Doctors quizzed over aged care prescribing: Royal Commission

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Pharmacists must be enabled to protect patients from poor outcomes associated with their medicines, say experts

Doctor prescribing is under the microscope as part of the Royal Commission into Aged Care Quality and Safety, with hearings in Sydney held this week.

In one case, two doctors were questioned over the decision to prescribe and increase the dose of risperidone to Terance Reeves, who was in respite care at an aged care facility.

Questions were also raised over the level of care provided to Mr Reeves, who has dementia, and had been admitted to the aged care facility in western Sydney on the 1 May 2018.

After just a few weeks in the facility, previously mobile Mr Reeves was no longer able to walk unassisted, according to his family.

He had also gone from toileting himself to soiling himself and being unable to communicate or stay awake.

On admission, a note had been made by staff that Mr Reeves’ family administered him with 0.5 milligram half tablet of risperidone to be taken three times a day “when he is perhaps really restless”.

However his daughter told the Commission that this was not the case.

“If they’re saying that we informed them that that’s something that we would do at home, it’s 100 per cent incorrect,” said Michelle McCulla.

“To recommend that as a treatment in a home, absolutely would never have happened.”

During Mr Reeves’ stay at the facility, a prescription order was made on 7 May for him to receive a dose of a half tablet of 0.5 milligrams risperidone, as needed, up to three times a day, due to his “unsettled” behaviour.

The doctor who had made the first order admitted he thought consent had been given, based on the note that had been made on admission.

“These sorts of medications are really last resort medications, and you don’t go flying into it straightaway. Half a tablet, which is 0.25 milligrams … is to be given at the last resort,” he said.

“I think in the context of where we are with this drowsiness and propensity to fall is very important, but there are other – there’s quite a big list of side effects.”

On 15 May a prescription order was signed by another doctor for a regular daily dose of a full tablet, 0.5 milligrams risperidone, to be given at night.

This was in addition to PRN prescription for 0.25 milligrams risperidone to be taken up to three times a day.

Ms McCulla told the Commission that the family had not consented to the medication order.

“I didn’t know as a fact that he was being given risperidone. I suspected that he had been given something as … he had his head drooped, he was drooling, he could no longer focus on us. It wasn’t normal. To me, it was medicated,” she said.

“So that’s when, on the 15th [May], we went, my sister was with me, and we asked to see his medical charts and we said that we don’t want them to prescribe or give him risperidone anymore at all.”

The next day Ms McCulla visited her father and found him restrained in the chair.

“He was asleep or he had his head in his chest, eyes closed, drooling. I tried to wake him and I shook his legs. He was shivering. He only had a singlet on. It was quite cold that day and it was all wet with saliva at the front. He had no shoes on. He was in the lap belt.”

She said from that day, every other day she visited she found him sitting in a lap belt, head hanging in his chest, drooling – except for one day when he was completely unconscious in a bed.

On 17 June Ms McCulla visited her father and found him in laying down and looking “very unwell”.

He was badly soiled and unable to wake up, with a piece of meat stuck in his throat.

“A lot of nurses walked past and would comment. They would say to us ‘What’s happened to this man?’ Me and my sister were in tears in the central dining room this day saying, “You tell us. He is no longer the man that he came in,” she said.

“I said you’ve given him something, this is not a man who is asleep. He has been given something, and they said ‘No, no, look at his charts’,” Ms McCulla told the Commission.

“I was convinced that it was risperidone, and they said, ‘No, look, we haven’t given him anything since 15 May when you told us not to.’ I couldn’t see it on the chart.”

Sadly, cases like Mr Reeves are not rare. — Dr Juanita Westbury

But Mr Reeves had been administered risperidone as prescribed by the second doctor on 15 May.

Mr Reeves theoretically could have received as much as 0.75 milligrams of risperidone during the daytime with the initial TDS PRN medication order, in addition to the nightly 0.5 milligrams.

The doctor admitted that it had been “illogical” for him to prescribe further risperidone, who had been mobile when admitted but after 14 days in the facility taking risperidone was reportedly a falls risk, according to nurses.

The doctor said he had prescribed the medicine because, according to nursing staff, a quarter tablet of risperidone was not effective in modifying Mr Reeves’ behaviour and he persisted to have sleep disturbance.

The doctor had also charted for a belt restraint.

“Isn’t that illogical; if risperidone was a falls risk and if somebody who was mobile only two weeks before is now by 15 May said to be at risk of falls isn’t it illogical to prescribe him more risperidone?” asked counsel assisting Peter Gray.

The doctor also admitted he had not obtained informed consent from an authorised representative of Mr Reeves to prescribe the additional risperidone, saying he had made assumptions that the man had previously been on the medication.

On 28 May the initial prescribing doctor made the decision to cease risperidone altogether after Mr Reeves suffered from a fall one week earlier. He was discharged on 7 July.

Pharmacy experts have weighed in on the case.

“Sadly, cases like Mr Reeves are not rare,” Dr Juanita Westbury, pharmacist researcher into psychotropic use in residents of aged care at the University of Tasmania, told AJP.

“The thought of a room full of physically restrained residents as described is repugnant. I can best talk to the blatant chemical restraint shown. Two issues are particularly worrying. No consent was sought from relatives before risperidone was prescribed. More concerning were the registered nurse and general practitioner both stressing that antipsychotics should be only used as a last resort – without describing any other therapeutic strategies they had tried.

