Would you ever give a lower dose of a psych medicine to a patient if that patient demanded it without a provider order?

[A Hit With The Ladies, BSN, RN]

I'm a night-shift inpatient Psych RN for eleven months, and this situation happened two nights ago. It was a very chaotic unit, with multiple emergency meds given to several patients already.

One of my patients comes up to the medication room for his meds. I see on his MAR that his psychiatrist has gone up on his Seroquel dose from 400 to 500 today. Show him the Seroquel 500 and he starts flipping out, going off about how the doctor really upped his dose too much without telling him, and saying he'll only take 400 but not 500. He ends up on the phone threatening to act out on the unit.

I've paged the resident on-call telling him the situation. Resident calls back and says "No, either he takes the 500 [the orders] or he refuses. If he ends up needing a shot, we'll give him a shot".

However, the house supervisor RN is on my unit, and she's telling me, "Just give him the 400! This is psych, we can give them a lower dose if that's all they'll take!" I told her that I can't just give a different dose without the doctor's orders, and moreover the resident already said no. She calls up the incoming night-shift supervisor and is trying to get him to agree with her. I'm angry at this point and say, "You can give it if you want to, I'm not giving it". She ends up giving it and charting it under her name. She told me to make sure to put in my nursing progress note he got 400 instead of 500, which I did.

Who was right here? Me or this nursing supervisor?

[hppygr8ful, ASN, RN, EMT-I]

Well purposely not following a physicians order can be reported to the board. IT could be considered a med error in some facilities or at least a variance that would be picked up by the pharmacy. You would have to be able to defend that you were acting in the best interest of the patient not just doing what the patient asked. I would most likely run it by the physician or if he/she is not available at least check with the nursing supervisor. Most of us at my facility have been doing this for a long time and our docs are very good about answering our calls. We have this idiotic facility rule about not calling physicians at night unless it is an Emergency. No matter what you decide or who you talk to always document, document, document it will save your butt in the end.

[penelopelp]

If you call the doctor and they say give 500 oral or 500 I'm, then that’s what you have to do. I wouldn’t give the lower dose without the doctor’s approval.

[B52, ADN, BSN, MSN, RN]

It would be inappropriate to call the doctor for guidance, and then ignore the guidance.

[umbdude, MSN, APRN]

On 4/26/2020 at 1:06 PM, A Hit With The Ladies said:

Resident calls back and says "No, either he takes the 500 [the orders] or he refuses. If he ends up needing a shot, we'll give him a shot".

This is a pretty inappropriate response. Unless the patient is court-ordered a medication, it's best to try to work with the patient and not put the nurse in a corner like that. Then discuss with the patient about the dose when they meet face to face. Patients have the rights not to take a dose that they don't want to unless they're involuntarily committed with court-ordered medications.

You did technically the right thing. You shouldn't give a different dose than what's ordered. I would've stick to that myself. On the other hand, a lot of old-school psych nurses will give the lower dose rather than escalating and possibly lead to mechanical restraints, which would be terrible for the patient and staff. IMO, neither you nor the supervisor is wrong. Just document that nursing supervisor administered the medication.

[LovingPeds, MSN, APRN, NP]

You mentioned that this was the resident on-call that you spoke to. Another option for future reference (in order to legally cover everyone) is to escalate it to the attending. Follow the chain of command. If the resident wants to power trip over 100mg of a medication rather than to give the usual dose and discuss it with him in the morning, then report the entire situation verbally to the attending. You can do so without throwing anyone under a bus. Just state the facts.

"My patient had his dosage changed to 500mg today. He is upset about the change. He feels that it was done without including him. He is willing to take his regular 400mg. I called the resident on-call and he ordered that he either takes the full 500mg or he refuses. The situation is escalating and I am concerned he will act out on the unit."

You have to right to escalate a situation up the chain of command if you feel that you are not getting an adequate or appropriate response from someone in regard to patient care.

I had an instance years ago where I reported a situation where a resident was really ugly to a patient. I gave it to my manager and assumed the attending got that information. Found out years later, that the attending really disliked that particular resident's attitude, had never gotten my report, and if he had known about it at the time, he would have taken it to the resident's educational supervisors.

Don't be afraid to go to an attending or up the chain of command when you know something is wrong. I would do that and document that I did prior to giving a dose that was not ordered. It can be considered practicing outside your scope of practice which can be reportable to the board.

