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

Disclosures

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

In This Article

Policy and Procedure

Regardless of whether a hospice program chooses to pursue JCAHO accreditation or not, for safety reasons it is advisable to have an established policy on how to interpret medication range, titration, and PRN orders. An example of a policy is shown in the Appendix. It is important to recognize that this is only one example of addressing these types of medication orders. The bottom line is that an organization should develop its own policy, written or unwritten, to handle medication orders such as these and consistently implement this policy.

Per the policy shown in the Appendix, a range order refers to an option for dosing given the clinical situation at a given point in time. This decision regarding choosing between options may be made by the patient (or family/caregiver) or by the practitioner. A range order gives the patient or practitioner the flexibility to select the appropriate dose according to symptom severity. Patients and families often find this to be a difficult decision; therefore, the hospice nurse can help establish guidelines, such as suggesting the lower dose for a pain rating of a specific level and the higher dose for more severe pain. An example might be, "take 5 mg oxycodone oral solution for unacceptable pain that is rated as 5 or less, or take 10 mg oxycodone oral solution for unacceptable pain that is rated 6 or higher (on a 0-10 scale)." Range orders should not exceed a doubling of the minimum dose. It is not necessary to offer a full doubling of dose, however, as the range option to patients/families. For example, it may be more appropriate to instruct patients/families to take morphine by mouth (PO) 80-120 mg as needed for breakthrough pain, as opposed to 80-160 mg.

This same thought process applies to PRN orders, such as "hydromorphone 8 mg PO PRN for breakthrough pain." The nurse should work with the patient/family/caregiver to determine what clinical scenario would warrant a dose of the breakthrough medication (such as an unacceptable pain rating of 4 or higher). An example would be "take 10 mg oxycodone oral solution half hour before dressing change" for consistently painful wound care. Verbal/written instructions should be provided when possible.

Most prescribers are very comfortable with hospice nurses titrating analgesic regimens to achieve the therapeutic goal. However, for clarity and safety purposes, it is unacceptable for a titration range order to have open-ended instructions to "titrate to comfort". Such an order is open to wide variations in interpretation and can increase the risk of adverse outcomes. It is more appropriate for the prescriber to provide a timeframe and/or clinical parameters to guide dosage titration (eg, may increase by 25%-100% every 24 hours for pain). Titration ranges should be wide enough to provide appropriate latitude for dose titration, but narrow enough to minimize risk to the patient. Reassessment should be used to guide titration.

A guideline frequently used in hospice care for opioid titration is described below.

  • Assess pain and patient condition, including the side effect profile of existing analgesic therapy. On the basis of the assessment, determine if the patient needs opioid therapy/an increase in opioid dose, or if the addition of a different class of analgesic, such as a nonsteroidal anti-inflammatory agent (for bone pain) or an adjuvant analgesic, such as tricyclic antidepressants or anticonvulsant (for neuropathic pain), is needed.

  • If continued opioid therapy is appropriate, but dosage insufficient, calculate the total amount of medication taken in the previous 24 hours, including doses of breakthrough opioid. This assumes the same opioid is used as the long-acting and short-acting analgesic. If this is not the case, use equianalgesic dosing.

  • If the patient rates the pain as unacceptable, and it is 5 or less for most pain ratings during the day (on a 0-10 scale), increase total daily opioid amount by 25% to 50%. If the pain is rated as 6 or greater for most pain ratings during the day, increase total daily opioid amount by 50% to 100%.

  • Consider available dosage formulations when selecting the dose and dosing interval.

  • If using long-acting opioid dosage formulations, calculate an amount of rapid-acting opioid used for breakthrough pain. Generally, this is 10% to 15% of the total daily amount of the long-acting opioid in divided intervals.

  • The policy shown in the Appendix outlines guidelines for prescribing range, titration, and PRN orders. For example, all medication orders must contain an indication for administration, such as pain, fever, nausea, anxiety, or confusion. Providing an indication addresses the fact that many medications have more than one potential indication and the importance of utilizing the medication for the indication(s) the prescriber envisioned. For example, acetaminophen may be used to treat pain or fever. Haloperidol may be used to treat nausea, confusion, or both.

As discussed in the examples above, a minimum and maximum dosage was included in the order for the practioner, thus allowing titration capability. When the patient or family/caregiver is making the decision on the dose to administer, providing them with a narrower range of options is preferred. When an experienced hospice nurse is accepting a range order for titration purposes, more latitude is appropriate, with directions for titration timeframe and/or clinical parameters, and maximum dosage.

Orders with a range for frequency are meaningless and should be discouraged. Obviously, if a medication order states that a drug can be administered every 2 to 4 hours, it is always permissible to administer the drug every 2 hours, and the range ceases to have meaning. It is recommended that the policy states that the prescribed minimal dosing interval be utilized. Patients without organ impairment (such as liver or kidney dysfunction) should have a relatively predictable response to drug therapy. Therefore, selection of a single dosing frequency should be based on the pharmacokinetics of the drug and the delivery system, as well as reflect the clinical situation.

The prescriber should be contacted if range, titration, or PRN orders are unclear or information is missing; the patient develops unexpected or severe adverse effects; the patient does not respond to the prescribed dosage; or a dosage higher than that originally ordered is required. Inclusion of these recommendations in the policy is recommended.

Documentation remains an important part of providing patient care. For home-based patients, the nurse should document the plan as described to the patient/family/caregiver for taking range-dosed or PRN medications. The patient or family/caregiver should be instructed on how to maintain a pain and symptom diary, including severity rating (before and after), medication administration (dose and time), and development of any adverse effects. Facility-based patients and their families should also be educated about range doses and PRN medications, but in this case the nurse will likely be documenting symptom severity ratings, adverse effects, and medication waste (if appropriate).

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