By Diane Briney RN, BSN
Senior Partner/Chief Clinical Officer
Hospice On Call, Inc.
Because the symptoms of hospice patients, progressing towards the end of life, are identical for many different diagnoses, many hospices have adopted Standing Orders or Guidelines for use by the Interdisciplinary Team in dealing with these symptoms. Standing Orders are generally a standardized set of directives that either the Physician may either approve upon the patient's admission in its entirety or modify them to fit the individual needs of the patient or the physician's preferred method of treatment. If additional orders are needed, the staff must contact the physician before initiating any care outside the current Plan of Care. In the case of
modified orders, the hospice staff must use those orders as the patient’s primary or hospice team physician has approved them.
For the After Hours Phone Triage Team, the Standing Orders can be a particularly valuable tool. There are several advantages to the After Hours Phone Triage Team, the hospice Staff, the physicians and, most importantly, the patients in the use of Standing orders or Guidelines:
- Consistency in the orders leading to greater familiarity with the medications and appropriate dose ranges by the staff.
- Consistency in the teaching regarding the uses and administration of the medication for the patients, families and caregivers.
- Enable the After Hours Triage team to give help and assistance much more quickly to patients, families and caregivers after accessing these orders. Symptom control measures can be initiated immediately.
- Lessen the use of on call field staff as triage personnel can act more independently.
- Decrease the need to contact physicians for orders after hours.
Of course, there are protocols, which must be followed both to assure “best practice” and to meet the criteria used by surveyors. The surveyors will be checking the Standing Orders to be sure they are in line with hospice regulations and the appropriate documentation and signatures are in place for each patient.
Here are directives that a hospice must follow when putting together a Standing Orders or Guidelines program:
- Each medication, treatment or procedure should be written as a separate order in the Standing Order format selected by the agency.
- Each medication, treatment or procedure should have specific criteria or qualifications for use. This should include the medical indication, purpose or conditions of use. The criteria should be specific and not allow for “choice” by the nurse. The scope of practice for a nurse does not allow them to practice medicine.
- Standing Orders should not include teaching instructions or processes. The RN or other hospice personnel should do instructions and processes.
- All Standing Orders MUST be signed and dated by the physician.
- There must be polices in place regarding when and how to use the Standing Orders which include the method used by the hospice to give the physician notification of the use of, or change in, Standing Orders.
- Standing Orders must be individualized to each patient. Individual patient identifiers must be clearly entered and documented on the Standing Order form.
There are several formats currently used by hospices across the country and they vary widely in the number and range of orders the physicians allow. The Medical Director in collaboration with the Clinical Director and Case Managers generally develops the Standing Orders. The Medical Director generally determines the range of the orders. Liability is an issue that cannot be ignored. The scope and range of the Orders must be very specific and clearly spelled out for each order and understandable by all hospice staff.
Another important aspect for nurses who utilize the Standing Orders is documentation when an order is utilized for a patient. The nurse must be very sure to document the symptoms, which lead to the use of the medication, treatment or procedure. This documentation should include a detailed description of the symptom, its duration, and pain or comfort issues involved. The nurse must speak with either the patient themselves or someone actually with the patient who can accurately describe the symptoms, the patient's recent history and the disease progression of the patient.
The documentation must then include specific details of the application of the Standing Order:
- Dosage
- Concentration
- Mode of administration
- Possible adverse effects
- Teaching initiated or reinforced
- Desired outcome
- Time period to evaluate effectiveness of treatment
- The level of understanding and agreement with the intervention
Standardized Orders and Guidelines can be a wonderful tool for the entire hospice staff, but especially for the After Hours Triage Team in their role as first contact with the patient, family, or other care provider. The use of Standing Orders requires clearly defined processes, complete understanding and accountability from the entire Hospice team, and strict adherence to the protocol from all who are part of the team. |
