On call nurse recommending treatment

toomuchbaloney · Apr 27, 2015

What to do?

Assess the patient who had a pain concern during after hours which caused them to call for assistance.

Discuss the options for improved pain control which might include continuous infusion as apparently discussed by the nurse who handled their call. If the patient and family feel that this is might be a better approach then discuss the possibility with the MD, OR if you don't agree (as RN CM) tell them why and what a reasonable alternative might be.

It sounds like you are annoyed that this happened, why?

JaneGilletteRogers · Apr 27, 2015

I guess it bothers me because

1. If the patient needs the med via infusion, it should have been started on the weekend.

2. If the patient doesn't really "need" the patient until the next day, does the patient really "need" the medication?

3. I don't like when families are told about a medication option they may not even need because then they expect it to be given whether or not it should be given.

Families grasp onto anything they think might help. Of course I want to help the patient but not sure the on call is doing any favors by telling the family they should use a medication but wait for me to bring it to them. Does that make sense?

toomuchbaloney · Apr 27, 2015

I guess it bothers me because
1. If the patient needs the med via infusion, it should have been started on the weekend.
2. If the patient doesn't really "need" the patient until the next day, does the patient really "need" the medication?
3. I don't like when families are told about a medication option they may not even need because then they expect it to be given whether or not it should be given.
Families grasp onto anything they think might help. Of course I want to help the patient but not sure the on call is doing any favors by telling the family they should use a medication but wait for me to bring it to them. Does that make sense?

Maybe.

I wasn't there, didn't speak with the patient and didn't read the notes but...

When I have had to respond to patient calls after hours I often speak with them about various options. That patient may have had a rough go of it and it may be perfectly acceptable to be considering the next step should they continue to have break through discomfort. It is not unacceptable, IMV, for the oncall RN to discuss what the next steps in a POC might look like.

The patient obviously didn't need the medication right then because the oncall nurse didn't initiate it. However, something about the interaction with the patient caused the RN to believe that it was time to consider another method of achieving pain control. What was that? Did the nurse's notes reflect her concern or explain the introduction of a different POC?

So the family expects something that isn't appropriate...that happens over and over again in hospice, it is part of our daily challenge. Fortunately, we as nurses do not decide what the medication plan of care includes, the physician and the patient together make those decisions.

I am fine with the oncall staff getting the patient comfortable with the POC that is currently in place while discussing with them what a revision of the plan might include.

I am going to guess that the biggest difference between me and you in this matter is that I don't feel a great deal of "ownership" in my cases. I MAY be the only case manager, but I am but one member of a team which cares for the patient. The care is not directed by me and the POC is not mine. I am not offended or threatened, nor do I feel in any way diminished because another nurse may bring something to the conversation that I did not.

The exception to this is when the admitting RN tells the family that certain schedules or routines will be adhered to, etc, during the routine hospice care...he/she cannot possibly make those sort of promises for other staff. We call that writing checks that the visit team cannot cash.

DLS_PMHNP, MSN, RN, NP · Apr 30, 2015

I am going to guess that the biggest difference between me and you in this matter is that I don't feel a great deal of "ownership" in my cases. I MAY be the only case manager, but I am but one member of a team which cares for the patient. The care is not directed by me and the POC is not mine. I am not offended or threatened, nor do I feel in any way diminished because another nurse may bring something to the conversation that I did not.

Bingo. I have been in both the CM shoes and now the on-call shoes. When I was a case manager, I always appreciated someone else's opinion regarding the patient. They were never "my" patient. I find that as an on-call nurse my recommendations are usually appreciated by the case manager.

jschut, BSN, RN · May 13, 2015

The on call nurse is my friend, and I trust her judgement to make that call. But by the same token, she would always confer with me before putting anything in the chart.

I understand about the "ownership feeling". I'm kind of that way too! Haha! Probably not a good way to be, but I admit it, I am... :)

TammyG · May 23, 2015

The on-call nurse is part of the team too. Having been an on-call nurse for many years, I occasionally can see things that the CM may overlook just from being so close to the situation. I frequently make recommendations to the team.

Jack Hazz, BSN, RN · May 25, 2015

You seem more annoyed that the on-call made that decision for you. Please remember that on-call nurses are supposed to help you and that they made that recommendation based on what they saw at that time. You sounded more like you felt stepped on or bypassed but the reality is, you are still the CM and you can either agree or disagree to it. It will depend on how you explain the case to family members. I, too, am a case manager... While some on-call nurses (we call them pool nurses) do get carried away, I always think that they mean well. Besides, I always have a great relationship with my patients and their family that they defer to me more when it comes to the patient's care than the nurse that they saw only once.