Guidelines for Benzos

The Society of Critical Care Medicine has revamped its guidelines in an attempt to keep doctors from overprescribing benzodiazepines to sedate patients. “Benzos,” as they are sometimes called, are a class of anti-anxiety drugs including Valium, Klonopin and Ativan which can bring on a nightmarish set of side effects including delirium and hallucinations, even in the most clear-minded individuals.

These drugs have a heightened effect on the elderly, and are associated with an increased risk of falling.  For patients who are under the confusing influence of these drugs, painful medical procedures may feel more like torture.  A breathing tube can be interpreted as someone choking them.  A catheter insertion may seem like rape.  Often patients in this situation will later develop post-traumatic stress disorder, suffering nightmares, flashbacks, memory loss, and lingering phobias. They may feel confused and embarrassed about what they remember from their treatment.

Some treatment centers and families in Europe keep journals for their patients so that disturbing memories of hallucinations can be cross-referenced with the actual procedures which took place. While these journals seem to speed up mental recovery after a scary medical procedure, they have been slow to take hold in the United States.

See articles here, here, and here.

Survey Guidelines for Antipsychotics

The Centers for Medicare & Medicaid Services has updated survey guidelines regarding nursing homes' use of antipsychotic medications for dementia care. The interim guidance revises Appendix P and Appendix PP of the State Operations Manual. The Appendix P update includes new surveyor tasks to ensure that survey samples include enough residents who have dementia and who are taking an antipsychotic medication. Updates on Appendix PP include new interpretive guidance related to care of residents with dementia, including medication use. For more information, read the article in McKnight's.

Cost cutting and Ethics

Kaiser Health News reported that the American College of Physicians released an updated ethics manual requiring doctors to provide "parsimonious care" – in other words, "to practice effective and efficient health care and to use health care resources responsibly."  Is it ethical to withhold care when the benefits are not cost-effective?

It's been viewed as a definitive statement of medical ethics directed at the organization's 132,000 members – physicians who practice internal medicine and its related specialties, among them cardiology and oncology, that often involve expensive procedures. 

Consumer advocates and experts complain that cost consideration ultimately hampers patient care. 

DEA Guidelines on Dispensing Medications

The New York Times recently had an article about the recent guideline issued by the Drug Enforcement Administration which will give LPNs more authority to get residents narcotics.  Historically, pharmacists dispensed the prescription for patients after direct oral or written orders from a doctor.  The new guideline grants physicians the power to authorize nurses at long-term care facilities with the ability to call in oral prescriptions to pharmacies.  Prior to the guideline, the agency did not recognize nurses who were employed by nursing homes as legal agents acting in lieu of physicians to call in prescriptions to pharmacists.  The pharmacies were able to dispense these drugs to patients only via direct communication with a doctor. The new guideline permits physicians to authorize more than one nurse or health care worker to communicate the need for certain medications.

However the new guideline does not apply to all prescription drugs, with morphine being a perfect example of a prescription drug which nurses cannot call in for their residents.

Some argue that shortening the time it takes for residents to get the painkillers and anti-anxiety medication will be an improvement, and allow nurses to address their residents’ needs. Prescription pills still need to be monitored very closely, as the DEA recently had their first national prescription drug “Take-Back” campaign. This effort worked to collect prescription drugs so that they could be disposed of properly.

 

The system is rife with abuse and neglect including staff stealing narcotics and nursing home patients in distress aren't getting pain-controlling medications in a timely manner, and delays run from hours to days. Delays in treatment occur because the nursing homes refuse to put a doctor on staff or have all-hours access to a physician able to write prescriptions whenever needed.

DEA spokesperson Gary L. Boggs told the Times that the DEA had the best interests of patients in mind when it tightened the relaxed access to powerful drugs. "What we see is nurses unilaterally calling in prescriptions, or pharmacists dispensing controlled substances without a prescription, then trying to get a doctor to sign a prescription for a patient he never saw."

The result too often was over-medicated nursing home residents, and residents taking addictive drugs that no doctor had prescribed. While the lax rules were convenient for nursing home personnel, abuse was rampant.  The the larger problem is that nursing homes aren't providing quality, crucial medical care to their residents.

Senior policy lawyer at the Center for Medicare Advocacy Toby Edelman told the Times that nursing homes must provide medical care for residents. "If people are so sick that they desperately need pain medication, they should be seen by a doctor," Edelman said. "The absence of doctors in nursing homes has been a problem for decades."

Sen. Herb Kohl (D-WI) continues to express his reservations about Michelle Leonhart, the nominee to lead the U.S. Drug Enforcement Agency. In a Senate Judiciary Committee hearing for Leonhart, Kohl said he still has concerns about the DEA's policy regarding the delivery of pain medications in nursing homes.

“I will not hold her nomination in the Committee today, but I do intend to hold her nomination on the Senate floor until we have made more progress towards our goal of ensuring that nursing home residents get timely access to the prescription drug care they need,” Kohl told the committee.

Kohl is working on legislation that would allow nurses—acting as agents to doctors—to call in controlled substances such as Schedule II drugs to pharmacies. The Senate committee also conducted an investigation that found much confusion still exists among nurses as to what new protocols allow.

 

CMS issues new guidelines

U.S. News & World Report had a great article summarizing the spirit and intent of the new federal regulations for nursing homes. The article states "A warm, welcoming environment where residents are free to make choices regarding their care."  These recommendations or standards are long overdue and need to be enforced right away.

The CMS guidance aim to "transform nursing homes into environments that are more like [residents'] homes through both environmental changes and resident-centered caregiving," CMS wrote in an agency news release.  The guidance will serve as an outline that CMS nursing home inspectors will use to make sure a particular facility is reaching federal regulations on good quality care.

Included in the new proposals:

A call to "de-institutionalize" the nursing home's physical environment by doing away with things such as meals served on "institutional" trays, blaring noise from overhead paging speakers, and large nursing stations.

Efforts to individualize and personalize care, stressing the importance of personal one-on-one relationships between residents and staff, and a warm, welcoming environment.

Giving residents real choice over daily routines, including the scheduling of waking, bathing, mealtimes and bedtimes.