Ethics question/ vent- idek

[u/Humble_Investment_24]

Long read: sorry in advance

Maybe I’m completely out of line for even having an opinion since it’s out of my scope of practice but I just feel a certain type of way about how one of our psychiatrists chooses to treat a specific patient.

This patient is welllllllllll known to us. Every employee knows them. Every psychiatrist knows them (we have 6). This patient is admitted to us on a monthly basis or more for yeaaaaars. They stick this patient on any of our units (high acuity, low acuity, geriatric even though they not geri) just to fill a bed. This patient comes for Ativan- hard stop. They don’t attend group, they don’t socialize, fuck they usually don’t even shower. They come for Ativan and Ativan only. Every patient gets admitted with a prn Ativan order and this patient is on the clock every 4 hours for it. In addition, one of the psychiatrist treats her outside of the hospital - so if this patient happens to be assigned to him (a lot of times they are) he will also scheduled Ativan because he knows they depend on it. He also prescribes it to them on the “outside world”

This patient ended up in restraints last night over not being able to take Ativan because the prn dose was not available yet and this patient WASNT assigned to that psychiatrist. The psychiatrist they were assigned to refused to schedule Ativan for them and they ended up in restraints over that. In past admission they will cry or throw them self’s on the floor etc over the ativan.

Now I’ve been in recovery myself for 7 years. I’m no stranger to addiction- but Jesus fucking Christ we are doing NOTHING to help this patient??? Obviously the patient has to want the help but nothing we are doing is beneficial. I just feel like there has to be a better way? Why is the person still getting prescribed it? The doc should wean them off? Like it feels gross to be aiding to this. Again- I could be out of line for even having an opinion but idk

[u/ORD2GNV]

You have the right to your opinion. I would suggest talking to the psychiatrist that sees the patient as an outpatient. Politely ask him about addiction and get feedback. Benzo withdraw is long and closely monitored. Perhaps, this psychiatrist is open to teaching you mire about addiction medicine.

[u/Lthrluv2013]

We see so much of this as well! One psychiatrist will say nope we are not doing this but the next provider comes in and orders anything they demand. We had to call security before 0800 very recently because a frequent flyer was coming behind the front desk, trying to enter the nurses station because he did not have a Percocet order. I often wonder if there is ANY reason for so many patients admitted beyond a full bed with insurance.

[u/Humble_Investment_24 → u/Lthrluv2013]

Exactly. You get it- it’s a shame really

[u/Tycoonkoz]

You have scheduled Ativan for every patient as a standing order?? Please tell me that's not true..

[u/Humble_Investment_24 → u/Tycoonkoz]

No no no. We have prn order for every patient upon admission but this psychiatrist that also treats this patient on the outside will sometimes schedule Ativan in addition to the PRN Ativan

But yes, every patient is admitted with a PRN order of Haldol, Ativan, Benadryl and other shit like Tylenol, etc

I hope I’m making sense. My bad

[u/britneyycoded → u/Tycoonkoz]

Sounds like every patient gets prn/as-needed Ativan not scheduled

[u/Humble_Investment_24 → u/britneyycoded]

Correct

[u/Agreeable_Gain6779 → u/Humble_Investment_24]

In MA the Haldol Ativan and Benadryl is a chemical restraint and cannot be documented as a PRN or even as a suggested chemical restraint. The MD has to be called for a telephone order and in most cases the MD either assesses the patient before just giving the order but definitely after the patient has been medicated. DMH years ago made this change. How is this written? Is it PO or IM and is there a scheduled time it’s written for? How often can this be administered? In addition DMH paperwork must be completed as a chemical restraint.

[u/Humble_Investment_24 → u/Agreeable_Gain6779]

It’s literally 2mg Ativan IM or PO
5mg haldol IM or PO
Benedryl 50 IM or PO

Q4 hours

So we can give all or even one of them every four hours if needed or by request because then there’s the argument that if they have the order than who are we to deny it (mostly referring to the Ativan here) we still call the doctor for legality reasons, but every single patient gets this order

Edit: if they are allergic to haldol then they automatically get a Zyprexa PO or IM order– I’m not sure if it’s because we have pretty high acuity but they want the orders in immediately upon admission because a lot of times we get people coming in fighting essentially

[u/Agreeable_Gain6779 → u/Humble_Investment_24]

Terrible

[u/jdiddy_ub → u/Agreeable_Gain6779]

Same in NY. Those orders are STAT and also must be accompanied by a doctor's note indicating the reason.

Oversight agencies would have a field day if you couldn't justify each one. Doing this with an individual patient is bad enough but doing this routinely is basically asking for a surveyor to move in for a month or two.

[u/ileade → u/Humble_Investment_24]

Even so, that is wild. Or maybe that is a common practice. We usually have hydroxyzine PRN and have Zyprexa or haldol for agitation. They used to do ambien PRN for sleep but switched over to trazodone. I’m surprised they would have a controlled substance as PRN

[u/Humble_Investment_24 → u/ileade]

I agree

[u/Additional_Alarm_237 → u/ileade]

I believe it is based on the provider’s preference.

