Wednesday, May 20, 2009

Prescriptive Authority Update

Once again, the State of Florida has ignored the facts and listened to the vested interests of the Florida Medical Society in denying Florida NPs the authorization to write prescriptions for scheduled drugs. In all fairness, I will say that many MDs spoke out on behalf of NPs, and the issue came much closer to reality than it ever has. Several MDs I've spoken with have been honest about the bottom line, that this is a turf issue, and that it's about power and money. I appreciate their honesty, but would like more that they would set aside their hubris and work for the real loser in this fight: the patient. From my viewpoint, this is about access to care, timely access, not just eventual access. They cloak their objections in talk of increased drug dependency rates, but in no state where NPs have this authority does this bear out.

However, Florida NPs are organized now as they have never been before. We have a plan for the summer while the legislature is out of session. We will bring this back next year, and the next, and the next, until the legislature finally does the right thing.

Saturday, April 25, 2009

Why I Avoid Propoxyphene

Many clinicians use propoxyphene and its variants for pain control. I never do. In fact, the agency where I work has declared itself a "propoxyphene free zone". Independent studies have shown that it is no more effective than placebo at reducing pain. Any pain relief obtained is due to the acetaminaphen in the preparation and/or placebo effect. It is not on the WHO ladder for pain control. There are places in Europe where it is banned. The fact that propoxyphene is on the Beers list of drugs to avoid in the elderly is not entirely why I don't use it, because I do use drugs on that list for elders, but in small doses and while closely monitoring their effect. The primary reason is that it is so ineffective, especially for the kind of pain that most of my patients have, and there are so many other alternatives.

When I choose a pain medication, I want something that is not too strong, but not too weak. I usually give tramadol or hydrocodone, or morphine or oxycodone in small doses. I may even start with very low doses of methadone. It depends entirely on the clinical situation: reason for pain, level of pain, age of the patient, renal and liver function. These medications have a more predictable affect and can be adjusted easily one way or the other as needed. Oxycodone and morphine have long acting preparations, and methadone itself is long acting.

So I don't use this drug. It may have some use for acute musculoskeletal pain, in young people under 40. I'll be interested in your feedback.

I'm back

Sorry to have been away from this for a few weeks. Sometimes there is more to do than time to do it in. Between work and family obligations, I've had to take a breather. I hope to be back and posting more frequently.

Saturday, March 7, 2009


The use of restraints is an issue with large ethical as well as practical considerations. The Joint Commission has strict rules about their use, and in my facility we simply don't use them. The issues surrounding documentation don't exist for us, because we don't even own them. I suppose someone could make something out of rolled gauze, but they would be facing termination if they did.

So the question becomes, how do we control people who are out of control? First and foremost, we try to find the reason for the agitation. If this is a dementia patient, we try to meet their needs. If they need to walk, we find a staff member who can walk with them. If there is a toileting need, we help take care of that. We do use medications, from benzodiazepines to anti psychotics, which is a form of chemical restraint. We have also gone so far as to put the mattress on the floor to keep people from falling out of bed.

It's clear that tying people down makes the agitation worse, and is cruel and demeaning. Some may say that chemical restraint is just as bad, but I don't think so, because the person is still able to move about and interact. I try to give only as much as is needed for symptom control, not to render them completely helpless.

We're fortunate in my facility to have a staff/patient ratio of 3/8, and if the need arises for a 1/1 sitter that can be arranged. We are committed to never needing to restrain our patients, but to maintain their safety in other more creative ways. I'm interested in how others manage this problem.

Saturday, February 28, 2009

Prescribing controlled drugs

One of the more frustrating aspects of working in Florida is that NPs are not allowed to prescribe any controlled drugs. Not just schedule II drugs, as in some states, but all scheduled drugs. The law not only confounds NPs in hospice and palliative care, but in nearly every other specialty. Psychiatric NPs can't independently prescribe Ritalin, and how often does one suppose there is the need? In my practice, I need to prescribe scheduled drugs every day. Because I work in an inpatient unit with a physician usually nearby, I can get things done fairly efficiently, but there isn't always a physician available.

So how do I manage? What I do, is write the orders, which means doing all the medical decision making, then the MD signs the order. All of the MDs I work with trust all of the NPs in our practice, and they may read the order but rarely question it. The extra step of getting the signature is time consuming and disruptive, and most importantly adds nothing to the process.

When I work on the home teams it's a different story. I carry a small laptop computer, and send the order by email to the team MD for signature. The MD may not be available at the time, or the technology may not be working so the email is slow to arrive. It can be hours by the time the patient finally gets the medication needed for symptom management.

For this reason, the NP groups in Florida have worked year in and year out to get legislation passed to reverse the law. The studies clearly show the safety of NPs prescribing scheduled drugs. The issue is about power and money. NPs in other kinds of practices have to have a "supervising" physician, who does nothing more than review charts on a monthly basis and is available to sign these kinds of prescriptions. The NPs have to pay the MD for this service, and in Florida many retired MDs use this to supplement their income. The Florida Medical Society supports many of the legislators, so it's difficult to get our bills through.

