Psychiatric Medication Treatment Plans: Part 1 (Introduction)

Medication tablets and capsulesIn Massachusetts, we have a document which follows a person’s behavior-modifying meds. It’s called a Psychiatric Medication Treatment Plan/Consent. It is typically authored by the DDS provider agency (sometimes I write them) and documents psychiatric medication treatment (its back-story, current treatment regimen, historic response, prior treatment tries/fails/successes, and reference to non-drug treatment modalities in use.

The goal of this plan is to keep a person’s psych meds in line with real need. This document is a communication tool, a teaching tool and a legal tool. As a legal tool, it serves to document the informed consent of the person (or her/his guardian). As a communication tool, it’s intended to convey a person’s need for support across time through a changing array of caregivers, professionals, and providers. Why do we need this?

Objective, not just subjective

Well, imagine Joe is going to his three-month psychiatric medication review. Joe’s regular caregiver couldn’t bring him, so Bill, a relief staff-person, comes in. Bill meets Joe for the first time on the afternoon of the appointment. Joe doesn’t communicate verbally, but does use a few signs, and personalized sounds and facial expressions. Bill probably shouldn’t be there in the first place. The only real service his orientation and training are qualifying him for at this point is driving the car. But we’re also expecting him to advocate for Joe and to support the psychiatrist to make informed decisions! How on earth can he do that?

First, he needs to learn Joe’s communication style, but that’s another discussion. Next (and where we’ll focus): how can Joe’s response to treatment be effectively conveyed to the prescriber? If we want the prescriber to make good decisions (taper or titrate doses, initiate therapy, refer to another practitioner) we need to give good information. If we’re supporting someone in their home 24/7, no one person is going to have the whole story without a trusted system of recorded observation and documentation. The best we could do without data is give our impression of how a person is doing, which would be entirely subjective. To give powerful, potentially dangerous medications ordered on the basis only of shifting, subjective data is unreasonable and unnecessary.

A reliable system that connects the person, the prescriber, the caregivers and the family/guardians is essential. This system needs to focus attention on specific mental-health symptoms once they’ve been identified as troubling, and connect their intensity with the efforts made to relieve them. Only with such a system can a person be protected from over-treatment, under-treatment, or neglect based on a lack of advocacy or a lack of objective data.

Who gets a Psychiatric Medication/Treatment Plan?

DDS requires this for persons under legal guardianship who are taking behavior-modifying medications. These can include (but not be limited to):

  • Antidepressant meds: e.g., Celexa, Zoloft, Prozac…
  • Antianxiety meds: Ativan, Klonopin, Zoloft…
  • Antipsychotic meds: Abilify, Clozaril, Geodon, Risperdal, Seroquel, Zyprexa… (in Massachusetts, a court-appointed monitor is required if persons under guardianship are treated with meds from this category)
  • Mood-stabilizing meds: Lithium, anticonvulsants like Depakote and Lamictal prescribed for mood stabilization…
  • Sleep/insomnia meds: Ambien, Lunesta, melatonin, valerian

To be honest, meds for insomnia wouldn’t be in the same class with the psychiatric meds if I had my way. The support and protections needed to helpfully but not excessively help someone sleep are different and much more narrowly focused. We kind of have to shoehorn the Psychiatric Medication/Treatment Plan to make it work. It is, however, required in Massachusetts to do it this way at the moment.

At my agency, we’ve implemented plans for persons not under guardianship to extend similar protections and supports to people who can or do give their own consent.

 

Next: The plan itself….

(Note: The situation might be very different for a person whose disability allows him/her to effectively self-report symptoms and self-advocate concerns.)

When the end looms close: explaining meds for comfort

Nothing is more emotionally challenging for a caregiver than coping with the demands of caring for a person who is dying from a painful illness. Shifting the focus from obtaining a cure and regaining health to maximizing the quality of each day and reducing suffering is a paradigm shift for which there isn’t much time to prepare. Much and needless suffering can result when caregivers and teams are not ready to respond to a terminally ill person’s changing needs. Some (not all) need pain control.

Ironically, the medical advances and technology which can reduce or eliminate pain during the final days and weeks of life have been readily available for decades, but much misunderstanding still surrounds their use. Some may hesitant to use these medications for fear of creating a dependency; others worry that their use will shorten life/hasten death. It is necessary to refocus on the fact that the goal of comfort care is comfort: this begins with the removal of or absence of suffering.

