Passing Meds

TheCommuter, BSN, RN · Sep 5, 2011

Your post has been moved to the General Nursing Discussion forum for more replies. Good luck with this situation!

xtxrn, ASN, RN · Sep 5, 2011

With patients when I was working- there were times when meds were ordered for 'off label' diagnoses...sometimes, these meds were just not approved in the US, but had been approved in Europe, Canada, and elsewhere for months to years. The docs felt OK in trying them where other meds hadn't helped. If there were no potentially toxic/harmful doses, and the patient agreed with it, I didn't get too uptight.

The only time I refused to give a med was a dosage situation for a pain med- I had been a nurse for a couple of years, and wasn't used to large doses of Demerol needed in acute sickle cell crisis. Another nurse gave alternating doses- the patient got what she needed, and I didn't do what felt too risky. LOL- when I ended up working drug/alcohol rehab, we gave doses that would drop a mule. But that's what the patients needed.

Personal experience:

I had PEs in all three lobes of my R lung, and had been on large doses of Coumadin for 4 years (some genetic issues and need for high dose). Last year, I ended up on chemo, which totally messed up the Coumadin- for months (20mg/DAY resulted in months of INRs of 1.1-1.3...WAY below the therapeutic level range).

My hem/onc put me on Pradaxa- only really labelled for anticoagulation for a fib with inadequate INRs on Coumadin. It was a situation where the use of Pradaxa for patients who were not responding to Coumadin was the reasoning for using it with me. I was somewhat hesitant because of its "only" approved use for a fib...but I'm not dead for being on it, so I'm going with it :) Because the hem/onc I've been seeing has been very good with informing me of various things over this past 18 months, it was easier to give it a try. I had some history with him that built enough trust to go ahead and try it. With the Coumadin essentially useless, why not?

The risk of NOT using it was worse than trying it. There are no routine coag tests to monitor for it- but I keep an eye out for changes in bleeding with accucheks, insulin injections, bruising, gum bleeding, (and obviously any GI bleeding).

I'm also on Neurontin for dysautonomia (and a adjunct for seizures). Last I checked, it wasn't approved for that- but it allowed me to work for 8 years longer than I would have without it. The neurologist who first prescribed it was up on the uses for dysautonomia, and extended my usefulness considerably. I trusted her- and that made a difference in being willing to try it- I was hesitant, but it worked, with minimal side effects :)

Is there any way you can talk to the doc who prescribed this med, and let him/her know you want to learn about the benefits of this particular med? Some docs are willing to teach nurses (and more should, since more knowledge makes both parties jobs' easier, and that can only be better for the patient :) Good luck :up:

scaredtorelocate · Sep 5, 2011

Thank you for your input. This meds situation is a little different. I've done a lot a research on it in my own time. Its NOT used or approved in any other country and even the World Health Organization does not approve of it being used for this particular "off label" use. The U.S. is the only country that uses it and I personally believe it is because it is less expensive than the alternative approved drugs that serve the same purpose. In fact, it is not used at any hospital in the city I just moved from for this particular use either! It is also scary to me because there is no way to reverse the effects of the drug if a toxicity occurs. There are ways to "calm" what has happened but no specific fix all antidote. The other thing that really bothers me is I feel the patients are not fully aware of the possible side effects and/or the fact that if this does happen it becomes an emergency situation where we are pumping some more drugs into them and basically praying they work in time without causing a whole list of side effects themselves. I am new, both at nursing and at my job, so that is why I wanted to know my rights before approaching the docs or my manager about it. Nothing like being the pain in the ass new grad/new hire! Thanks again for your input! :-)

mazy · Sep 5, 2011

Can you post the name of the med? I'd be interested to know what it is and what they're using it for.

Jenni811, RN · Sep 5, 2011

Can you post the name of the med? I'd be interested to know what it is and what they're using it for.

Agreed. I've given medications that i question. I document document document! can't stress that enough. Cover your bases.

I've consulted with pharmacy.

I had to give theophylline, 600mg at one dose. The max dose was 450mg. I called pharmacy and discussed it with them. Pharmacy assured me it was a safe dose, although high.

You may feel better consulting pharmacy. We have a pharmacist on every unit during the day shift. During night shift we have some on call. I like our pharmacist, he is really great and always willing to answer questions!!

One time i was giving Tikosyn, which at times makes me nervous just because all the warnings with it but nothing ever comes of it. So i'm always cautious when giving Tikosyn. It was contraindicated with another drug this patient was receiving, so i talked to our pharmacist. Our pharmacist looked it up and researched it. He too agreed a call to the attending was a must. So insead of ME doing it, getting my butt chewed out for "questioning the doctors orders" he called. For some reason they don't get annoyed when pharmacy makes the call....

mazy · Sep 6, 2011

You may feel better consulting pharmacy. We have a pharmacist on every unit during the day shift. During night shift we have some on call. I like our pharmacist, he is really great and always willing to answer questions!!
One time i was giving Tikosyn, which at times makes me nervous just because all the warnings with it but nothing ever comes of it. So i'm always cautious when giving Tikosyn. It was contraindicated with another drug this patient was receiving, so i talked to our pharmacist. Our pharmacist looked it up and researched it. He too agreed a call to the attending was a must. So insead of ME doing it, getting my butt chewed out for "questioning the doctors orders" he called. For some reason they don't get annoyed when pharmacy makes the call....

Yes, this is good advice. Call the pharmacist. The pharmacist is a great resource and you can then tell the doc that the pharmacist questioned the order.

Jenni811, RN · Sep 7, 2011

Yes, this is good advice. Call the pharmacist. The pharmacist is a great resource and you can then tell the doc that the pharmacist questioned the order.

Yup That is may way around it when i question an order. Pharmacy seems to understand and acts as that barrier between RN and MD. I love pharmacy for this reason :redbeathe

Pharmacist is placed on every unit for a reason. utilize them!

MrChicagoRN, RN · Sep 7, 2011

I worked where there was a lot of research, and a lot of cutting edge medicine. Off label usage was not unusual, and we were often the first to do things in a certain way.

As others suggested, talk to the pharmacy, talk to the Doc. If you refuse to administer, and hand it off to another nurse, you're CYA; but not protecting the patient. How fair is that?