The undated standing order on night shift
Leilani is an internationally qualified RN six months into practice at a 42-bed aged residential care facility 90 minutes from the nearest hospital. She is the only RN on the 2300–0700 shift, supported by two healthcare assistants. At 0215, Mr W, 86, who has advanced dementia and an advance care plan agreed with his whānau stating 'comfort care only - do not transfer to hospital', has become agitated and frightened, is febrile at 38.6°C, respiratory rate 30, SpO2 88% on room air, with noisy chest secretions. An HCA hands Leilani a folder containing a standing order for 'respiratory distress at end of life'. It is signed by a GP but undated, and names a subcutaneous medicine Leilani has never administered. Mr W's daughter, his enduring power of attorney, then phones and insists he be sent to hospital immediately.
1. Outline what Leilani should do in the next 30 minutes, and justify the order in which she does it.
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The reasoning frame: three obligations are pulling in different directions - relieving distress, acting only with lawful authority, and following the agreed plan of care. Distress is the clinical priority; authority is the professional constraint. Both must be met, and neither excuses abandoning the resident.
1. Attend to comfort first (does not depend on anyone else). Stay with Mr W or ensure the HCA stays; sit him upright, loosen clothing, clear secretions, offer supplemental oxygen if available and authorised, reduce noise and stimulation, use a calm voice and gentle touch. Hypoxia and fear are being treated by nursing care, not deferred pending paperwork.
2. Establish the goal of care. Locate and read the advance care plan - is it signed, current, and does it record Mr W's own wishes while competent (Right 7(5)) or the outcome of whānau hui? This determines whether the aim is comfort or transfer.
3. Test the standing order against the legal requirements. A standing order must be in writing, current, signed and dated by an authorised prescriber, and must specify the medicine, dose, route, indication and the group of people authorised to administer it. An undated order cannot be shown to be current, so it fails that test. Separately, Leilani has never given a subcutaneous medicine, so she is not competent in that route. She must not administer, and she must not substitute another medicine on her own initiative.
4. Phone the after-hours GP service. Use a structured report (identify, situation, background, assessment, request) and ask for urgent review plus an order she can lawfully and competently carry out.
5. Escalate and document - notify the nurse/ facility manager, and record times, observations, advice received and actions taken.
2. The daughter insists on transfer to hospital. How should Leilani respond, and what should she do if the disagreement continues?
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Acknowledge the person before the paperwork. The daughter is frightened and grieving in advance; she is not being obstructive. Start with that, then be clear and specific about what is happening and why.
Explain, don't defend. Describe the observations in plain language, the agreed plan of care, what comfort measures are in place, and what transfer would actually involve for an 86-year-old with advanced dementia at 0200 - ambulance, waiting, an unfamiliar environment, likely death in an acute setting rather than home. Check her understanding back.
Be accurate about her role. An enduring power of attorney for personal care and welfare acts when the person lacks capacity, but cannot override a valid and applicable advance directive made when the person was competent. Leilani should not adjudicate that legal question herself; she should state what the documented plan says and who can resolve the disagreement.
Give her access. Offer to have the after-hours GP phone her directly, and give her the facility manager's number and information about her right to complain (Right 10). This de-escalates more reliably than argument.
If disagreement persists: escalate to the nurse manager and the prescriber, record the conversation and the plan in the notes, and continue comfort care in the meantime. Never allow a family conflict to leave the resident unattended. The task is to hold the plan and the relationship simultaneously, not to win.
3. What should Leilani do about the standing order itself, and what does it tell her about the organisation?
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Do not fix it quietly. Photocopying a signed order, adding a date, or asking a colleague to 'just give it' would convert a documentation defect into an unauthorised administration and would make Leilani personally accountable for it.
Actions:
- Report the defective order to the prescriber who signed it, the facility manager and the clinical governance lead the same night or at the earliest safe opportunity.
- Complete an incident report, framed as a systems issue rather than a person's failing.
- Request an audit of all standing orders held at the facility for currency, signature, date, named medicines, and the competency of staff authorised to use them.
- Check her own competence: if end-of-life subcutaneous medicines are within the expected scope of her role, that is a learning and supervision need to raise with her manager, not something to discover at 0215.
The wider reading: a single undated order in a folder is rarely a single error. It points to absent version control, no scheduled review, no verification at the point of use, and no process for assuring that the only RN on night shift is competent in the interventions her residents may need. That is a quality and risk matter for the organisation, and Leilani's obligation is to name it clearly in writing rather than absorb it as her own shortfall.