Joint Statement on Medication Management of Pain in End-of-Life Care (Adopted by the North Carolina Medical Board, North Carolina Board of Nursing, and North Carolina Board of Pharmacy)

Through dialogue with members of the healthcare community and consumers, a number of perceived regulatory barriers to adequate pain management in end-of-life care have been expressed to the Boards of Medicine, Nursing, and Pharmacy. The following statement attempts to address these misperceptions by outlining practice expectations for licensees and other health care professionals authorized to prescribe medications, as well as nurses and pharmacists involved in this aspect of end-of-life care. The statement is based on:

• The legal scope of practice for each of these licensed health professionals;
• Professional collaboration and communication among health professionals providing palliative care; and
• A standard of care that assures on-going pain assessment, a therapeutic plan for pain management interventions; and evidence of adequate symptom management for the dying patient.

It is the position of all three Boards that patients and their families should be assured of competent, comprehensive palliative care at the end of their lives. Healthcare providers, including physicians, physician assistants, advanced practice registered nurses, nurses, and pharmacists, should be knowledgeable regarding effective and compassionate pain relief, and patients and their families should be assured such relief will be provided.

Because of the overwhelming concern of patients about pain relief, the physician or other prescriber needs to give special attention to the effective assessment of pain. It is particularly important that the prescriber frankly but sensitively discuss with the patient and the family their concerns and choices for the end of life. As part of this discussion, the prescriber should make it clear that, in some end of life care situations, there are inherent risks associated with effective pain relief. The Medical and Nursing Boards will assume opioid use in such patients is appropriate if the responsible prescriber is familiar with and abides by acceptable medical guidelines regarding such use, is knowledgeable about effective and compassionate pain relief, and maintains an appropriate medical record that details a pain management plan. Because the Boards are aware of the inherent risks associated with effective pain relief in such situations, they will not interpret their occurrence as subject to discipline by the Boards.

With regard to pharmacy practice, in general North Carolina has no quantity restrictions on dispensing controlled substances—including those in Schedule II. The STOP Act limits initial prescriptions for opioid medications in Schedules II and III to five- and seven-day supplies when prescribed for acute pain or post-operative acute pain, respectively. But those limitations do not apply to treatment of chronic pain or pain being treated as a component of hospice or palliative care.

Federal law allows partial filling of Schedule III and IV prescriptions for up to six months, and, for terminally ill patients, partial filing of Schedule II prescriptions for up to 60 days. This allows the pharmacist to dispense smaller quantities of the prescription to meet the patient’s needs, thereby minimizing patient expenses and unnecessary waste of drugs. The prescriber should note on the prescription that the patient is terminally ill to facilitate these partial fills.

Transmission of prescriptions for terminally ill patients is often a matter of urgency. Federal and state law allow the fax transmittal of all schedules of controlled substances. For Schedule III, IV, and V prescriptions, the fax serves as the original. For a Schedule II prescription, the fax serves as the original if the prescriber notes on the face of the prescription that it is for a patient receiving hospice care or who is a resident of a long-term care facility.

Federal and state law allow electronic transmission of prescriptions for all schedules of controlled substances using an e-prescribing tool that meets DEA security requirements. E-prescribing is often the quickest, most secure way to meet a patient’s urgent needs.

The nurse (RN or LPN) is often the health professional most involved in assessment of pain and in the on-going management of pain, through implementing the prescribed/ordered pain management plan, evaluating the patient’s response to such interventions, and adjusting medication levels based on prescriptions/orders and patient status. Consistent with the licensee’s scope of practice, the RN or LPN is accountable for implementing the pain management plan utilizing his/her knowledge base and documented assessment of the patient’s needs through the use of designated pain evaluation tools.

If, in order to achieve adequate pain management, prescriptions/orders include a medication dose and/or frequency range, the instructions on how the nurse determines the appropriate administration dose or time frame should be included in the order. In the absence of such instructions, the nurse has the authority to adjust medication levels within the dose and frequency ranges stipulated, in accordance with the agency’s established protocols. However, the RN or LPN does not have the authority to change the medical pain management plan. When adequate pain management is not achieved under the currently prescribed/ordered treatment plan, the nurse is responsible for reporting such findings to the prescriber and documenting this communication. Only the licensee or other health professional with authority to prescribe/order may change the medical pain management plan.

Communication and collaboration between members of the healthcare team, and the patient and family are essential in achieving adequate pain management in end-of-life care. Within this interdisciplinary framework for end of life care, effective pain management should include:

• Thorough documentation of all aspects of the patient’s assessment and care;
• A working diagnosis and therapeutic treatment plan including pharmacologic and non-pharmacologic interventions;
• Regular and documented evaluation of response to the interventions and, as appropriate, revisions to the treatment plan;
• Evidence of communication among care providers;
• Education of the patient and family; and
• A clear understanding by the patient, the family and health care team of the treatment goals.

It is important to remind health professionals that licensing boards hold each licensee accountable for providing safe, effective care. Exercising this standard of care requires the application of knowledge, skills, as well as ethical principles focused on optimum patient care while taking all appropriate measures to relieve suffering. The health care team should give primary importance to the expressed desires of the patient tempered by the judgment and legal responsibilities of each licensed health professional as to what is in the patient’s best interest.