In hospice care, is there a guideline for how many Pro Re Nata (PRN) medications need to be changed to transition to or from General Inpatient (GIP) level of care?

Guidelines for PRN Medication Use in Hospice GIP Level of Care

There are no specific numerical guidelines for how many PRN medications are required to transition to or from General Inpatient (GIP) level of care in hospice. Instead, the decision should be based on symptom management needs and the patient's overall clinical condition.

Determining GIP Level of Care Appropriateness

Criteria for GIP Admission:

1. Uncontrolled Symptoms:

   • Patients with symptoms that cannot be adequately managed in other settings
   • Symptoms requiring frequent medication adjustments and intensive nursing assessment

2. Medication Management Factors:

   • It's not the number of PRN medications but their effectiveness in controlling symptoms
   • Patients requiring frequent PRN medication administration (indicating poor symptom control)
   • Need for rapid titration of medications to achieve symptom control

3. Clinical Indicators:

   • Acute pain crisis requiring IV pain medication or frequent dose adjustments
   • Severe respiratory distress requiring around-the-clock management
   • Intractable nausea/vomiting not responding to routine hospice care
   • Severe agitation or terminal restlessness requiring intensive monitoring

Transitioning from GIP Back to Routine Care:

1. Symptom Stabilization:

   • Symptoms are adequately controlled with established medication regimens
   • PRN medication use has decreased in frequency and effectiveness is demonstrated

2. Medication Conversion:

   • Successful conversion from IV to oral medications
   • Established effective dosing schedules for symptom management
   • PRN medications still needed but at predictable intervals

Evidence-Based Approach

The decision for GIP level of care should be based on clinical assessment rather than counting PRN medications. Research shows that:

• Only 22% of patients with comfort measures only (CMO) status receive GIP hospice care 1, suggesting underutilization of this service
• Patients in GIP care have better symptom management and quality of life outcomes 2
• Hospices with capacity to provide GIP care have lower live discharge rates than those without such capacity 2

Best Practices for PRN Medication Management in Hospice

1. Assessment of PRN Effectiveness:

   • Monitor frequency of PRN administration
   • Evaluate symptom relief after PRN medication administration
   • Consider converting frequently used PRN medications to scheduled dosing

2. Medication Appropriateness:

   • Discontinue non-essential medications for actively dying patients 3
   • Focus on medications that directly impact comfort and symptom control

3. Caregiver Considerations:

   • Assess caregiver ability to manage PRN medications at home
   • Caregiver adherence to PRN analgesic regimens is approximately 51% 4, which may impact symptom control

Common Pitfalls to Avoid

1. Focusing on medication count rather than symptom control

   • The decision for GIP should be based on symptom management needs, not the number of medications

2. Delayed transition to GIP when needed

   • Waiting too long to initiate GIP care can result in prolonged suffering
   • GIP care is often provided too close to death, limiting its effectiveness 2

3. Premature discharge from GIP

   • Ensure symptoms are truly stable before transitioning back to routine care
   • Consider a trial period of reduced nursing interventions before discharge

4. Inadequate caregiver education

   • Ensure caregivers understand PRN medication administration before transitioning from GIP

Remember that the primary goal of hospice care is to optimize quality of life through effective symptom management. The level of care should be determined by the patient's needs rather than arbitrary medication counts.