Should we teach unlicensed caregiver . . . . .

[Spidey's mom, ADN, BSN, RN]

Hi - something came up this week with a hospice patient who is home and her caregiver and I'm not comfortable with it.

Our patient is getting more agitated and combative. Her diagnosis is CHF and co-morbidities include diabetes with right leg pain due to insufficient circulation. She's on anti-psych meds and anti-anxiety meds - dosages just increased a few days ago. Long-time caregiver (prior to hospice) sometimes has to deal with hours of agitation and hasn't called us.

We've dealt with that - encouraging her to call. We also have a new order for Haldol 4 mg IM for agitation that doesn't respond to her cocktail of meds. The nurse has given one dose so far and it worked well. Now the powers-that-be think we should teach the caregiver to give an IM of Haldol prn.

I'm uncomfortable with this for 3 reasons. One - Nurse Practice Act:

A health facility licensed pursuant to subdivision (a), (b), or (f), of Section 1250 of the Health and Safety Code shall not assign unlicensed personnel to perform nursing functions in lieu of a registered nurse and may not allow unlicensed personnel to perform functions under the direct clinical supervision of a registered nurse that require a substantial amount of scientific knowledge and technical skills, including, but not limited to, any of the following

1) Administration of medication.

(2) Venipuncture or intravenous therapy.

(3) Parenteral or tube feedings.

(4) Invasive procedures including inserting nasogastric tubes, inserting catheters, or tracheal suctioning.

(5) Assessment of patient condition.

(6) Educating patients and their families concerning the patient's health care problems, including postdischarge care.

(7) Moderate complexity laboratory tests

Two: Can you imagine a layperson doing an assessment to decide about giving prn Haldol and then giving an IM injection to a combative and agitated elderly women? Is this even fair to the CG? Or the patient.

Three: Um - isn't this what hospice nurses are for??

So, I'm asking for advice here.

Have any of you taught a caregiver to give an IM injection of a drug such as Haldol? Do you think it is against the Nurse Practice Act? Do you think it would be unfair to do this to the CG or patient? Do you think this is the nurse's job?

Thanks!

[Kittypower123, BSN, RN]

Could you get an order for Haldol cream/gel? Easier to teach the caregiver to administer and safer for CG and patient.

[chopwood carrywater]

It might be easier to give the haldol sub q. Perhaps placing a sub q port would make it easier and safer for pt and caregiver. Typically our orders start with 1 mg sq every 2 hrs prn, and may be titrated up and even scheduled if needed.

Sent from my iPhone using allnurses.com

[Spidey's mom, ADN, BSN, RN]

Unfortunately the Haldol cream went by the wayside HERE years ago.

Even a sub-q on an agitated woman by an unlicensed caregiver who is simply a very nice homemaker who helps out this woman and has for year seems inappropriate to me.

We are a small hospice associated with a small rural hospital. In order to get a port, we'd have to send the patient 70 miles away to a bigger hospital. We don't do ports up here.

We have sent some longer-term hospice patients out for PICC line placement. Of course hospice has to pay for that.

I really appreciate the comments! Keep them coming.

[softrbreeze]

Doesn't come up often, but I've been told by different supervisors that if the RN teaches the cg, gets a return demonstration and FEELS comfortable with the cg's demonstrated skill, that it is okay. I had one cg years ago that demonstrated competence with administering meds to a pt that was sent home on a PICC line. Never had any problems. I had several that demonstrated competence with administering meds and feedings thru a GT. As long as cg and RN both feel reasonably comfortable with the task, I don't see a problem.

[morte, LPN, LVN]

what was the reason for the Haldol cream being no longer available?

Unfortunately the Haldol cream went by the wayside HERE years ago.

Even a sub-q on an agitated woman by an unlicensed caregiver who is simply a very nice homemaker who helps out this woman and has for year seems inappropriate to me.

We are a small hospice associated with a small rural hospital. In order to get a port, we'd have to send the patient 70 miles away to a bigger hospital. We don't do ports up here.

We have sent some longer-term hospice patients out for PICC line placement. Of course hospice has to pay for that.

I really appreciate the comments! Keep them coming.

[cayenne06, MSN, CNM]

The reality is that lay people give IM injections all the time. It's an easy skill. Would you feel differently if it was the patient's spouse you were teaching? I understand that they are not really able to do the same type of assessment an RN would do, but if the nurse is coming out regularly to check on the patient, and the CG is aware of s/s that necessitate a phone call/hospital visit, then I don't see the problem.

[Spidey's mom, ADN, BSN, RN]

what was the reason for the Haldol cream being no longer available?

It isn't that it isn't available but it has supposedly been determined that it doesn't work. In fact, interestingly enough, some of our team just returned from the annual CHAPCA Conference in Palm Springs (California Hospice and Palliative Care Association) where they were told Haldol cream doesn't work.

I know folks give IM injections all the time but still wonder about what it says in the portion of the Nurse Practice Act I put in the first post about delegating nursing functions in lieu of a registered nurse to unlicensed folks. (Isn't that what the hospice nurse on call is for? To assess and then if appropriate, give the IM injection?).

We had a court case here in California that may go on to the Supreme Court about school nurses training school district employees to give insulin to kids. The NASN (National Association of School Nurses), the ANA, the BRN, and the teacher's union were all opposed. The American Diabetic Association, our Governor Jerry Brown and some parents' groups were for it. The CA courts decided in favor of letting unlicensed people give insulin to kids. Right now, as far as I have heard, it might still go to the Supreme Court. We'll see.

So, there are concerns in other areas of nursing where we let folks take over what our scope of practice should be.

[ktwlpn, LPN]

I'm using Haldol gel on a resident -it's working. I think too often we discount meds and therapies without trying them because of these studies. It may very well be effective for your patient-and a reasonable alternative to the IM.I recently had a nurse from the local hospice tell me that lorazepam topical gel "doesn't work and we don't use it". In our LTC we are using it and seeing good results.I would first advocate for trying the Haldol gel.But why jump to an IM? Is she not taking PO meds at all? Does this patient need a few days as an inpatient in the hospice unit to tweak the meds?

I interpret that section of the nurse practice act as applying to a facility,not a home care situation.In this state and in my experience family members and home care givers have been performing this type of skilled task in the home for years.

Theoretically this patient could need an injection every 4 hours-how can a hospice agency possibly provide that level of care? It sounds like this patient's needs are becoming overwhelming for her caregiver-does she have any family?

I think she needs LTC.

[Spidey's mom, ADN, BSN, RN]

ktwlpn - all good points.

As to the Nurse Practice Act part . . . we as hospice are an extension of the local hospital. We are not a hospice agency all by ourselves. So I walk into a patient's home as an employee of Brand X Hospital.

We used to have Haldol cream in our Symptom Relief Kits until supposed research was showing it didn't work. Well, like you I found it worked well for our patients.

Thanks for your responses everyone.

[MelissaC71]

I would insert a sub q cleo for Haldol admin. It can safely be given sub q and the Haldol might help with aggitation as well as ease her breathing a little. It can be left in for up to a week. I would feel confident teaching a lay caregiver how to give sub q haldol. She sees her the most and should be able to adequately decide if she needs it. Considering she's hospice as well, why would you have her aggitated unnecessarily.

[FLArn]

I have taught many skills to FAMILY caregivers who are willing to learn, however, I would never attempt to teach nursing skills to unlicensed paid caregivers. That is an entirely different matter legally. Family members may learn whatever skills are needed to provide care but HHAs, CNAs etc are limited by state practice acts as to what care they are allowed to provide. If you are uncomfortable or unsure what can or can not be taught to paid caregivers, contact your education department or risk management.