Kidney Failure - Dietitian "Playing doctor"

Author

Dietitian "Playing doctor"

desulliv@seidata.com

2006-08-21, 9:24 pm

Everyone,

I've got a dilema and I'm not sure what to do...

My mother is a dialysis patient and received in-center dialysis three
times a week.

Over the last 2-3 weeks, the center's renal dietitian is actually
making adjustments and dosage changes to my mother's medication... many
times conflicting with information that nephrology has told my mother.

I've addressed this issue of "playing doctor" with the RNs and they
seem to follow the dietitian's orders just like she was a doctor. I've
approached the facility administrator with my concerns and she doesn't
see any problem.

Can a registered renal dietitian "legally" adjust and change
medication/dosages on their own???

This whole situation is causing undo and unneeded stress on my
mother.... to the point that she's coming home in tears following every
treatment because she feels that no one is really managing her care.

We live in a small community and there are no centers close enough to
transfer out of this mess.

Has anyone else ever dealt with this? What should I do?

The whole idea of a dietitian prescribing and adjusting medication
dosages seriously concerns me.

Any help, advice or guidance is GREATLY appreciated.

- Viper73

Alan

2006-08-21, 9:24 pm

desulliv@seidata.com wrote:
> Everyone,
>
> I've got a dilema and I'm not sure what to do...
>
> My mother is a dialysis patient and received in-center dialysis three
> times a week.
>
> Over the last 2-3 weeks, the center's renal dietitian is actually
> making adjustments and dosage changes to my mother's medication... many
> times conflicting with information that nephrology has told my mother.
>
> I've addressed this issue of "playing doctor" with the RNs and they
> seem to follow the dietitian's orders just like she was a doctor. I've
> approached the facility administrator with my concerns and she doesn't
> see any problem.
>
> Can a registered renal dietitian "legally" adjust and change
> medication/dosages on their own???
>
> This whole situation is causing undo and unneeded stress on my
> mother.... to the point that she's coming home in tears following every
> treatment because she feels that no one is really managing her care.
>
> We live in a small community and there are no centers close enough to
> transfer out of this mess.
>
> Has anyone else ever dealt with this? What should I do?
>
> The whole idea of a dietitian prescribing and adjusting medication
> dosages seriously concerns me.
>
> Any help, advice or guidance is GREATLY appreciated.
>
> - Viper73
>
Absolutely NOT

Spot

2006-08-22, 2:24 am

I would approach the administration again and tell them if they don't take
action to stop this that you are going to report them to the state medical
board for allowing it and report the dietitian for practicing medicine
without a liscense. That should get their attention.

Celeste

<desulliv@seidata.com> wrote in message
news:1156208961.628682.156010@i42g2000cwa.googlegroups.com...
> Everyone,
>
> I've got a dilema and I'm not sure what to do...
>
> My mother is a dialysis patient and received in-center dialysis three
> times a week.
>
> Over the last 2-3 weeks, the center's renal dietitian is actually
> making adjustments and dosage changes to my mother's medication... many
> times conflicting with information that nephrology has told my mother.
>
> I've addressed this issue of "playing doctor" with the RNs and they
> seem to follow the dietitian's orders just like she was a doctor. I've
> approached the facility administrator with my concerns and she doesn't
> see any problem.
>
> Can a registered renal dietitian "legally" adjust and change
> medication/dosages on their own???
>
> This whole situation is causing undo and unneeded stress on my
> mother.... to the point that she's coming home in tears following every
> treatment because she feels that no one is really managing her care.
>
> We live in a small community and there are no centers close enough to
> transfer out of this mess.
>
> Has anyone else ever dealt with this? What should I do?
>
> The whole idea of a dietitian prescribing and adjusting medication
> dosages seriously concerns me.
>
> Any help, advice or guidance is GREATLY appreciated.
>
> - Viper73
>

Judanne

2006-08-22, 8:26 am

I agree totally with Celeste.
Is it legal where you live for a dietician to change meds?
If not, why are they allowing this illegal practice to continue?
What does the renal specialist / nephrologist who prescribed the medications
in the first place think of this practice. I'd be giving him / her a call
ASAP and letting him /her know that the unit is undermining the treatment
that has been prescribed for your mum.

