When do you get Narc orders?

[casi, ASN, RN]

I'll preface this by saying I'm not a hospice nurse, but I'm a LTC nurse who tends to have A LOT of patients on outside hospice services.

Most hospices I work with once a patient is enrolled they get all of the basic hospice meds (morphine, atropine, ativan, and sometimes more) at bedside once the patient is admitted to the facility.

The current facility I work with mostly uses one hospice agency (related to facility and specific religious group), this agency gets us these meds as they are needed. It's beyond frustrating when someone is starting to go from stable to needing meds that we don't have them available. Meds like atropine and tylenol supps aren't a big deal, we've got those in our facility e-kit and as house stock. The problem comes in when we narcs and we need them NOW, but have to go through a lengthy process to get them (call hospice, argue with hospice who should be calling the on-call to get orders, and then wait on pharmacy to okay us to pull a med from the narc e-kit or deliver a stat med). I won't go into when hospice refuses to order comfort meds for someone who would benefit for them.

So the purpose of my rant is to ask when do most hospice agencies get comfort meds at the bedside?

[NC29mom, ASN, LPN, RN]

I try to get my pts comfort kit meds right after admit....with a dnr (if they want). Nothing makes me madder than being on call in the middle of the night with a newly transitioning pt who has NOTHING in the home. Not a good way to have good relationship with ur co-workers.

I tell my pts to put up in cabinet. ...better to have and never need, than to need and not have....

I will say in my experience with nursing homes and trying to get comfort meds in place. ...most have policies if med not used within 30-90 days they d/c. I just write on med order DO NOT DISCONTINUE R/T NOT USING. ..HOSPICE PT

[Nascar nurse, ASN, RN]

Agree with the above re: LTC d/cing for non-use and I also have facilities that request that I not order meds not needed at the moment because they don't want to have to count the narcs for months.

[jschut, BSN, RN]

Anytime one of my patients takes a turn, I get end of life meds ordered. I would rather have them ther and not used than to not have them when they are needed.

[mrstack]

Our patients will have comfort meds available at the first sign of transitioning, if not before. Our hospice has liberal standing orders and narc meds in backup box so if a facility needs them in the middle of the night we would deliver them. That said, we don't like making runs in the middle of the night so our nurses are very good about having them ordered and in-house ahead of time.

[curiousauntie]

We cannot order meds in a facility. We can leave "Suggestions for care from Hospice nurse" with what we would use, but cannot call the MD and actually get the order. The facility nurses have to do that as the facilities say we are not their employee and their nurses cannot take an order that we get from their doc. I'm not sure if this is a State thing or a regional thing but all the nursing homes in our territory do it this way. Most of the nursing homes do not want us ordering Morphine or Lorazepam until the patient needs it and yes, I think it is because they don't want them in the narc boxes on the unit to be counted 3 times a day forever...or be there forever then all of a sudden come up short in the narc count.

We are also absolutely forbidden to transport ANY medication, especially narcotics, from a pharmacy to a patients home. This is a company-wide policy (and we are a rather large national company with everything from assisted living, home care, LTC, out-patient rehab and hospice). It is a safety issue, and believe me, when I have to go into sketchy areas I am glad I am not allowed to carry even a Tylenol to a patients house. So that precludes the whole "emergency box" to borrow from for the nursing home patients. All home patients get a comfort kit on admission.

To the OP, just a question (asked with an incredulous look on my face) What kind of hospice gives you grief when you want to order comfort medications for THEIR HOSPICE PATIENT???? There is actually a hospice in business who doesn't want their patients comfortable at end of life? I wonder what their definition of Hospice is??? Our patients are seen frequently, especially once they start to decline and as soon as either our case manager sees the signs or a facility nurse calls us to tell us of the signs, we get the Morphine, Lorazepam and Atropine drops ordered as quickly as possible. If they aren't used, so be it, but better safe than sorry. And we don't send comfort kits, but just order the individual medications as most facilities won't allow the Haldol from the kit, either.