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

Case Scenarios

Let us look at several examples that include PRN, range, and titration dosing of analgesics and other medications used in palliative care. As discussed above, a PRN order is an optional dose of a medication, taken or administered when necessary. MJ is a 42-year-old woman with end-stage cervical cancer. She becomes very anxious when she thinks about the care of her children after she dies. Her hospice nurse has maximized nonpharmacologic interventions, including discussions with the social worker and spiritual counselor. Despite these interventions, her symptoms continue; therefore, the hospice nurse requests an order for an antianxiety medication from the prescriber. In turn, the prescriber orders "lorazepam 0.5 mg PRN." The nurse recognizes that several elements are missing from this order and contacts the prescriber for missing information, resulting in this new order: "lorazepam 0.5 mg PO PRN anxiety-induced breathlessness q3h." To implement this order, the nurse would educate MJ on the administration of this medication, including the use of nonpharmacologic interventions to reduce anxiety and minimize the development of dyspnea, as well as clinical cues that would warrant the administration of the PRN lorazepam dose. The patient should record symptoms, lorazepam use, and adverse effects in her symptom diary, and the nurse will review the diary and advise the prescriber of the patient's response to therapy.

A range order gives the patient or practitioner additional flexibility in treating a symptom, depending on severity. For example, BR is a 58-year-old man with pancreatic cancer, referred to hospice for terminal care. He has been experiencing insomnia, and his prescriber ordered the following on admission to hospice: "Restoril one to two capsules at bedtime as needed." The nurse case manager would perform a careful patient assessment to determine if there are any reversible causes of insomnia, such as pain, psychosocial or spiritual concerns, or other causes that may need treatment. If a sedative-hypnotic agent is warranted, the admissions nurse would contact the prescriber for order clarification, as there are several issues with this order. The order should preferably be in the generic name (temazepam), and clarification of the dose is needed as two capsule strengths are available (15 and 30 mg). By ordering "one to two capsules", this order could be interpreted as anything from 15 mg at bedtime, up to 60 mg, depending on the capsule strength ordered. The indication is also missing. While the only indication for temazepam is the short-term treatment of insomnia, one might assume listing the indication is not necessary. However, temazepam is a benzodiazepine, and some hospice practitioners may inadvertently assume that it may also be used to treat anxiety, which would be inappropriate. Therefore, a more appropriate order for BR would be "temazepam 15 mg PO PRN insomnia; may administer an additional 15 mg in 2 hours if needed." The nurse would educate the patient about the following: (a) nonpharmacologic interventions to enhance sleep quality/quantity; (b) decision making regarding use of temazepam, including clinical circumstances warranting the first dose and the second dose; and (c) documentation of insomnia, use of temazepam, and adverse effects.

Titration orders allow the nurse case manager to treat a symptom with the minimally effective dose of a medication, without having to contact the prescriber with each dose increase. JG is a 74-year-old man with prostate cancer. He was referred to hospice on oxycodone hydrochloride (OxyContin) 20 mg PO q12h, with 5 mg of oxycodone orally for breakthrough pain, and there was an order to "titrate to comfort". As discussed earlier, "titrate to comfort" is not an acceptable endpoint. The nurse contacts the prescriber and gets a new order as follows: "OxyContin 20 mg PO q12h plus 5 mg oxycodone oral solution for breakthrough pain q4 hours. Increase OxyContin by 25% to 100% every 24 hours as needed, up to 60 mg PO q12h; increase oxycodone oral solution for breakthrough pain by 25% to 100%, up to 15 mg q4h PRN breakthrough pain."

When the nurse visited him today, the patient reported that his pain is consistently between a 6 and 8 on a 10-point scale. He is not satisfied with this level of pain control, as it interrupts his sleep and makes him unhappy. The nurse does a complete pain assessment. She considers the possibility of bone pain, since prostate cancer frequently metastasizes to bone. However, the patient is describing diffuse abdominal pain that is consistent with the pain he has been describing all along, and had responded well to OxyContin therapy. Whether the increase in pain is due to disease progression or tolerance to analgesic effect of the opioid, his clinical situation warrants a dosage increase.

JG tells the nurse that he has been using about four doses per day of his breakthrough oxycodone oral solution fairly consistently for the past 3 to 4 days. The nurse calculates his total daily amount of oxycodone: 20 mg PO q12h is 40 mg, plus four doses of the 5 mg breakthrough, and an additional 20 mg, for a total daily amount of 60 mg. According to the rules outlined in the previous section, because his pain rating is above 6, this would call for a 50% to 100% dosage increase, which would be an additional 30 to 60 mg, resulting in a new total daily amount of 90 to 120 mg of oral long-acting oxycodone (OxyContin) administered in divided doses (q12h). JG has also said that he wants to be as alert as possible, so the nurse decides to increase his opioid to OxyContin 40 mg PO q12h, with 10 mg oxycodone oral solution for breakthrough pain. She instructs JG to keep a diary of his pain ratings and his use of the breakthrough medication. She encourages him to use caffeine products to combat sedation as needed and to report excessive sedation or sedation that is not counteracted by caffeine. Twenty-four hours later JG reports a pain level between 2 and 3 of 10, and stated that he used the breakthrough medication only once since starting the new regimen. JG and the nurse decide not to make any further dosage adjustments at this time. Had his pain not been controlled after 24 hours, however, the nurse might still have increased the dosage to 60 mg PO q12h per her judgment based on the original opioid order from the prescriber.

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