rescue meds...or not.

[johnys]

So, this is one part question, one part unloading, and 4 parts heartache. It is long, and I apologize for that. I am an admissions hospice rn. What I experienced with two patients on back-to-back days is making me question what I am doing. Both cases are similar, involve patients in SNF's (two different facilities) and in both situations the patient's were in the active process of dying. Both patients were clearly in distress. The 1st one had a HR in the 130's, temp 104.5, resp rate in the low 50's, PaO2 on 3L of 81%, lungs filled to the brim from aspiration PNA. I evaluated her in les than 5 minutes, got confirmation for admission from our doc, and got orders for roxanol, ativan, atropine and tylenol suppositories faxed to the pharmacy. The order was for a stat delivery. The SNF had a locked e-kit with everything I needed. The delivery from the pharm never came, the SNF refused to open the e-kit (their rational was why bother, the pharm meds would be here anytime...) This pharmacy is notorious for being 4 to 6 hours on a stat delivery. The poor woman died with nothing on board - 4 hours after I arrived, and 3 1/2 hours after I started begging and pleading for the e-kit to be opened. 2nd pt, next day... no e-kit in the facility; pt 63 yr old male actively dying, (DKA and stroke), agitated, clearly in pain, resp 40, HR 115. Facility had a pyxis med admin system...but not a drop of morphine or ativan in the joint. Once again, 4 hours after my arrival and faxed orders received by the pharmacy (same pharm in both cases, but I will leave them nameless) no meds arrived. The family was very upset and so was I. I got called down to the administators office to be chewed out for being "unprofessional" with the staff. (What I said to a staff RN was I thought it was "rediculous" that the facility did not have any rescue meds, that was reported back, and hence the chewing out by the admin. MY bad, sorry, I should have been more attentive to the feelings of the staff and less concerned about "our" patient who was trying to throw himself out of his bed, he was so agitated with pain.) I recommended to the tearful and angry family (reluctantly) that they send the patient out to a nearby hospital for symptom relief, which the did end up doing. I prayed to god the transfer didn't kill him. The pharm delivery of my stat meds came after he left, 6 hours after they were ordered and CONFIRMED. He died the next morning. My question to you all now is this; do any of you have state laws or regulations requiring SNF's to have rescue meds in the facility, and are there any time frames within which they must open them once orders are verified? I am thinking legislative changes need to take place in my state; I am looking for a place to start. What I do know is something has got to change. I know you may be thinking get a different pharm, but the rest of them in this state are worse, believe it or not. I didn't get into hospice to sit by and watch dying people suffer. I am not leaving. I am going to effect change, so God help me. I am angry, hurt, and feeling utterly useless.

[FLArn]

I am so sorry you had that experience and kudos to you for attempting to advocate for your patient. The thing to always remember is that "we" hospice are guests in the SNF and must play by their rules. Sometimes trying to educate staff that what they are seeing are the signs of the very end of life and the patient is in extreme distress may get them to try and get an order to use from the E kit. Remember that use of the Ekit in SNFs is not as simple as opening the kit and signing out the meds. It may involve a hard copy signed script from the MD to the pharmacy if not an actual phone call to the pharmacist from the MD. Also most states prohibit or strongly discourage the use of psychotropics for ANY reason so the SNFs simply do not stock them in the Ekit. (Sorry, Dr X that's not in the Ekit. What would you like to order instead?) Unfortunately the presence of hospice patients and their special needs are simply not addressed in the regulations that determine care in the SNFs.

[toomuchbaloney]

It can be very frustrating.

I would try reaching out to the SNF staff by asking them how you can help THEM get the patient comfortable.

Is it possible for you to carry an E-Kit with you on admissions?

Do the facilities have the capacity to provide inpatient level of care for symptom management? If they can provide that level of care, the hospice could contract with them and pay them the higher rate while the patient is stabilized or until he/she dies if they remain symptomatic and uncomfortable.

This could be a great opportunity for your marketing staff to get in there and get some education done for the SNF staff which will build the professional relationship between the hospice and the SNF.

Good luck

[TriciaJ, RN]

Can you contact your hospice administration about these situations and ask for some problem-solving help? Like having some sort of agreement in place with the SNFs for having the meds available or carrying your own E-kit. I would also contact whomever oversees SNFs in your state and ask if there are any regulations regarding the care provided to hospice patients. I might even contact the pharmacy board to check if there are any state statutes about what constitutes a STAT order.

Sometimes you just have to rattle enough cages to finally get a ball rolling. You may in future want to drop a quiet word to the distraught families about who they can complain to. It may take awhile to achieve critical mass. God bless you for stepping up.

