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.