Revocation of hospice service?

tewdles, RN · Sep 11, 2010

When the hospice delivers medications to the patient they become the property of the patient. If the patient revokes it would be inappropriate to remove the needed meds from the home. The hospice should ask the family if they would like hospice to destroy any "emergency meds" which may have been maintained in the home...the family has the choice...if they want to keep the med...ok...it is important to educate them about the dangers of using ANY prescription medication without medical direction and the hospice documents their choice and has the family sign off. The hospice should arrange for a smooth transition to a more conventional way for the patient to receive his/her next round of meds (MD/Rx/Pharmacy) especially considering that they will have 14 or fewer days of the med in the home in the vast majority of cases.

Your team B approach is more correct.

tencat · Sep 11, 2010

Sometimes in my neck of the woods it is about impossible to get back INTO a home to destroy meds if the patient is a live discharge or revocation. Makes it quite difficult to get the documentation signed or the meds taken care of.

Hospice Nurse LPN, BSN, RN · Sep 11, 2010

I agree with Team B. The meds belong to the pt once they are delivered. If it is a true revocation, they are going to need their pain meds, etc. until they make arrangements to get Rx from their doc. If they are transfering to another hospice for whatever reason, we coordinate with the new hospice and let them know how much medication SHOULD be in the home so they can plan accordingly.

tewdles, RN · Sep 12, 2010

yes...getting back in is generally a problem. That is why it is good to speak with the family when they are considering revocation and help them with a transition plan. I prefer to be very proactive about this sort of thing. Revocation is only rarely a surprise, in my experience.

The comparison to transfer of service to another hospice provider is important...because the two are COMPLETELY different in crucial ways. In revocation, the patient is terminating the hospice benefit. The insurance reverts to default status according to the effective date (not the signature date). The remainder of the days in the certification period are forfeit. A revocation does not exclude possibility of re-admission, even immediately.

In transfer to another provider the patient is arranging for continuation of care and services from a different provider. In my area it is often because of patient relocation, I live in MI and we trade patients back and forth with FL and surrounding areas during the winter and summer. The benefit periods are unchanged and there is no interruption of service.

Another important distinction is that only a patient can revoke the hospice benefit. It is not at all correct to think in terms of visiting a patient with the intent to revoke. We can speak to them in terms of discharge, only the provider can discharge the patient. It is correct to think in terms of visiting a patient with the intent to discharge.

Ginapixi, BSN, RN · Sep 13, 2010

i have to agree with team b as well besides:

was the medication not prescribed by a physician for the patient?

so why would hospice be liable? because hospice covered the cost? actually medicare paid for it (or insurance if they covered hospice care) and that includes emergency meds; not really different from medication the patient had prior to hospice coming in and we do not destroy their prior meds; and if patient needs those meds it makes no sense what so ever to destroy them.

mschelee, MSN, RN · Sep 14, 2010

To clarify, we were told that if a patient revoked hospice service (usually due to a choice to try aggressive tx) we nurses had to destroy their narcotics. ALL us case managers said NO! But the administrators are raging that we have to. I don't think any of us a willing to do it. It wasn't specifically said only for revokes, and I believe the administrators mean for with a revoke or a discharge form our services. Either way I personally won't destroy medication that belong to a patient. I feel it is illegal and certainally it is unethical.

rn/writer, RN · Sep 14, 2010

Are there any state laws that govern this situation? Would a pharmacist be able to shed any light on this.

From the outside looking in, trying to get in the home to go on a search and destroy mission seems barbaric, intrusive, and very possibly illegal, regardless of any prior agreement. The agreement can state an expectation, but "enforcement" is another story altogether.

I, too, would think that the patient "owns" the meds.

Maybe all that needs to be done is some kind of sign-off sheet stating that the patient or family members accept responsibility for any remaining meds and will not hold the hospice agency accountable.

Hope you're able to sort this out to everyone's satisfaction.

tewdles, RN · Sep 14, 2010

There is no question here really...when meds enter the home they ARE the property of the patient. We (hospice) may not confiscate and destroy patient property at the time of revocation.

Katillac, RN · Sep 16, 2010

Good for you guys for sticking to your ethical guns in the face of management insanity. Another case of going way too far to CYA. Try these as rationales in response:

1) If you as hospice nurses go into a home after revocation and do ANYTHING in a professional capacity you are practicing without consent, as the consent is presumed to be revoked along with the services. Much greater risk of liablilty than if you MAYBE get actioned against for a patient mismanaging narcs. As an extension of the "discontinuing the care plan" logic, you are off the hook because you have discontinued monitoring the patient for anything, including med management, as of date of term.

2) If you destroy meds and leave them without, you are liable for any pain and suffering they experience, and by extension so is your agency. Ask your management how that would look in court; hospice, the very people trusted to alleviate suffering, came in and by destroying the meds THE PATIENT OWNED causing the patient agony.

3) In terms of being held liable if the patient mismanaged the meds, of course you could be sued, anyone can bring suit about anything, but to prevail it would need to be proven that you as nurses and/or as an agency failed to perform your duties in a reasonable and responsible way. So at revocation it needs to be documented that education was done/reinforced about medication safety: taking them as ordered, safe storage, not transferring or letting another take, etc. That's the reasonable professional course.

By the logic your management is using, you should also destroy the walker you gave your patient in case he/she "mismanages it", falls down and breaks a hip and then then brings action because you left this potentially dangerous item in the home. Furthermore, you are no more at risk after the patient revokes of the patient mismanaging the meds than before the revoke. At any time a patient could give away or sell the meds, or, like one of my agency's patient did, drink the bottle of Roxanol (BTW, he slept for two days, but lived) or whatever. So if it's too dangerour to leave them in the home after they revoke, why is it OK for them to be there at all?

volsfan · Sep 17, 2010

I would find out why the management thinks this way; where are they coming from. Is it b/c they are misinterpreting some law, policy, etc. I am in total agreement with Katillac. Many times the pt will have already been on narcotics when they came on hospice it is crazy to think you would destroy those meds when they revoke. The only thing our hospice destroys is the Comfort Pak and if we have been using medications from that pak we would have gotten them a regular prescription for it anyway.

mschelee, MSN, RN · Sep 20, 2010

May I ask what is your companies reason for destroying the comfort pack? is it in the patient name or in the companies name? what meds are in it?