Judanne

"Spot" <noSPAMme@somewhere.net> wrote in message
news:wYuGg.3310$0J6.2281@trnddc02...
>I would approach the administration again and tell them if they don't take
>action to stop this that you are going to report them to the state medical
>board for allowing it and report the dietitian for practicing medicine
>without a liscense. That should get their attention.
>
> Celeste
>
>
> <desulliv@seidata.com> wrote in message
> news:1156208961.628682.156010@i42g2000cwa.googlegroups.com...
>
>

desulliv@seidata.com

2006-08-22, 8:26 am

Everyone,

I live in Indiana and already have calls into the the ESRD Network to
find out if there's some wierd loopole to allow this. So far I haven't
gotten a response though they assure me that someone will contact me
today.

In the meantime, I've basically demanded that the nephrologist remove
my mother from the center's "protocol" and that written orders be
issued by the nephrology team for any and all medication changes. I
have my doubts if this will actually happen, but that's at least a
start.

I've contacted Davita, the dialysis provider, at their corporate
offices and they just referred me back to the local administrator.
Figures...

Depending on what I find out today after talking with the ESRD Network,
I may be going to the American Diatetic Association and the medical
board. Barring that, I'm not sure what else I can do to make sure this
practice doesn't continue.

- Viper

Judanne wrote:[vbcol=seagreen]
> I agree totally with Celeste.
> Is it legal where you live for a dietician to change meds?
> If not, why are they allowing this illegal practice to continue?
> What does the renal specialist / nephrologist who prescribed the medications
> in the first place think of this practice. I'd be giving him / her a call
> ASAP and letting him /her know that the unit is undermining the treatment
> that has been prescribed for your mum.
>
> Judanne
>
> "Spot" <noSPAMme@somewhere.net> wrote in message
> news:wYuGg.3310$0J6.2281@trnddc02...

Objective_Man

2006-08-22, 8:26 am

Greetings,
This happens at my clinic all the time. One must first consider what
the medications in question really are about. My dietician changes my
meds all the time but the meds being changed are all related to my diet
and the effects nutritionally of my dialysis.

It is very common for the staff in a clinic to make changes and then
the doctor in his 30 second visits just scribbles the "OK" on the order
sheet. This is perhaps why the staff in your situation is viewing the
dietician as a proper authority.

I think the very first issue is to find out what medications are being
changed here. Mine adjusts my Renagel, Phoslo, Sensipar, bicarbonate
and Hectorol as she pleases with good results. Can you speak about
which medications are being adjusted in your situation?

Jim

desulliv@seidata.com wrote:
> Everyone,
> I've got a dilema and I'm not sure what to do...
> My mother is a dialysis patient and received in-center dialysis three
> times a week.
> Over the last 2-3 weeks, the center's renal dietitian is actually
> making adjustments and dosage changes to my mother's medication... many
> times conflicting with information that nephrology has told my mother.
>snip<

nomorepeeing

2006-08-22, 8:26 am

I agree with what everyone is saying here. The renal dietitician that
we deal with in our dialysis ward makes the same suggestions, but the
actual prescription is administered by the attending physician. They
should be working together, not at odds from one another. Definitely
pursue this further.

Ron.

desulliv@seidata.com wrote:
> Everyone,
>
> I've got a dilema and I'm not sure what to do...
>
> My mother is a dialysis patient and received in-center dialysis three
> times a week.
>
> Over the last 2-3 weeks, the center's renal dietitian is actually
> making adjustments and dosage changes to my mother's medication... many
> times conflicting with information that nephrology has told my mother.
>
> I've addressed this issue of "playing doctor" with the RNs and they
> seem to follow the dietitian's orders just like she was a doctor. I've
> approached the facility administrator with my concerns and she doesn't
> see any problem.
>
> Can a registered renal dietitian "legally" adjust and change
> medication/dosages on their own???
>
> This whole situation is causing undo and unneeded stress on my
> mother.... to the point that she's coming home in tears following every
> treatment because she feels that no one is really managing her care.
>
> We live in a small community and there are no centers close enough to
> transfer out of this mess.
>
> Has anyone else ever dealt with this? What should I do?
>
> The whole idea of a dietitian prescribing and adjusting medication
> dosages seriously concerns me.
>
> Any help, advice or guidance is GREATLY appreciated.
>
> - Viper73