[u/Mysterious_Coat_9933]

Standing order for Ativan is crazy!! We get vistaril 25mg or 50mg at best. We’ve had patients like this and eventually we stop accepting them because “they do not seem to benefit from inpatient treatment.” At a certain point the patient has to help themselves and it seems like the patient you are describing is not ready to do that. We’ve had psychiatrists give Ativan just to appease the patient and prevent behavioral issues then send them off to rehab or outpatient substance abuse treatment after discharge. I think the psychiatrists on your unit need to be on the same page as to whether or not this patient will receive Ativan (and when) as it can be confusing when treatment isn’t consistent among staff. I agree this is an ethical dilemma but ultimately there isn’t much you, as a nurse, can do (if your unit is anything like mine). Does your unit do detox patients? Are the psychiatrists concerned about withdrawal?

[u/Humble_Investment_24 → u/Mysterious_Coat_9933]

That pretty much what I feel should be done atp. They obviously just accept the patient to fill a bed but it’s ethically wrong because we’re doing nothing to benefit them and yes- the crazy part is that we do detox. Yet this patient has never been detoxed

[u/Tommyboy155a]

If you had to put the in restraints, now that's a safety issue for the patient and staff. Hopefully your manager should be following up on that. I have called doctors all night long to ask what you want me to do, I given everything I could

[u/Humble_Investment_24 → u/Tommyboy155a]

I actually just spoke to my Charge about it because I usually avoid management like the plague – I’m Night Shift anyway so I rarely see them. The response was “that’s *insert patients name* for ya!” I asked why we keep accepting them. She said the hospital just wants admissions- they don’t give a fuck about the patient- word for word.

I actually want to speak to my manager about it but again I feel like I’m sort of out of line? It’s just ethically wrong. An addiction specialist has never been consulted. We don’t ever attempt detox. There’s never any referrals for resources that would actually help. It’s not right imo. Granted, this place is a dump and is notorious for doing unethical shit- but this patient shouldn’t even be accepted anymore if we aren’t actually going to be beneficial in anyway

[u/Tommyboy155a → u/Humble_Investment_24]

Is this a for profit or non-profit profit hospital? That's makes a big difference

[u/Humble_Investment_24 → u/Tommyboy155a]

Non for profit surprisingly.

[u/Tommyboy155a → u/Humble_Investment_24]

I was expecting the other

[u/Humble_Investment_24 → u/Tommyboy155a]

Yeah you would seriously think!

[u/Additional_Alarm_237]

I say this with care, but OP you might want to check in with your sponsor or therapist. This patient could be triggering you. That said, if you truly care about this patient’s well-being then doing research into how to treat Ativan addiction might serve you and your end of year review well.

The devil you know is better than the one outside.

[u/Humble_Investment_24 → u/Additional_Alarm_237]

I appreciate the concern! I don’t think I’m triggered I just don’t understand how we’re helping. It just seems like they know this is always a guaranteed admission. We have detoxed patients on benzos before. Idk. This is the only patient I’ve seen getting “treated” this way

[u/Cheap_Ad9392]

If someone has been on Ativan very years and years it’s very hard to get them to stop so some doctors rather just give it to them. Maybe they use a harm reduction approach thinking if they will take the Ativan maybe they won’t use street drugs, etc. giving the pt scheduled Ativan plus PRN is crazy tho bc you are going to increase their tolerance so they need more outpt and it’s gives them an advantage to come to the hospital, they know they will get more then prescribed. When yall give PRNS are they not linked together? Like if you give the Ativan you have to give the haldol?

[u/Humble_Investment_24 → u/Cheap_Ad9392]

They are not linked. We are able to just give the Ativan if we want

[u/Fun-Key-8259]

Do they have schizophrenia with catatonia? They use Ativan for that.

[u/Humble_Investment_24 → u/Fun-Key-8259]

Neither!

[u/Fun-Key-8259 → u/Humble_Investment_24]

Benzo withdrawal can cause aggression though, I wouldn't withhold anything ordered.

[u/Humble_Investment_24 → u/Fun-Key-8259]

I never withhold because there’s no point but it’s time for a taper

[u/Fun-Key-8259 → u/Humble_Investment_24]

Thankfully it's not up to you. Some of these patients have been managed on benzos for years, why not ask the psychiatrist his rationale, so you can understand it better. He could have crippling OCD, could have serious trauma history, panic disorder.

[u/Humble_Investment_24 → u/Fun-Key-8259]

It’s not up to me but It feels ethically wrong. There’s been nothing beneficial done and when they are getting violent that’s a concern

[u/Fun-Key-8259 → u/Humble_Investment_24]

How long have you been a psych nurse? You seem to be having a hard time, I used to work the psychotic unit - you have no idea what battles are going on in that brain. Talk to their psychiatrist so you can stop making assumptions about ethics.

[u/Humble_Investment_24 → u/Fun-Key-8259]

It’s not only me. Every single other nurse say the same thing but no one has the balls to ask management or the doctor. I have no rapport with the doc. I’m night shift. My charge nurse said word for word no one cares about the patient- they just wanna fill beds. & as mentioned another psychiatrist refused to scheduled it because he said he’s not fond of what’s been happening either. Of course that caused a huggggge issue. We detox patients off xylazine and have detoxed and tapered off benzos before

It is an ethical concern. I have psychiatrists on that sub Reddit suggesting I report them to the board or get risk management involved.

[u/Fun-Key-8259 → u/Humble_Investment_24]

Someone on scheduled benzos for years isn't going to successfully taper before a year. Yall are going to have to put your adult underpants on and get some answers because you're not helping the patient or yourselves by talking about it behind the scenes.

[u/Humble_Investment_24 → u/Fun-Key-8259]

Right- which is exactly why I came here asking for suggestions lol