reduced dose at the request of the patient .

it's not the same situation

But at my hospital insulin requires 2 licensed signatures.

why ? even though the evidence bases suggests tht double checking is not necessarily the best approach

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You are both wrong. A patient has the right to refuse part or all of any medications. We do not have the right to say "if you don't do it my way, then you get nothing". Is that what you have been telling patients: "doctor's orders there's nothing I can do?"

As long as you inform the patient of the potential consequences of their actions, document the refusal AND notify the physician of the patient's refusal then the nurse has done no wrong. The nurse did not change the dose; the patient refused it. There is a difference.[/quote

Have we all forgotten the 5 rights of medication administration? Right dose. Not reduced dose.

We aren't telling a patient they have to do it 'our way'. 'Our way' is the Physician's way, and scope of practice way, and policy way...

Of course a nurse would contact the Physician, explain the patient's request, and then abide by orders. Once it is ordered, and a patient complains, THEN you say "sorry, nothing I can do. Feel free to contact the Physician yourself." Yes, I have informed patients "all or nothing" as that is my job. I am not a Doctor.

I really believe that dose reduction is out of our scope of practice, but would be interested in any information that clarifies this.

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Specializes in Oncology, Triage, Tele, Med-Surg.
Sorry, I also think you are way off base. It is practicing medicine. And you would tell the patient "all or none".

Lots of "what if"s in your statement. Thankfully, we have specifics in nursing, not alot of "what if"s.

"Here is the order-here is the medicine- this is what the Dr. said-I'm sorry you feel that way but my hands are tied-I understand, but there is nothing I can do"

Very simple. Don't change dosage. It isn't in our scope of practice.

The wording isn't that the ORDER is being changed. The order is what it is. What was administered was under the ordered amt. due to pt refusal. I don't get where folks keep saying the ORDER was changed.

I had a diabetic recently who called when her tray arrived for her insulin but d/t her knowing she wasn't up to eating the typical carbs she does, she refused part of the dose so her sugar wouldn't bottom out. If I did the "all or none" she would have

A). either spiked after eating if I gave "None" (or had to get ahold of the doc)

B). possibly gone too low in her sugar b/c she took the whole dose despite what she felt was right at that time.

Some forms of medication can't be split/ divided into a partial dose, so refusing part of a dose in that situation would require an all or none and an additional order. But if I only want half of my Darvocet dose- my nurse best not be telling me "all or none" or "I have to call the doc for permission to give you a smaller dose" If that were the case, I'd also be requesting a nurse with better judgement. :rolleyes:

It may not be so easy to have a blanket statement. One size does not fit all with every scenario.

:redbeathe:nurse::redbeathe

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Please consider all the different types of medications. Which would it be okay to give a partial dose without first checking with a Dr. (which results in a new order).

Diuretics? Antihypertensives? Antiseizure? Pain medication? Sedatives? Antidepressants? Behavioral?

Giving less insulin than ordered- (without first checking with the Doctor) would you reduce the amount of oral antidiabetic medication?

If a patient said "snap that 80 mg tab of Lasix in half- I don't want it all" "I only want a 100 mg tab of depakote, not the full dose of 300mg".

If a pt's bp was 138/88, would you only give them 1/2 the antihypertensive dose- it reallly isn't that high, and you don't want to bottom them out.

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Specializes in Just about all of them.
Actually, unless a person is committed, they have a right to refuse meds. So if a patient has an order to take 10 units of insulin but only wants 5, would this not be within a patients right? He is not asking for more than whats ordered, which would be a no-no. Now the LPN should find out WHY the patient wanted less...(probably because they know their body and know the ordered dose may be to much, based on the blood sugar) and let the Doctor know whats happening. And document! But she can not FORCE the patient to take the full dose of insulin.

How is asking for more any different then asking for less? in the case of insulin dosage, not referring to the obvious dilemma of asking for more pain meds.

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Specializes in ICU, telemetry, LTAC.

What concerns me about this case is that the doctor wasn't notified for years. Huh? Most physicians, if you call them and say, oh Sally insisted on a smaller dose of insulin last night, here are her blood sugars and how it turned out, do you want to adjust the sliding scale? You'd see some who didn't like it, some don't back you up or write an order, some who say sure and fix the order, etc. In other words, there might be a range of reactions based on personality type and the particulars of the patient's situation.

Now. That's sort of understood because it's ONE time and followed in a reasonable time period by a phone call. If you suddenly come up to a doctor and say, well Sally has only gotten this amount of her med every day for a while... like since two years ago (make up a number, I dunno)...

I know what the doctor will say. Don't you? "Why has no one called me?"

The simple fact that it has been going on for a long time without physician notification means that there can be some serious heck raised here - and it may not be by the facility, or the DON. The doctor can report people if he or she so chooses. So I'd be quaking in my boots if I were the DON, and if I were the nurse... wait. I'm a nurse who calls people. Nevermind.

Seriously, on a side note, how in the sam hill does our culture become so anti-call the doctor that something like that could happen for years?

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Specializes in A little of this & a little of that.

It is definitely unacceptab;e nursing practice that the doctor was never notified. It is not practicing medicine to honor the patient's right to refuse all or part of any medication or treatment as long as it is documented as such. I have given partial doses of prsecribed meds when a) the patient insisted or b) the patient was confused and spit out part of the dose. If these things happen once in a very great while, I just document. If they happen routinely, I notify the doctor.

The all or nothing approach, IMO, is more dangerous practice as it seems to me some is better than none.

What is going on in the scenario presented by the OP, I would say that the nurses are guilty of negligence for failure to notify the physician of an ongoing situation that jeopardizes the patient. Unless they have actually changed the written order, which would include writing a note like "give only 5, pt preference", they are not practicing medicine. I changed the pronoun to "they" since, if this has gone on for years, it has to be more than one nurse at fault.

Why worry about the semantics and what rule exactly has been broken?Report it to the BON. The nurses involved will likely be re-educated not lose their licenses.

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Specializes in Spinal Cord injuries, Emergency+EMS.
Please consider all the different types of medications. Which would it be okay to give a partial dose without first checking with a Dr. (which results in a new order).

Diuretics? Antihypertensives? Antiseizure? Pain medication? Sedatives? Antidepressants? Behavioral?

Giving less insulin than ordered- (without first checking with the Doctor) would you reduce the amount of oral antidiabetic medication?

If a patient said "snap that 80 mg tab of Lasix in half- I don't want it all" "I only want a 100 mg tab of depakote, not the full dose of 300mg".

If a pt's bp was 138/88, would you only give them 1/2 the antihypertensive dose- it reallly isn't that high, and you don't want to bottom them out.

surely this is where the difference between being a professional nurse and a residential care home worker authorised to give out meds lies ...

a patient who is competent can refuse all or some of their meds , as a nurse you surely have the skills to recognise when this will cause harm or equally where giving the med will cause harm

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How is asking for more any different then asking for less? in the case of insulin dosage, not referring to the obvious dilemma of asking for more pain meds.

Please give an example where giving half a med will result in more harm to the patient than withholding the entire med when a patient refuses to take the full dose? I can give you a lot of examples of when giving more of a med than was ordered will result in harm to a patient.

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surely this is where the difference between being a professional nurse and a residential care home worker authorised to give out meds lies ...

a patient who is competent can refuse all or some of their meds , as a nurse you surely have the skills to recognise when this will cause harm or equally where giving the med will cause harm

actually, i think your last line comes very close to "practicing without a lic"

we know what the med is for.....what reaction to expect, we dont have the training to decide a dose.......

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