Larry Krzewinski

2006-08-22, 4:28 pm

On 22 Aug 2006 04:21:08 -0700, desulliv@seidata.com wrote:

>Everyone,
>
>I live in Indiana and already have calls into the the ESRD Network to
>find out if there's some wierd loopole to allow this. So far I haven't
>gotten a response though they assure me that someone will contact me
>today.
>
>In the meantime, I've basically demanded that the nephrologist remove
>my mother from the center's "protocol" and that written orders be
>issued by the nephrology team for any and all medication changes. I
>have my doubts if this will actually happen, but that's at least a
>start.
>
>I've contacted Davita, the dialysis provider, at their corporate
>offices and they just referred me back to the local administrator.
>Figures...
>
>Depending on what I find out today after talking with the ESRD Network,
>I may be going to the American Diatetic Association and the medical
>board. Barring that, I'm not sure what else I can do to make sure this
>practice doesn't continue.

Have your mother change dialysis units if another is available.

You never did mention what medications were being changed. Is it the
amount of the phosphorus binder such as Tums or Phoslo?

desulliv@seidata.com

2006-08-22, 9:30 pm

Everyone,

To clarify what's happening is that the dietitian is adjusting dosages
for Zemplar, Epogen and Ferlocet.

For example, during a patient care conference with the nephrologist I
was told that he wanted to keep her Zemplar dosage 6.5-7 to see if her
PTH could stabilize.

The next day the dietitian changes it to 5.

When speaking with the other nephrologist, he said that they'll review
the records again following the labs on Monday and adjust it then.

The dietitian changes it down to 2.5 --- three days before the
nephrologists even had an opportunity to review the records.

When questioned on who ordered the change, her response was "I did".

It's like no one's managing her care.... and worse.... they're not
communicating with each other.

-Viper
Larry Krzewinski wrote:
> On 22 Aug 2006 04:21:08 -0700, desulliv@seidata.com wrote:
>
>
> Have your mother change dialysis units if another is available.
>
> You never did mention what medications were being changed. Is it the
> amount of the phosphorus binder such as Tums or Phoslo?

Dave

2006-08-23, 9:31 pm

This is something that is happening more and more often. The way it
works in most units, the doctor writes a medication order for the meds
you are talking about, and then the Dietician "tweeks" the dosages
according to an established set of protocols, with the doctor reviewing
them as he or she is able(we all know this is never enough, if you see
the doc once a month, then you are pretty lucky. My unit has a PA that
is there every week, and she is as knowledgable as most of the
Nephrologists I've ever met. Of course, she has been a PA in Nephrology
for 20 years, and has even taught Nephrology courses at a couple of the
local Medical schools).

Unfortunately, when doctors establish plans as it appears in your case,
some dieticians don't always follow through. Or still more shocking is
that some of the dieticians today really are not very good at making the
adjustments. They have the belief that all patients respond the same
way to changes in medication and take no consideration for a patient's
history with medication changes. They should also be contacting the
doctor to at least tell him/her what changes have been made.

As to your approaching the Network, I agree with this move. At the very
least, it will get the matter documented outside the company.
Unfortunately, the muscle that the Networks once had is gradually being
whittled away. This has been from a combination of factors. First is
that as the for-profit corporations have taken over the industry, they
have made unilateral changes to how things are done in the units. They
have been very brazen, stretching the boundaries of what is considered
acceptable, all in the name of making a profit. Second, The Republican
administration, acting through medicare, has been moving away from the
close monitoring and control of protocols that has been the norm over
the past several decades. This monitoring and control used to be done
by the Networks, but the rules they are enacting now are handcuffing the
Networks to the point where they are almost just a data collection,
education and greivance arbitration organization. The Networks used to
weild enough power that if a unit was stepping out of bounds, they could
be administratively dealt with to force the unit to improve. Currently,
the Administration is pushing for the actual monitoring to be done by
PRO's, Peer Review Organizations. The problem here is the PRO's are
created and run by the Dialysis corporations. It is like the Fox
guarding the henhouse. It just doesn't make sense. But it fits right
in with conservative beliefs that self monitoring rather than government
interference is the correct way to go. While I agree that it would
lessen the financial load on the Government, my belief is that it puts
patients in serious jeopardy. I have been on dialysis or transplant for
over 19 years, and while the technology and knowledge are far better now
than when I started, it has become scary at times at what passes for
adequete care. Not that all units are dangerous, but the remedies for
dealing with truly bad units is now so hamstrung that I don't see how
truly bad situations will ever get taken care of.