“New regulations to start in July 2019 do not require informed consent from residents or legal proxy if chemical restraint is used. This goes against basic human rights. This law hopefully will be challenged at the royal commission next week,” she said.

PSA chief executive Shane Jackson agreed with Dr Westbury that the scenario happens all too often.

“Unfortunately this is not an isolated occurrence with the prescribing of medicines in aged care,” he said.

Dr Jackson said pharmacists need to be involved in all areas, including aged care facilities, that involve medicines to keep patients safe.

“Whether that be in aged care, hospitals, general practice or in community pharmacies, pharmacists must be enabled to be able to protect patients from poor outcomes associated with their medicines,” Dr Jackson told AJP.

“The sooner decision makers wise up to that fact, the better. Break down the barriers to pharmacists being able to support patients with their medicines, and a lot of this starts with funding mechanisms.

“Improve the funding mechanisms to give pharmacists more time with patients to be able to help them understand and best use their medicines, and to make sure the medicines are individually appropriately for them.”

Dr Westbury agrees that pharmacists have a role to play and require more funding to do so.

“What can pharmacists do? Stop Residential Medication Management Review (RMMR) capping. Do meaningful Quality Use of Medicines Services such as provide staff training on the drawbacks of using these medications – not just attend a meeting once every three months,” she said.

“Be allowed to utilise their skills and get provider numbers to practice as independent practitioners like most other health practitioners.

“RMMRs are presently limited to once every two years. Pharmacist funding for aged care services should not be taken from the funding historically intended for community pharmacy owners.”

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  1. I’m unsure of what is meant from ““New regulations to start in July 2019 do not require informed consent from residents or legal proxy if chemical restraint is used. This goes against basic human rights. This law hopefully will be challenged at the royal commission next week,” she said.”

    New legislation proposed clearly states that use of chemical restraint requires a consumer representative to be informed or as soon as practicable.

    RMMR should be removed altogether. It is unnecessary in the aged care environment. Same funding should be provided to the pharmacist for clinical services akin to what happens on the ward. Chart checks, collaboration with nurses, rounding with doctors. Increased pharmacist presence. Recommendations can be made straight into the progress notes.

    • Debbie Rigby

      To say RMMRs are “unnecessary in the aged care environment” is absurd. RMMRs have been effective in improving quality use of medicines since 1997. There is a wealth of published studies to support the benefits.
      I agree that funding should be expanded for a model of aged care pharmacists embedded in aged care facilities providing individual medication reviews in collaboration with GPs, geriatricians and nursing staff, as well as system—wide services such as DUEs, clinical audits, medication error audits and staff education (currently funded as QUM services).
      Aged care pharmacists already exist and a number of accredited pharmacists providing RMMRs and QUM services have been battling the current inadequate funding through CPAs to provide a similar level of care. Community pharmacists must take greater responsibility at the point of dispensing for residents in aged care facilities.

      • What is the rationale for the extra step of writing a report? If you can make a compelling case then I may reconsider.

        I’m not saying we get rid of medication reviews, but we get rid of medication reviews in the current format ie. through a report. Therefore the funding of RMMR’s as such can be utilized in other areas, such as running a proper clinical pharmacy service.

        • Debbie Rigby

          I think we actually agree with the big picture and ideal model. However I support the medical model of how health professionals communicate with each other when not physically working together or doing rounds as in the acute care sector i.e. a letter communicating what you have contributed to patient care and additional recommendations/referrals etc. This is then stored in the patient’s/resident’s medical record and acted upon as appropriate. Even with adequate funding for a pharmacist embedded in an aged care facility, it will not always be full-time nor coinciding with when the GP, geriatrician or allied health provider visits. Hence we need a form of communication and documentation.

          Not all recommendations as a result of a RMMR are aimed at the
          prescriber, some can be on administration and therefore annotated on the
          medication chart. Not all RACFs have integrated resident notes – some will have separate notes section for the GP and a separate section for the nursing staff. When doing RMMRs I also write in the GP section.

          Pharmacist’s role in aged care needs to be in real time not retrospective, as RMMRs often are. We should be contributing at the time of prescribing and deprescribing, in a collaborative manner.

          • 13/05/2019

            I agree Debbie, huge steps can be made for the better.

            I believe the hospital model can be brought through to aged care. The only difference being, they will not be at the facility everyday. Which is probably OK, as they are residents and not technically patients. A pharmacist may need to look after a few facilities to make it full-time. The contracted pharmacist would be their go to for any clinical query.

            I still believe the need to write a letter etc. is not required. Those are done, because they are seen independently in the clinic. Visiting geriatricians and GP’s all make their notes in the resident files.

            I absolutely agree that clinical checks, reviews etc can be made straight onto the facility documents / charts and not through an unnecessary RMMR report.

            The RMMR report needs to go.

          • Debbie Rigby

            Even though RMMRs have been conducted for more than 20 years now, the quality, impact and outcomes are variable. I still see long reports to GPs with theoretical and not a patient-centers focus. Before we reach the stage of integrated notes, there needs to education and reflection on how to document in a residents notes. Doctors are taught to use SOAP – subjective, objective, assessment, plan. Also need to take responsibility and have the courage to make a recommendation rather than give options, or not even give a solution to the problem.

          • 14/05/2019

            100% agree. This is basic clinical pharmacy. Reports are unnecessary. So much time and energy wasted. Educate and change the system.

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