February 2018

What would you do?

The following scenario demonstrates your accountabilities when administering a substance that was obtained in another country, or is not approved in Canada. 

Bill has Amyotrophic Lateral Sclerosis (also known as ALS or Lou Gehrig’s disease). Bill lives in a small town and receives care from his local community care clinic. His primary care provider is Nancy, an NP.

Bill also receives non-nursing care from his wife, Susan, and his daughter, Nikki. Nikki is an RN, and helps out her family when she can by grocery shopping and running other errands for her family. Nikki also works at the local community clinic.

Bill’s condition is deteriorating. He has recently started using a wheelchair. As well, he is beginning to require more help at mealtimes. His treatment plan to date has not been effective, which is frustrating everyone. Bill’s family has begun to explore other treatment options. 

A potential treatment
Through the ALS community, Susan has heard about a drug called edaravone. It is not available in Canada and is not approved by Health Canada. However, it is for sale in the U.S, Japan and South Korea. Susan is hopeful that this treatment might help Bill.

Nikki wonders if it is legal for a member of her family to buy the drug and bring it into Canada. Together, Nikki and her mom do some research and learn that bringing the drug into the country is permitted under the Food and Drugs Act. By law, drugs not listed on Health Canada’s Prescription Drug List or the Controlled Drugs and Substances Act can be imported into Canada for personal use.

After a family discussion, Bill, Susan and Nikki decide to try and obtain edaravone. Bill receives a prescription for edaravone from a physician in the U.S and the family has the drug imported to Canada.

When it arrives, Susan tells Nikki that she will need her help giving the drug to Bill, since the drug needs to be administered intravenously.

An ethical issue
Nikki explains to her mother that setting up an I.V. requires a trip to the local clinic, since they don’t have the equipment at home. Nikki also knows that, according to the Therapeutic Nurse-Client Relationship, Revised 2006, practice standard, she cannot provide nursing care to friends or family members unless there is no other care provider available. Nikki explains to her mom that a colleague at the clinic could administer the edaravone instead. Nikki calls the clinic and sets up an appointment for her father.

When they arrive at the clinic, Nikki asks her colleagues Beth, (also an RN) and Nancy, an NP, to administer the edaravone to her father. But Beth and Nancy are unsure if they should.

Beth’s dilemma
Beth knows that since administering a substance by injection is a controlled act, she requires an order. She is also unsure of her accountabilities when administering a drug that Health Canada has not approved. 

How should Beth proceed?
Beth consults the Medication practice standard and notes that the order, should Nancy decide to give it, must be clear, complete and appropriate. She knows that if the order is not all of these things, she must not perform the medication practice and should follow up with Nancy.

Beth also reads the Decisions About Procedures and Authority practice standard, and notes that she must have the competence to perform the procedure and be able to manage potential outcomes.

Nancy’s dilemma
Nancy is also unsure how to proceed. She knows she needs to first determine if it’s an appropriate plan of care. She is also unsure if she should give an order to administer a substance that Health Canada has not approved. 

How should Nancy proceed?
Together, Beth and Nancy research the drug to determine if they have the knowledge, skill and judgment to administer it and to manage potential outcomes. They collect evidence by consulting relevant drug databases, scholarly articles on the drug, drug formularies and their clinic’s drug policy.

Nancy and Beth also consult the relevant practice standards, including the decision tree about medication administration in the Medication practice standard; Professional Standards, Revised 2002, the Decisions About Procedures and Authority practice standard, and Authorizing Mechanisms.

Beth and Nancy also check the Ask Practice section of the College’s website and read the FAQs about administration. They learn that federal law does not prohibit administering a drug that is brought legally into Canada for personal use. They also determine that RNs and RPNs can administer edaravone if there is an order in place from an NP or physician.

Making a decision
Finally, Nancy speaks with the client, Bill, and determines that the drug aligns with the client’s wishes and plan of care. Using the steps in the Consent guideline, Nancy obtains consent for the administration. Nancy then gives the order for Beth to administer.

After reviewing best practice evidence and with the order in place, Beth feels confident that she has the knowledge, skill and judgment to administer the drug.

Ask us a question

You can find answers to frequently asked questions on our Ask Practice page at www.cno.org/ask. The questions come from nurses and the answers are written by the College’s Practice Support Team. Ask Practice is updated on a regular basis, so come back often to see what new questions have been added to the list.

Do you have a practice-related question? Contact the Practice Support Team at practicesupport@cnomail.org.

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