To date, the Networks have not been taken completely out of the loop,
and they are fighting to try and keep their role, but I fear they are
fighting a losing battle.

And for those that wish to know, I am a registered independant voter. I
am a fiscal conservative, but a liberal when it comes to programs for
the disadvantaged, i.e. those that for no fault of their own require
help from the rest of us just to survive, such as most dialysis
patients. This means I have some Republican leanings and some
Democratic leanings. It just depends on the specific issue.

As I stated earlier, I have been ESRD for over 19 years. I have served
on the Network Medical Reveiw Board in my region, and helped to create
the Network Patient Advisory Committee here. I have a college education
in Engineering, and am now the proud owner of my own small business, so
I have first hand knowledge from dealing within the Network and as a
business owner dealing with the gov.

Well, enough ranting for now,

Everybody be good

Dave

desulliv@seidata.com wrote in news:1156284324.762208.273810
@h48g2000cwc.googlegroups.com:

> Everyone,
>
> To clarify what's happening is that the dietitian is adjusting dosages
> for Zemplar, Epogen and Ferlocet.
>
> For example, during a patient care conference with the nephrologist I
> was told that he wanted to keep her Zemplar dosage 6.5-7 to see if her
> PTH could stabilize.
>
> The next day the dietitian changes it to 5.
>
> When speaking with the other nephrologist, he said that they'll review
> the records again following the labs on Monday and adjust it then.
>
> The dietitian changes it down to 2.5 --- three days before the
> nephrologists even had an opportunity to review the records.
>
> When questioned on who ordered the change, her response was "I did".
>
>
> It's like no one's managing her care.... and worse.... they're not
> communicating with each other.
>
> -Viper
> Larry Krzewinski wrote:
to[vbcol=seagreen]
haven't[vbcol=seagreen]
remove[vbcol=seagreen]
Network,[vbcol=seagreen]
this[vbcol=seagreen]
>

Judanne

2006-08-24, 4:29 pm

Another disturbing insight into the US medical system. I'm just astounded
that a dietician in the USA can change dosages at all. That practice would
be considered highly illegal in Australia because here only a registered
doctor can prescribe, so for someone unregistered to tamper with another's
medications would be seen as both unorthodox and illegal. Even for another
doctor in the unit to change meds is unacceptable if that patient is not
specifically under that doctor's care.

The registered nurses on the unit here can't even change the strength of the
'juice' used in the machines without at least a verbal say-so from the
nephrologist.

Judanne
Tassie

"Dave" <Someboby@someplace.com> wrote in message
news:Xns9828C9DD463AFSomebobysomeplacecom@66.150.105.230...

Larry Krzewinski

2006-09-02, 2:30 am

On 22 Aug 2006 15:05:24 -0700, desulliv@seidata.com wrote:

>Everyone,
>
>To clarify what's happening is that the dietitian is adjusting dosages
>for Zemplar, Epogen and Ferlocet.
>
>For example, during a patient care conference with the nephrologist I
>was told that he wanted to keep her Zemplar dosage 6.5-7 to see if her
>PTH could stabilize.
>
>The next day the dietitian changes it to 5.
>
>When speaking with the other nephrologist, he said that they'll review
>the records again following the labs on Monday and adjust it then.
>
>The dietitian changes it down to 2.5 --- three days before the
>nephrologists even had an opportunity to review the records.
>
>When questioned on who ordered the change, her response was "I did".
>
>
>It's like no one's managing her care.... and worse.... they're not
>communicating with each other.

You need to have your loved one moved to another dialysis unit if one
is available nearby. I saw a nephrologist twice a week while on
dialysis and he was the only one allowed to make changes to any
medications. I'm pretty darn sure that the law stipulates that only
physicians are allowed to prescribe medications and adjust dosages.

Larry