Verbal orders and Hospice?

[Kimberly71]

I am an experienced RN with 15 years experience but I am new to hospice nursing. I just completed a 2 1/2 week orientation when I had a sticky note on my desk stating one of my patients needed pain medication. I looked through the chart and there were no orders for pain meds. I ask my PCC what pain medication is appropriate and is asked if there is a standing order for any pain meds. The only standing order we have for pain in Ibuprofen and Tylenol. Without consulting a doctor she stated write a verbal order for lortab and call it in to the pharmacy. Is this acceptable practice in hospice nursing? We have two medical directors but the only time I see them is for team meetings and orders are signed then and sometimes taken to their office to be signed. I was just not comfortable writing a physician order without him knowing. Any suggestions?

[jaqs96]

Hi, I've been working in Hospice for almost 2 years. What I normally do is call or fax my written order to the patients's pcp for a signature. If I don't hear back quickly then I call my medical director for the order. In my state, all narcotics need a written or physician verbal order. RNs are unable to call in a verbal order on narcotics. For over the counter or non narcotic meds, I do write the order to start or d/c a med. Lots of autonomy in the line of nursing... I enjoy it but am also very careful. If I start or d/c anything, I call and leave a message telling the pcp of the pt what has happened regards to meds. Most pcps wash their hands of hospice pts and rely on our expertise to take control. Hope this helps.

[SoCalRN1970]

DO NOT EVER PRACTICE WHAT YOUR MANAGER TOLD YOU TO DO EVER...

In hospice I have worked at several agencies that give the nurse on the sly pro quo for writing orders.

I have had MD's tell me that they dont' need me to call for vicoden, or ms or ativan! BUT! I am not willing to risk my license by working for a complacent hospice.

Keep in mind, that all it takes is the MD to say they never gave you that order, and your office could contact your BRN claiming you are writing orders without physician's orders.

( I saw this happened on a case where a nurse inserted a foley catheter on a patient who was retaining urine. She failed to contact the MD for the order and placed a 16 fr standard foley... The MD found out and took it to administration.. the nurse was terminated on the spot and they turned her in to the local nursing board... saying that I'd never even place a catheter at this point without calling the MD.. not worth the risk!)

I do know for fact the management was seeking reasons to terminate this RN and this was the winning ticket.. but they took it further and potentially caused her to have conditions placed upon her RN License... it did happen just that way.

[lumbarpain, ADN, RN]

I am a LTC with 17 years of experience. I NEVER wrote any order without notifying the MD first...I didnt care if it was a placebo. I covered myself, I didnt care if they got angry....but this was LTC. Heck, it was MY license that was on the line not theirs. I always tried to have good communication with the Mds also. Getting on their good side so to speak. If you have great staff, and the same for auxillary personnel as well as doctors working with and understand your position for not writing out those orders than I say stick with them cause they are the best!!!

[ErinS, BSN, RN]

Amen to the previous posters. We just had 2! nurses fired for writing orders and they are darn lucky that they were not reported. NEVER write an order without an MD okay. In my state we can call in lortab and ultram, but all other narcs must be faxed, and ritalin must be hand carried. Like a previous poster said, it is our word against an MD, and you never know when that MD will come under fire to not be as supportive...

[tewdles, RN]

As you know, prescribing medications is outside of the practice of RNs. DO NOT write orders for any medication without consulting a physician and obtaining an order first.

Perhaps you need better standing orders for pain meds?

[Bubbles]

Agree with above nurses! That's why hospice companies provide their nurses with Blackberries and medical directors! So no playing phone tag waiting for orders. Plus the admitting nurses needs to get orders for pain medication, etc. when pt. is admitted. Protect your license!