Hospice-Appropriate Universal Precautions for Opioid Safety

Catherine Covington-East, MA, RN, BSN, CHPN


Journal of Hospice and Palliative Nursing. 2017;19(3):256-260. 

In This Article


Theoretical Framework

The midrange nursing theory of Duffy's Quality-Caring Model[19] forms the basis of the hospice agency's professional practice model. Duffy's quality-caring nursing theory holds that research should come out of the caring factors and caring relationships that are the center of nursing practice. From the caring relationships of nurses with their patients, families, and other team members, mutually identified problems can help identify research questions and data. Duffy's theory posits that recipients of caring may feel free to take risks and participate in evidence-based decision making. The outcome will be enhanced caring relationships.[19] This project identifies the enhanced safety for patients, families, and the community as part of the caring relationships for which nurses are responsible. Hospice nurses sometimes find that patients and families may fear hospice as a guise for providing narcotics with the goal of "easing them out." Other patients and families may have a history of problems with drugs or fear introducing them into their homes. Hospice clinicians acknowledge that opioid medications have serious risks and present a plan for managing those risks. Hospice nurses assist patients and their families who may have fears of opioid use that conflict with comfort goals. This project seeks to enhance the caring relationships among the hospice team, the patient, and the family by ensuring that a mutually respectful, well-informed agreement is in place. This reassures the patient and family that the hospice team will work with them for safety, so that patient suffering can be addressed confidently with needed medications. The relationship of the nurse with the hospice patient and family as partners for safety is fundamental to the process component of the Quality-Caring Model. Possible outcomes would include enhanced confidence among patients, families, and the hospice team to safely manage opioids with attention to broader community concerns and enhanced focus on patient and family quality-of-life goals.

Preimplementation and postimplementation surveys comparing nurses' attitudes toward universal precautions was planned as part of this project. The methodology and all supporting documents were submitted to the hospital institutional review board. The board granted expedited review and waived informed consents and Health Insurance Portability and Accountability Act authorization. Completion of the surveys was voluntary, and the small sample precluded significant results.


Strengths of hospice caring relationships among patients, families, and the hospice team were identified as frequent nursing visits, patient and family as a unit of care, comprehensive medication management as a key responsibility of hospice nursing, and frequent and close interdisciplinary team review of the patient's plan of care. Based on these strengths, universal precautions appropriate to hospice patients were designed, comprised of an informed consent and medication management document, an updated document on medication disposal,[20] routine pill counts, and enhanced documentation of pain management goals and progress toward those goals.

The centerpiece of hospice-focused universal precautions is the informed consent and safe management agreement, shown in the Figure. This document lays out the expected benefits and possible side effects and risks of using opioid medications. It outlines the guidelines for safe management and notifies the patient and family that should problems that cannot be resolved arise the patient may no longer be prescribed opioid medications by the agency or may be discharged from hospice services. It instructs patients and their caregivers that the hospice team is responsible for ordering refills of all medications and that opioid medications will be counted at nursing visits. The goal of this document is to provide a teaching tool for ongoing emphasis on safe medication management that includes the patient/caregiver as partners for safety.


Pain medication informed consent and safe management agreementVhospice.

This document was reviewed and approved by the agency leadership, including the medical director. It was then submitted to corporate departments, including legal and the pain best practices committee for approval and further revisions aimed at reducing the reading level.

All home patients and designated family members or caregivers are asked to review and sign this agreement on admission, thus placing medication safety in the context of the family and patient partnering with the hospice team. Nurses are instructed to present this at admission as an informed consent, laying out the expected benefits, possible side effects, risks of opioid therapy, and the agency's plan for using opioid therapy safely. The patient's copy is included in the patient/caregiver information admission packet, which contains other educational materials used frequently by the hospice nurses and medical social workers throughout the trajectory of the patient's illness.

Updated policies on medication storage and disposal were produced and made part of the admission materials. These include offering a locking bag for medication storage if patients/caregivers felt this would be helpful for safety, to be provided by the agency.

Assessment of opioid abuse risk was not made part of hospice-oriented universal precautions. Although some tools are validated,[2] their original intent as part of universal precautions was to triage patients needing more complex support than may be provided in a primary care practice.[5] In the context of hospice patients, however, these tools were judged to be intrusive and potentially detrimental to trusting relationships between the hospice team and the patients and unnecessary in a context of frequent clinician visits. Furthermore, the risk of opioid misuse in a home hospice setting seems as likely to involve the family or caregivers as the patient, and assessing risk of extended family and friends using standardized tools is not desirable. However, hospice nurses recognize their responsibility to be aware of problems occurring in their patient's homes and to report them to the interdisciplinary team for support in managing them.

Likewise, neither the algorithms for interventions based on the assessed risk of misuse nor urine screens were made part of hospice universal precautions. Analysis of the algorithms did not show significant differences in the interventions assigned to patients according to risk. Instead, it was decided that use of the informed consent agreement and the frequent (minimum weekly) pill counts would be more effective in discovering problems. Nurses were instructed to report problems to the biweekly interdisciplinary team, where implementation of additional interventions could be discussed.

These elements comprising hospice-focused universal precautions were presented in a PowerPoint (Microsoft, Redmond, Washington) to the agency nurses. The reasons for the project, strategies for introducing and discussing the documents with patients and families, their use as teaching tools, emphasis on the context of hospice team responsibility for medication safety and management in partnership with the patients and families, and strategies for dealing with potential problems with opioid safety were discussed.

Nurses were instructed to count amounts of opioids in their patients' homes, at least weekly. The nurses requested pill-counting trays, which were subsequently provided by the agency. The patients were also to be instructed to keep a log of as-needed medication use, which was to be compared with the amounts of medication as counted at nursing visits. The nurses were instructed to notify the interdisciplinary team of discrepancies. Possible interventions for resolving problems were also discussed, for example, reinforcement of education to patients and families, providing premeasured doses of medication, increase in frequency of pill counts, and reduction in amount of opioid medication ordered at a time.

The nurses were also refreshed on the need to document quality-of-life goals as part of expected pain management benefits. For example, a patient might rate pain at the same level as before an opioid was started but might be better able to participate in family life, be repositioned without moaning, or has improved sleep or appetite. On the other hand, if patients did not show benefit from using opioids, the nurses were instructed to discuss the possible need to adjust the dose, try a different analgesic, or discontinue the use of the opioid. Nurses were instructed to refer back to the informed consent agreement for expected results to help guide these discussions with their patients.

New documentation tools for the electronic medical record were also introduced. These included "smart text" for documenting where scheduled drugs are stored, opioid pill counts, and the date the informed consent agreement was signed. Electronic documentation support for pain assessment also included prompts for documenting quality-of-life goals and patient response to therapy.

The PowerPoint presentation was sent via e-mail to all nursing staff after the meeting, for use as reference and to instruct those nurses who did not attend the meeting. A second in-service was held at the next meeting of admission nurses, because they would be the main ones to review and obtain signatures on the informed consent agreement.