For me, the issue is really about access to care. While everyone is worried about power and money, people are not getting the care they need in a timely manner. To have to wait as much as 8 hours, as one patient I know did, for pain medication to finally be delivered, is criminal. If any one of these legislators had to wait like that, suffering pain and shortness of breath, there would no longer be an argument.

There seems to be more support in the Florida legislature this year. I'm hopeful. Stay tuned.

Sunday, February 15, 2009

The psychiatric conundrum

This week I learned about Lithium toxicity. In the four years I've been practicing, it's just never come up, but I think that like Digoxin toxicity, I won't forget it. The hospice diagnosis was lymphoma, with a history of bipolar disease, treated at this point with Lithium. I've learned this week that Lithium is no longer considered the best drug therapy for this disorder, for exactly the reasons I found: levels are difficult to manage and even a bout of the flu affects concentrations.

I don't know what started the cascade, but somewhere in the past month the levels became toxic. Toxicity is exhibited by nausea, vomiting, and diarrhea, which lead to dehydration and increased concentration and further toxicity. If the person is unable to take the drug due to vomiting, there is self-weaning, but if they are not well educated about this, they will try to take the drug and keep it down. Double whammy. She was having myoclonus, fasciculations, and decreased level of consciousness.

By the time I discovered what was going on, she had not been able to take her medications for two days, so was self-weaning, but she was also having vomiting and diarrhea so her dehydration was counteracting that. I started an IV and got a blood level. The level was only 3 by this time, and people are only dialysed if over at least 4. And what was really going on was she was entering the dying process: remember the lymphoma diagnosis?

What this really underscores is the challenge of caring for terminally ill people with psychiatric illness. Psychiatry is not my forte, and I fumble whenever someone with a serious mental illness comes my way. I'm fortunate to have people to consult with, but it's hard to separate out some behaviors like anxiety and agitation at end of life. Which is the mental illness and which is end of life behavior? Are the hallucinations new or part of the schizophrenia? Does the patient understand their physical illness or does their mental illness prevent that?

So the next time I see a patient with nausea, vomiting, and diarrhea, and Lithium on the medication list, I'll stop the drug and get a level on the first day rather than the fourth. It may not change the ultimate outcome, but stopping the myoclonus and fasciculation would be worth it.

Friday, February 6, 2009

Friend or patient?

This week I took care of my friend's husband. He died yesterday morning when neither of us were there, which was probably the way it should have been, as he was such an independent person. It was a first for me, to be in charge of the care of someone I know.

I didn't know him well, just through my friend. That helped, in a way, to take the liberties that we must in order to ask the questions and do the exam. It was a little awkward at first, asking all the questions, getting the history, delving so deeply into his personal life. My friend is a nurse, and she understood what I needed and why, and that made it easier. In some ways, she was caring for me. Then the physical exam, which is intrusive at best.

In many ways, he was no different from many people I have cared for. The diagnosis was not unusual; the end of life course was typical and predictable. He was happy that it was me and not a stranger managing his care. What a blessing that I could give him the peace of mind that he seemed to need, that he was surrounded by friends, and friends of friends, to his last breath.

And people wonder how I can do this work.

Monday, January 26, 2009

The Work, or the Job

There is the Work, and there is the Job. The Work is what I do at the bedside, one on one with the patient or the family, or both. The Work is what I love the most, and what stimulates, inspires, and nourishes me.

Then there is the Job. The Job is the Monday through Friday going through the day getting it done part. I love this part too, although lately it's been a bit tough. My Job, primarily, is to provide medical care to patients in an inpatient hospice house. These patients are all what's considered acute level of care, meaning that they have uncontrolled symptoms in the context of a terminal and life-limiting illness. About 50% of them leave the hospice house and either return home or go to a nursing home. The other 50% of them die there. I make rounds, examine them, get histories, write orders, and answer questions from the patients and families. Sometimes there are conflicts that need to be resolved among the family members and I help with that. Sometimes they need help figuring out what the goals of treatment should be. Of course there is loads of paperwork associated with all of this, and similar loads of government regulations that must be met.

Sometimes I go out and see hospice patients in their homes, which is a completely different experience. The focus at home is usually not on symptom management, although that is part of it, but on disease progression. You also see how people manage their illness, and being chronically ill, and having disabilities. In many ways, it's very inspiring.

The last two weeks, I've been really immersed in The Job. It's been busy, and we've been short staffed. The Work is all part of it, interwoven in all I do, but harder to think about and tease out when I'm moving from one task to the next. Have the patients been seen? Do the nurses have the orders they need to give the care? Has the documentation been completed? What about the other paperwork? and the checkout note for the on-call? Oh, this family member wanted a call back, and this one needs FMLA paperwork completed.

