Issues with patients having family members inject LAI?

[finalpsychyear]

Inherited a patient that has been having family member who is not a medical professional do his LAI for the last 2 years. They are adamant that they will not take orals and will refuse the LAI if they are forced to come into clinic and have staff give the medication due to inconvenience.

Is there any medical liability to allowing this to occur provided they are actually getting it for the prescriber of the LAI?

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[forchinet121]

Inherited a patient that has been having family member who is not a medical professional do his LAI for the last 2 years. They are adamant that they will not take orals and will refuse the LAI if they are forced to come into clinic and have staff give the medication due to inconvenience.

Is there any medical liability to allowing this to occur provided they are actually getting it for the prescriber of the LAI?

What is the alternative? There can’t be liability if there’s no reasonable alternative

 

[Celexa]

We had a few patients in my residency clinic who had this arrangement. I think in each case the family member was medically trained (nurse, etc) but it's not like it's complicated to give an injection. I don't see much of a problem with it, and it's probably way higher liability to cut the patient off from a medication that's working.

Just to throw in an example from another field, the final medication in IVF cycles is an IM medication which people either give to themselves or a family member or friend can. There are instruction videos online and that's that. So it's not that the idea of giving an IM injection by a non professional at home is completely without anaologue in other specialties.

 

[VA Hopeful Dr]

We had a few patients in my residency clinic who had this arrangement. I think in each case the family member was medically trained (nurse, etc) but it's not like it's complicated to give an injection. I don't see much of a problem with it, and it's probably way higher liability to cut the patient off from a medication that's working.

Just to throw in an example from another field, the final medication in IVF cycles is an IM medication which people either give to themselves or a family member or friend can. There are instruction videos online and that's that. So it's not that the idea of giving an IM injection by a non professional at home is completely without anaologue in other specialties.

Testosterone patients do it regularly as well.

 

[annoyedpsychiatrist]

fair question. Lets say an adverse event happens and now they want to make a complaint against you. But wait a minute, you're the one who has been giving him a necessary medication to maintain his quality of life, you have been acting in the patient's best interest, you have advocated for the patient and explained the risk/benefit of untrained people giving the LAI. Youve documented all this well. The family has refused your advice. If you stop giving him the medication, he will likely decompensate and his quality of life will be compromised, and perhaps he gets admitted. Ultimately you cant force the family to do what is right so what would any reasonable psychiatrist do, especially in your setting? They would likely give the medication after documenting risk/benefit ratio. I think most would argue the benefit ratio vastly outweighs the risks.

 

[michaelrack]

Inherited a patient that has been having family member who is not a medical professional do his LAI for the last 2 years. They are adamant that they will not take orals and will refuse the LAI if they are forced to come into clinic and have staff give the medication due to inconvenience.

Is there any medical liability to allowing this to occur provided they are actually getting it for the prescriber of the LAI?

Give them a prescription for the LAI with instructions to have it injected at a clinic (In my area there are "Shot Nurse" clinics that give b12 etc). tell them they can also have it done in your clinic. If they ignore your instructions, that's not your responsibility

 

[comp1]

I've never seen this done. Will a pharmacy just give it to the family? Second the other advice here. You can only weigh the risks and benefits, you can't force anybody to do things (in an outpatient setting).

 

[Merovinge]

Around me, almost every pharmacy gives these medications. They can literally get it done as they pick it up from the pharmacy, way better than having to go in for a seperate appointment. Now if the patient is too paranoid to leave their apartment/house and you have documented why they cannot access an ACT team, I can certainly see the justification for this type of setup. I do think mistakenly injecting an LAI would be fairly dangerous in comparison to say the final shot for IVF but the risks of not having the treatment are much higher as well.

 

[ObsequiousAplomb]

Having someone give their own or have a lay family member give an LAI can vary widely based on some details.

Zyprexa Relprevv? Absolutely not. Trained person in a REMS facility only.

Loading doses of Invega Sustenna? No, come in for the visit or get this done inpatient.
Stable, reasonable (lower end of the dosing spectrum) doses of Sustenna? Sure, adequately trained family seems fine.

Invega Hafyera? Come on. Go to a health facility or pharmacist at least once every 6 months and get the injection. You oughta be getting labs / seeing this person in-person at least every 6-12 months so there's not much of an excuse to let family do this.

Risperdal Consta 25-50 mg? Yeah, coming in every 2 weeks can be annoying. As long as they're occasionally coming in that's fine. Make sure the family is diligent about changing the injection site up. Doses above 50? Sorry, you're coming in for that.

Haldol decanoate 100 mg IM that someone has been taking Q28 days for 10 years? I don't care who gives it as long as the patient gets it.

 

[Candidate2017]

Inherited a patient that has been

I inherited a patient that has been [insert your favorite example of a psychiatrist behaving badly, e.g., prescribed Xanax 2 mg five times daily, having sex with the psychiatrist, allowed to be used as a human pin cushion for his Sustenna wielding family member, etc.].

No. My philosophy is I am not required to continue the poor choices of a prior psychiatrist. This is merely a boundary issue, like the majority of "dilemmas" that arise in psychiatric care.

While chances of anything bad happening may be low, the package insert states the LAI must be given by a HCP. There are also 20,000 psychiatrists (and even psych interns) who can swear they have never seen any psychiatrist practice this way and hence it is not the standard of care.

Maybe your patient will never develop injection site necrosis, an air embolism, or nerve damage. Maybe your patient isn't throwing away their LAI. Maybe the family member isn't a Scientologist who throws away the LAI. Maybe the family member isn't hiding signs of physical abuse like welts and bruises on the patient. Whatever the case, having a nurse give the LAI solves a lot of pesky potential issues (for which your employer/clinic is responsible, and not you).

Practically, you can send them to a pharmacy that does injection, go back to orals, or even discharge the patient.

 

[birchswing]

Madonna has her backup dancers inject her in the glutes with B12 in the interlude between songs, so there is a precedent.

Joking aside, something interesting I discovered recently is that there are only four states that require phlebotomists to be licensed or certified. I know it's not the same as a IM injection, but venipuncture is an invasive procedure. There are all these pop-up phlebotomist one-woman companies (I don't say that to be sneering, I have not come across one that isn't run by a woman) near me that come out to your house to draw blood, which is convenient, but I also find it a little sketchy that literally anyone (since I'm not in one of the four states that requires licensure or certification) can be a phlebotomist. These are not companies with brick-and-mortar buildings. Just someone with a web-site who comes out to your house (presumably with equipment from their house where they store it), draws the blood, and brings it to a lab. And there's no oversight. If you were injured or got infected (which I know is rare), I don't even know if you'd have any standing given that it's not a licensed profession. Also discovered this last year that medical assistants (MAs) are not licensed in any way, and my PCP has his doing more than you would think a nurse would. Even if they do get registered or go to school it's through these predatory for-profit colleges that train you in office work, like MS office, and then load them up with debt and send them off to jobs where they're expected to deal with all the patients the PCP can't for customer service wages.

I can't speak to IM injections in the home—but randos (as the kids say) work drawing blood and do medical care as MAs. Not much better. Who knew—I didn't until this last year. I like to know someone is at least licensed with the state.