Interpretation and Implementation of Range, Titration, and PRN Orders in Hospice

Mary Lynn McPherson, PharmD, BCPS; Karen S. Kaiser, PhD, RN, AOCN; Cameron Burns, PharmD


Journal of Hospice and Palliative Nursing. 2005;7(5):289-298. 

In This Article

Abstract and Introduction

For safety reasons, the 2004-2005 Joint Commission on Accreditation of Healthcare Organizations standards require organizations to develop policy addressing various types of medication orders that have the potential for being ambiguous to those dispensing or administering medications. This includes range, titration, and as needed orders for analgesics and other medications used in palliative care. One sample policy that addresses prescribing and interpretation of these types of orders is presented, as well as case examples illustrating this process. These types of orders should contain an indication, a minimum dosing frequency, the dose range if appropriate (not to exceed a doubling for patient/family medication administration), titration instructions, and clinical parameters to guide dose administration. Hospice and palliative care organizations should develop their own policy for accepting orders of this nature to enhance patient safety.

Many end-of-life illnesses can produce severe pain in the majority of patients with cancer and noncancer diagnoses such as AIDS, multiple sclerosis, cerebrovascular disease, and others.[1] Data from the 1995 Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT), designed to evaluate end-of-life care, showed a high incidence of uncontrolled pain (from 74% to 95%).[2] A primary goal of hospice and palliative care is to keep terminally ill patients comfortable up to their death. In recent years, practitioners have become increasingly skilled in using analgesics to control pain, in response to increased knowledge and expectations of accrediting agencies. However, the potential for serious and/or life-threatening adverse effects of these agents, notably opioid analgesics, has also become a high priority for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

The JCAHO is a nonprofit institution that establishes "state-of-the-art, professionally based standards" by which it evaluates participating healthcare organizations. Its stated mission is "to continuously improve the safety and quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in healthcare organizations."[3] In concordance with this statement, healthcare professional oaths mandate that we "do no harm", with patient safety as a primary consideration. The Joint Commission suggests that safe administration of analgesics can be enhanced by developing and implementing policy that addresses three types of orders deemed to be high-risk: range, titration, and PRN (as needed) orders. Although not all hospices pursue JCAHO accreditation, for the safety of their patients, all hospices should develop a policy to address this issue.


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