Hasten end so wife won't doubt DNR decision????

Greetings to all!

I am amazed at, and grateful for, the insight, wisdom, and even courage which can come from a collective effort such as this! I really appreciate your thoughtful and comprehensive replies more than you know.

I was off for 2 days after this incident, and go back tomorrow (Saturday.)
I may check to see if the pt. is still on our census. One thing I need to check is what dose of morphine was actually given to the patient when my preceptor walked in there, as he didn't tell me. I say that because of an odd conversation he had with me a couple of weeks ago.

We had a patient who was breathing over her vent, and he said she needed to slow down, and that it probably meant she was in pain. That was reasonable, and her order was for 2 mg of morphine prn. This didn't help her, and when it didn't, he said that I needed to learn how things really work up there, and proceeded to say - not exactly in these words, but this is what it amounted to - that the nurses up there pretty much use the drugs available in the Diebold as they felt was needed - in other words, titrating to effect
rather than sticking to the dose written on the MAR. He did say this verbatim: "For example, you'll have someone come back for more of a drug out of the Diebold.....ooops, they dropped the last dose!" ...giving me the eye to indicate that the nurse was lying about the reason for overriding the Diebold and that she was actually giving the amount of the drug she felt necessary.....he then proceeded to say, "But on the MAR, they just cross off the dose as written."

When I asked a question, he looked at me and said, "You know, I think you'd better forget what I just said." I said, "But you just said it!" He said, "Well, forget I said it."

The first day that I had the aforementioned COPD patient in my original post, he was extremely agitated in the a.m. He was pulling his vent tubing off his mask for the BIPAP constantly (we had to restrain him, finally), and was moving around in bed enough that he was in danger of falling. We did not have any sedation orders, so I thought I would call the md for some, but he was so agitated that I was wishing I could give him some Ativan immediately, so I went up to my preceptor, and, based on his previous little "unspoken protocol" conversation he told me to forget, asked him, "That guy need some sedation NOW; do we have an unspoken protocol to go ahead and give him some Ativan?"

He proceeded to look at me and act as if the conversation of the other day didn't happen, and acted all self-righteous about it..."We don't HAVE unspoken protocols! That is a controlled substance....." He later reiterated, saying that I could lose my license over that....yet, I was just trying to respond in kind with how he tried to describe to me how things "really work" on the unit.

Another incident happened where we had a terminal pt. - 92 year old stroke pt. w/brain hemorrhage who came in the night before and would soon die - who had initially been put on a vent. It was decided by the family, since the bleed on CT was showing up in fully half her brain, and she would not recover, to take her off the vent and let her go naturally. We started our unit's formalized deescalation protocol; it stated that a morphine drip would be started which would run anywhere from 2-10 mg/hr.

Well, my preceptor said it should be started at 10 mg/hr. We did this. The daughter came out and kept asking us about every little movement her mother made, such as when her mouth moved a little - "Why is she moving her mouth like that?" I didn't mind this, as I knew it was a s/s of emotional distress on the daughter's part, and that she mainly needed reassurance; when she did this, I would go in and assess if anything was really wrong (there was usually no change), and then just give them both a little concerned TLC and a hug, as this was what I felt the daughter needed.

My preceptor later came and told me he turned the morphine drip up to 15 mg/hr so that the the mother would quit the movements which were upsetting the daughter (and there really weren't many, she was out of it), to create the impression to the daughter that everything was ok. Now, the argument could be made that the slight movements she made might indicate some discomfort, and that we were titrating to pain.....but, they seemed to me just to be reflexive, mainly consisting of occasional mouth movements where the ETT tube was touching her mouth (she was on a T-piece at this time.)

I say all this to say that this preceptor has a history of giving drugs as he pleases, and saying that this is how everyone on the unit does it; his backpeddling on the "nurses are walking around on this unit with extra drugs stored in their pockets that they use when they think they need them" was a little strange to me. So, I really don't KNOW how much he gave the pt. because of his history exhibited in both statement and practice! He may never tell me, as he may smell a rat if I come back and ask him how much morphine he gave that guy.

NrsKaren, I appreciate the resources you posted, and have looked them up; this is a great way for us to learn from each other. I am interested in hospice nursing, so this may be in my future.

Siri, I understand your reaction, as it is possible that his motives amounted to what you said, although one may argue that euthanasia may be the correct term (which can be argued to be synonymous with murder anyway.)
I certainly wouldn't want my own spouse to be subject to this without my knowledge.

I think the idea of this preceptor needing some inservice has hit the nail on the head. His ideas and practices have me totally confused on how far actual practice, in the ICU at least, differs from what we were taught in school - esp. pharmacology!! I really had medication administration drilled into me in clinical, and it became an area I was precise and competent in; to get out here and find out that ICU nurses do what they feel is best and carry drugs around in their pocket to use the amounts they feel appropriate despite orders, makes me wonder how safe this place and its patients are (and the whole hospital, for that matter.)

I appreciate the encouragement to question things and even approach ethics committees. I think, after hearing from you all, I will be more vocal in my questionings and objections.

Thanks!

ICU Newbie

"You are in a position right now to be victimized by association."

You really have me thinking about this one. My spouse and I were discussing the meaning of this, and it could be 1) guilt by association with this unit
2) Being in a position to be influenced by nurses who think this way
3) Being ridiculed for being so naive as to think that anyone in the ICU would actually think that the 5 medication rights were something to be adhered to...primarily speaking of right dose here.

I actually have thought about transferring out of this unit.....this may add to my rationale for doing so. It is true that it could become a "he said, she said" thing, as this nurse is very much respected by management.

ICU Newbie