[johnys]

FLArn, thanks for your response. Yes, the doc had faxed signed written scripts to the pharmacy. I confimed that from the nursing home. The staff nurse followed up with the pharmacy to see when the meds might be delivered. We had the confirmation we needed. The problem, again, was that this facility did not have an e-kit, no morphine in their pyxis, and the stat delivery from the pharm was anything but stat. Playing nice in the facility is good, but when they are lying to you, saying that they have meds (which they did not) to cover their butt hoping that the pharm delivery would come through, and meanwhile my client (THEIR resident) is dying in mortal pain what do you do. And Tricia, as much as I would love to carry my own narcs around with me that isn't going to happen...there's rules against that. Education is good, but the drugs have to be available in a timely fashion for any education to worthwhile. I am still convinced, now more than ever, that a law with teeth may be the only real solution, but open to other suggestions. TooMuchBaloney - this pt was GIP level of care...for symptom management of pain that we did not manage.

[toomuchbaloney]

If the facility is contracted to provide inpatient level of care for symptom management then they MUST have the medications available for urgent treatment and the nursing coverage to provide that care. If they do not have that capacity they are likely in violation of the contract.

Perhaps your management could review that contract and discuss this with the facility looking for ways to remedy the failures.

[MunoRN, RN]

Send to the ER for proper symptom management. In general I'm opposed to SNF patients having to go to the hospital for end-of-life care; the unfamiliar, hectic environment of an ER and hospital is typically a poor milieu for end of life care, but it's still preferable to not getting basic medical management of symptoms in a timely manner.

My state has various regulations that address end-of-life care requirements, although I don't know of any that address specifically what a SNF is required to stock. Even so, they take end-of-life care very seriously so it might be worth mentioning it to the department of health.

If the SNF isn't going to be set up to provide hospice care in terms of having medications readily available, it might work better to just view it as being no different than caring for a hospice patient in their private home.

[toomuchbaloney]

Send to the ER for proper symptom management. In general I'm opposed to SNF patients having to go to the hospital for end-of-life care; the unfamiliar, hectic environment of an ER and hospital is typically a poor milieu for end of life care, but it's still preferable to not getting basic medical management of symptoms in a timely manner.

My state has various regulations that address end-of-life care requirements, although I don't know of any that address specifically what a SNF is required to stock. Even so, they take end-of-life care very seriously so it might be worth mentioning it to the department of health.

If the SNF isn't going to be set up to provide hospice care in terms of having medications readily available, it might work better to just view it as being no different than caring for a hospice patient in their private home.

I am quite certain that the hospice provider is not going to like being responsible for the costs of that ED care. On an advocacy level, however, I agree that the symptom management of the patient should be a priority.

If the SNF is not equipped to provide GIP level of care then another option must be instituted to meet the needs of the patient. The SNF should NOT be getting the GIP level of reimbursement if they are NOT providing the GIP level of care.

[johnys]

Much thanks for all your insights. Post-script: pt was sent out to local ED, received IV morphine and ativan, and when meds were finally in place at SNF he went back; died next morning, peacefully. Honestly, I was out of my mind with anguish that I, my company, the SNF and the pharm were not able to provide for this guy when he needed it most. Maybe I just need to figure out how to let go in these situations and move on, don't know. But the SNF should have had meds available and they didn't, the (national) pharm did not deliver stat meds for nearly 6 hrs (too late to keep this guy taking a bus ride to the ED) and I am seeing way too much of this...so back to my question...any state regs or laws in your area that require SNF's to have rescue meds in-house? Any regs/laws that dictate the length of time a pharm has to deliver "STAT" meds? Any laws/regs that require a SNF within a certain time frame to open the e-kit after med orders have been verified by the pharm? I am aiming to get legislation enacted in my state to end this needless dying in pain. Looking for other state models...and again, thanks.

[toomuchbaloney]

We don't even have much in the way of SNFs here in AK, so I can't help you out.

When I worked hospice and used a national mail order pharmacy we carried an Ekit with us for admissions, signed out to the RN.

If the SNF has possession of an Ekit and then determines that they will allow a patient to suffer rather than access the medications that they have hospice orders to give that is an ethical problem that needs to be dealt with by your agency administration. Bring it up in a team meeting and discover how they want you to handle these situations. The IDT review of the death would be a really good place to start. The documentation should reflect that the pain goals were not met for the patient and why.

Good luck!

[sassrn]

We have E-kits at our office that we can obtain when needed in an emergency. Sometimes when we are quite a ways away from the office it can be quite a trip to get the meds but it is still faster then 6 hours. We are changing our hospice pharmacy, but we will continue to have E-kits.

[wooh, BSN, RN]

Looking for possibilities to get meds faster in such situations, short of transfer to an ED (which is traumatic in itself), perhaps some different communication with the pharmacy? I've found at my job when I make clear to other departments that their delay is causing acute harm to a patient, (with a bit of diplomacy sometimes, and just being direct others, depending on the person), I've had better results. They often just see their workload. They aren't there with the patient to see what a delay causes. The pharmacy sees it as a med delivery. Making sure they see it how we do, needed comfort for a dying person, can go a long way.