[Orca, ADN, ASN, RN]

Giving any dose other than what is ordered is a violation of a legal medical order, and it could be construed as prescribing. Regardless of whether the doctor's comments about giving 500mg or else giving a shot were appropriate, that was his medical judgment. He was obviously opposed to going back to a lower dose. The fact that the dosage was increased in the first place shows that the 400mg dose was not as effective as the provider wanted. The house supervisor was out of line.

[adnrnstudent, ASN, RN]

At my facility, we don’t have 400mg Seroquel tabs so we give 2 of the 200mg.

if a patient only takes 1, I can’t force them to take 2.

in my case if they agree to take 1 instead of 2 that’s what they will get and I will chart it.

now if it’s a 300mg tablet that I pull from Pyxis but they only want 200mg I couldn’t go pull a 200 anyway so if they refuse the tablet, I’ll chart refused in mar.

Haldol, we don’t have 10mg tabs, so we give 2 of the 5mg. If a patient agrees to 1 I will give 1 and chart it in mar.

any case we have multiple tabs to make the ordered dose I will give less if patient agrees. Better to get 1 500mg Depakote ER in them than none if they won’t take 3 of the 500mg

[hppygr8ful, ASN, RN, EMT-I]

3 hours ago, adnrnstudent said:

At my facility, we don’t have 400mg Seroquel tabs so we give 2 of the 200mg.

if a patient only takes 1, I can’t force them to take 2.

in my case if they agree to take 1 instead of 2 that’s what they will get and I will chart it.

now if it’s a 300mg tablet that I pull from Pyxis but they only want 200mg I couldn’t go pull a 200 anyway so if they refuse the tablet, I’ll chart refused in mar.

Haldol, we don’t have 10mg tabs, so we give 2 of the 5mg. If a patient agrees to 1 I will give 1 and chart it in mar.

any case we have multiple tabs to make the ordered dose I will give less if patient agrees. Better to get 1 500mg Depakote ER in them than none if they won’t take 3 of the 500mg

Having worked psych for many years I can see where some of you are coming from and the rationale "some psych med is better than no psych med." Still you are not following the physician order and by giving a dose that has not been ordered and a zealous board investigator might find that you are ordering and prescribing without a medical license and could have your nursing license sanctioned or taken from you. In the case originally stated the doctor ordered a specific dose of Seroquel which the patient refused stating he would only take a lesser amount. the OP called the doctor, explained the situation and asked for orders which the physician gave. OP then refused to follow those orders in favor of the lesser amount which the physician specifically stated he did not want.

With the case in question I would have prepared the meds. If the patient refused and the doctor said he takes it or gets a shot. I would have prepared the injection and gone back the patient and stated. The doctor really wants you to take the 500 mg. He said if you refuse I am to give you an injection. I suggest you go ahead and take the 500 mg and you can speak to the physician when he comes in. How would you like to do this?"

The other way to handle this would have been to allow him to refuse the initial order, document the refusal and let the physician know so he could address it with the patient. Seroquel does not have immediate action so if the patient was not actively psychotic or aggressive it might be prudent to allow the patient to discuss his complaint directly with the physician.

Hppy

[Orca, ADN, ASN, RN]

If you present a medication with two tablets and the patient only takes one, that isn't the same thing as altering the dose, which was done in the situation that the OP detailed. The correct dose was presented to the patient. In that situation, I would just document that the patient refused half of the dose.

[hppygr8ful, ASN, RN, EMT-I]

3 hours ago, Orca said:

If you present a medication with two tablets and the patient only takes one, that isn't the same thing as altering the dose, which was done in the situation that the OP detailed. The correct dose was presented to the patient. In that situation, I would just document that the patient refused half of the dose.

That would be one way to go about it and as long as you CYA by informing the Doc you would be OK -BUt the nurses called the doc he said "He takes the full dose or he gets a shot!" So now the nurse has been given clear direction and failed to follow orders.

[Orca, ADN, ASN, RN]

On 5/15/2020 at 6:54 PM, hppygr8ful said:

That would be one way to go about it and as long as you CYA by informing the Doc you would be OK -BUt the nurses called the doc he said "He takes the full dose or he gets a shot!" So now the nurse has been given clear direction and failed to follow orders.

I was once given an order along those lines that was impossible to carry out as written. The patient was prescribed oral Geodon, to be taken with meals. If she refused the PO, she was to be given a Geodon injection before she ate. She was already eating when she refused the PO, since it was supposed to be given with food.