This is not meant to be a complaint, just the reality of what's been going on. I think this is the way Real Life works: sometimes you just have to live life, and other times you get to think about it. I like to write about what I'm thinking, and I have several upcoming posts in my head. Right now I have to be happy with where I am in the process and know that it is a process.

Monday, January 12, 2009

The Little Things

Many times it's the little things that seem to mean the most. A patient came off of dialysis and we all decided that fluid restriction seemed pretty stupid. Water never tasted so good. Another patient came in wanting a cup of coffee. He had been in a hospital where no one had given him coffee for several days. He had been given iced tea and milk, but no coffee. He enjoyed that cup of java more than anything else we did for him, at least at first.

The best thing, is it's so easy to do these things. There was nothing difficult about getting either the water or the coffee. Either would have happened in the usual course of events. But for these patients, these were not ordinary, or usual, they were special occasions. The satisfaction for me is being a small part of making this happen for them.

For this reason, I never order special diets for my hospice patients. I do not impose any limits. If the patient wants to impose limits, that's a different matter. But I think that at this time of life, what is the worst that can happen? The person dies sooner? I also never order for a patient to be NPO. If a person is unable to eat, we note they are "not eating", which is more a statement of function than a restriction.

There are many other "little things" we do that mean so much. The extra blanket, the fan for the COPD patient, many things. But taken altogether, they become a large part of what makes hospice care different and special.

Friday, January 9, 2009

Time for renewal

It's been a busy week. I worked last weekend, with several new admissions which means new history and physical workups, and then this week the pace never let up. Yesterday was my birthday, and in spite of being so busy with patients, everyone gave me a nice little party with cake and ice cream, flowers and balloons, and cards that everyone signed. It's a measure of the close feeling we have for each other that we get to do this kind of thing. It was nice being on the receiving end.

The patient flow was hectic all week though. I don't know all the figures but it was like a revolving door, with admissions, deaths, and a few discharges home. I really felt like I was on a treadmill much of the time just to get the work done. The compensation for working last weekend is that I have a 3 day weekend now, and it's time to rest and recover.

Recovery is vital to being able to work in hospice for the long haul. This work is very stressful, even more so to me than critical care was. Burnout is a common occurrence, and you have to make a conscious effort to renew your own spirit. So this weekend I'll be taking walks, reading some fiction (I like mysteries), maybe sitting on a beach somewhere. I'll be spending some quality time with my family. Monday when I return to work, I'll be ready once again for the challenges.

Wednesday, January 7, 2009

Dying badly

Some people do not die easy. It's difficult for me to deal with, because I want to "fix" whatever is wrong, whether it's pain or anxiety or shortness of breath or whatever. But sometimes, even with all of that having been looked at and taken care of pretty well, the person is still thrashing around. It's as if they are fighting so hard not to die, they are fighting against the medications I've used to help their symptoms. I try calming words, and presence, and sometimes touch, but sometimes nothing works. It's very frustrating. More than that, it's humbling. After all, I don't have to be perfect do I? Well maybe I think I do. When I have my successes, it's so easy to think it's because I'm so smart and good at what I do, when really the patient had a great deal to do with how they responded. People have to be receptive. I am always amazed when some people fight death to their literal last breath. It doesn't happen often, thank goodness, but it does happen. I leave them feeling totally wrung dry, emotionally drained, always wishing for the happy ending but taking some comfort in knowing that the person did it "their" way.

Monday, January 5, 2009

Pain management success

One of the things that I LOVE about my job is the impact I can have on people with pain. Consider this woman: 46 years old, ovarian cancer, metastasis to the bone, pain in her right shoulder, lower back, and right hip. When I first met her she was on very high doses of methadone (good drug but not working for her), and was still doubled up in pain. She had not slept in days, except for naps disturbed by dreams. She had lost 25 pounds in 2 months because she was unable to eat due to the pain. I put her on a Dilaudid infusion at 5 mg per hour with a 3 mg bolus every 10 minutes. She used the bolus very little, because the basal rate turned out to be spot on. The next day after starting this, she told me she had slept all night. She was able to walk standing straight up. She was eating. The next day after that, she was smiling. She had again slept all night, but was not sleepy during the day. She was functional. She is still on her infusion at this dose, but we discussed the probability that at some point her illness will worsen and she may need more. It will be simple to increase the dose, just by adjusting the pump. Her hospice nurse is visiting her frequently and checking for any side effects, changing the tubing and bags as needed, and will let me know of any issues. Seeing her move about, eat normally, and function normally is such a rush for me. I don't know how long this will last, but if she gets even a week (although I think it will be much longer) of pain relief, it will be worth it.


This is my first time at this business of blogging. I want to write about the wonderful world of the Hospice NP, the good times and the bad. Some people ask how it is I, and others like me, can do this work, and hopefully this blog will answer that question. In a word, because it's meaningful. I know at the end of the day that I mattered to someone. But it's much more than that. So in the coming days and weeks, I hope to fill the posts with my thoughts and feeling about what's going on in my life as a hospice NP. If it strikes a chord, write a comment. I'd love the feedback.