In this post I simply convey how on one occasion, with one team of caregivers, some simple explanations cleared the way for positive, appropriate and effective pain control for a man who wished to spend his last days in his own home with loved ones. Explaining the rationale for continuing to administer meds for comfort (morphine, Ativan) on a regular schedule without the gentleman prompting us for medication:

“One way to give meds for pain is simply to take the medicine when the pain gets bad. For example, when you feel the pain of a headache and realize it’s not going away, you take a Tylenol. If it doesn’t work, you may take more. Eventually, you stop noticing the pain and go on to other things.

“A better analogy for giving morphine and Ativan for comfort is when you take a Vicodin after having a tooth pulled. You don’t wait until the Novocaine wears off and you feel the excruciating pain before you take the Vicodin. You don’t wait until you feel the pain, because you don’t want to feel the pain. You know you’re going to need the help, so you take the Vicodin before you feel anything. Then, if the order is for every four hours, you take the next one on the dot of four hours later, even if it doesn’t hurt yet. You do this because you know that if you don’t take the Vicodin before the pain comes, you’ll suffer, and then when the pain is really bad, even if you take two Vicodin, it won’t work as well.

“For the person who is dying, he may take morphine and Ativan. It takes away pain, also anxiety, and helps with the “gurgling” feeling, and the very uncomfortable sensation of not being able to get a breath, as congestion builds in his respiratory tract. Waiting until we see evidence of suffering would be a mistake, because if we give him the meds on a regular schedule, he won’t suffer! We don’t have to worry about giving “too much” medication. If we see that he’s very sleepy a lot of the time, we can adjust the frequency of the doses. For example, if morphine and every four hours and Ativan every eight hours is too much, we can try morphine very six hours and Ativan every eight. Our goal is that he not suffer at all.”

There can be barriers to doing this well. When a person has skilled nursing visits, the nurses can (and should) administer these meds for comfort, but they might not always be aware of the need due to not being with the person as much / as often.

Strategies for overcoming this obstacle: caregivers can remind the nurses, when they visit, that the person needs morphine and Ativan to continue to feel comfortable. Request additional visits from his nurses as needed. Obtain formulations of comfort meds which the caregivers can themselves administer (sublingual, etc.) if caregivers are unable to give medications by subcutaneous injection (as is often the case when unlicensed caregivers are certified to give oral medications).

The most important thing: keep the focus on the person who is ill. This person may want and need to spend the remaining time expressing love, receiving love, celebrating the accomplishments accrued and enjoying the relationships cultivated over her/his lifetime. Reducing suffering makes room for enjoying life. Achieve this with, among other things, mindful attention to administering medications for comfort.

Why I Love Being a Healthcare Coordinator

If you’re a fireman, or a doctor, or a nurse, people get a pretty clear picture in their heads of what you do as soon as you tell them your job title. As it happens, though, that first impression is usually wrong. The real workplace is far more diverse and specialized than the one on TV.

I have the happy privilege of coordinating healthcare for persons with intellectual disabilities. Some of them live in group homes, others with a caregiver, and still others independently. I’m a nurse, and my training and disposition is to care for my patients. In this role I get to do that and much more.

I’m with my patients for the long term; many months and years in most cases. I get to visit my patients in their homes, meet with their families, and talk with their doctors and therapists. I help make sure their medications make sense and are being taken appropriately. There is often a difference between what people want and what they think their doctor wants. I help a person choose a plan of action. I help make sure their caregivers understand how to meet their needs and why their efforts are beneficial. I get to support staff teams who have been supporting the same individuals for years and are sometimes as close as families. I help ensure that complex needs continue to be met and important needs aren’t overlooked. When trouble strikes, I support and advocate with hospital personnel to help them meet the unique needs of my patients. At the end of a person’s lifespan, I support their families to understand the choices with which they are confronted. I assess, I consult, I confer, I teach, and I care. This is a really neat job.

It’s not all rainbows and unicorns. There have been moments of frustration and grief, fatigue and regret. From this pain have come some of the most important lessons I’ve learned.

When I started in this field in 2003, I had some experience as a nurse, and I had years of experience as a direct-support caregiver in a group home for adults with disabilities. I did not have a clue as to the role of a nurse in a group home, or why healthcare coordination is needed. For bringing me up the steep learning curve, I am forever grateful to my teacher, mentor, and friend Cheryl Deignan. I also enjoy sharing what I’ve learned, in the hopes of improving quality care and quality lives for everyone who relies on healthcare coordinators like me.