Administration of Medications to Residents Receiving Hospice Services
Operating a Residential Care Facility for the Elderly and providing outstanding care for our residents can present many challenges, especially considering increasing acuity and higher levels of allowable care. If you are caring for residents receiving hospice services, which can be a very spiritual and emotionally rewarding experience for the care provider, it can multiply these challenges while providing compassionate care and a dignified end of life. No one wants to see their resident suffer the pain that unfortunately often accompanies the health challenges that occur in the end stages of life. Physicians have the enormous responsibility of utilizing their skills to make the residents’ time on hospice care as pain free as possible while we, as care providers, have the equally important responsibility to enable the resident to pass from this world in a dignified manner and move on to the next stage of their existence as their beliefs and spirituality guides them. When our resident is in pain, we ensure that their prescribed medications are given when needed. One of the aforementioned challenges is administering a medication when the resident is not able to participate in the administration. As we all know, unlicensed staff cannot administer medication, only assist the resident with self-administration. What are our options when we do not have a nurse on-site? The hospice nurse will visit the facility and will administer the medication, but in the real world this is not always a viable option. Pain follows no schedule and the alleviation of pain must be an available option as needed.
There has been much confusion on one available option for the resident receiving the medication when care staff cannot administer it. In the real world, on an everyday basis, residents’ family members have been administering their loved one’s medications. Community Care Licensing has not been able to develop a decisive decision on this practice. Is it allowable under regulation? In the defense of CCL, they have many conflicts to sort through. They must consider the best interest of the residents while considering the requirements of the Nurse Practice Act, Title 22 regulation, Health & Welfare Institution Code and more. It is not through lack of effort, and certainly not through lack of concern for our residents, that CCL has not reached a consensus on this practice. That is until now. They have concluded that a family member may administer medications (oral and injections) to their loved one as long as this practice is reflected in their service plan, that they are trained appropriately to do so, and the facility has a plan in place to ensure that if the family member is not available, a hospice nurse is available to give the medication. This decision will allow many residents to remain in the community and experience the loving care that they have grown accustomed to receiving from our care staff while in the end stage of life.
While Community Care Licensing cautions us that this decision may only be temporary while all legal, regulatory and resident care issues are scrutinized, we all hope that they come to the conclusion that the best interest of our residents is the motivating factor that we all share and that this policy should be permanent. Many thanks to Community Care Licensing for their tireless efforts in addressing this issue.
I always concur regarding this matter. When the family is not available and the staff nurse is not always present (although the hospice agency said that they are available 24 hour service) to administer meds.
One particular time in our facility I cared for an hospice client. I requested to switch pain meds into a patch form, one of the on call supervisor said, “it is a good idea, but you are shortening the life of the client”.
I had the same experience with a Hospice supervisor telling me that the patch would make my resident “stop breathing”. When I looked up information on the Duragesic Patch, it was clear that a slowing of respirations and decreased blood pressure are some of the side effects but “shortening life” was not identified as a result of using this strong but beneficial medication properly. Duragesic 100 is about equal to a combined dose of 360mg of morphine daily. When applied, the Duragesic patch peaks at 12 to 24 hours then maintains a constant dose for the remainder of the 72 hours making it an ideal solution for pain management of a dying resident who cannot manage their own meds any longer. As with any narcotic, the resident must be assessed prior to administration to ensure that breathing and blood pressure are not already compromised. Dosage may need to be started at the lowest rate and increased as tolerated. After application of the patch, the resident’s vitals must be monitored to detect any signs that breathing or blood pressure are falling into unsafe levels. Determining what’s best for the comfort of the resident should be a group decision with resident and family participation (if possible). Assuming the risk of “shortened life” is not for the supervisor to determine. Hesitation to provide this type of medication may more likely be due to cost. My resident’s Duragesic patches were costing about $1500 per month. If your resident is Medicare age, Hospice (who gets paid by medicare) usually has to absorb the cost of medicaitons.
You are probably correct regarding the duragesic patch being cost prohibitive for the hospice agency. I am blessed to be able to work for a non-profit hospice agency for the past 7 years. What is best for the patient (resident), is what we provide regardless of the cost. The one thing about the patch that needs to be carefully monitored is it’s effectiveness. There needs to be some subcutaneous fat for the medication to be absorbed. It is frequently ineffective in thin little residents.
It was stated that CCL has said that family members can administer hospice meds. to their family living in an RCFE.( if the hospice nurse is not available) _Where is this stated on paper and if so does the facility need something in writing to protect themselves? Thanks
END-OF-LIFE ABSURDITY: How many people (particularly the very elderly or demented) have the mental presence & skill to understand and self-administer their own palliative medications?? At the very point when they are weakest, perhaps in the most discomfort, or obtunded, the new rules ask them to “administer’ their own meds. EGAD: Many cannot even open their eyes. The logic of the new rules is, well, NOT Logical. Fast acting (Roxinal) and long-acting Morphine Sulfate (MS Contin) have long been the major drugs of choice, for pain ( and SOB — in the case of Roxinal). Wrong-headed, old-fashioned MYTHS that “MS will suppress breathing and/or hasten death” require hospice Nurses to regularly clarify and reinforce the facts to patients and family. Hopefully, we would not have to explain this also to RCFE & SNF nurses and non-medical administrators.
Sublingual ROXINAL (fast-acting MS) is easy to give & does NOT suppress respirations–in fact, it relaxes the diaphragm and HELPS Resps. As an MD I know said: “this is the BIGGEST Myth about palliative care and it is dangerous.” We often give Roxinal (MSIR) to patients with Respiratory conditions, with great success. As for the patch (Duragesic), hospice uses this strong level of pain control mostly for pts who cannot or will not take oral medications—but it does NOT KILL Patients! I have encountered non-medical FACILITY MGRS who try to dictate through “policy” what HOSPICE MEDS are safe or appropriate to give patients. POLICY SHOULD NOT TRUMP patient care—especially at the very end of life. No one should die in pain. I sincerely wish the State Rulemakers would relax their RCFE rules and apply the logic of End-Stage care. HOSPICE CARE is not about starving, suffocating, harming or hastening the death of the (already dying) patient; we ARE about easing their way so that they and loved-ones may simply BE TOGETHER at this precious time. Thanks for listening.