[s and t]

I think its important to remember that patients in hospice or palliative care situations can and do develop acute episodes of pain or resp. distress etc. that are not controlled by the medications that they are on. One poster pointed out DNR does not mean "no treatment", but we need to continue to provide comfort care for these patients.

Pts at end-of-life stages can and do receive what many people would consider to be 'massive' doses of narcotics - the big concern is that it will cause resp. depression. Well, most of these people have been on these doses for a period of time already and do not experience depression. My bigger worry is that they would be denied further medication when they needed it.

Breakthrough pain must be treated in order to keep these patients comfortable. other meds as Ativan are also helpful to anxiety and SOB. Frequent VS are not necessary - in fact, when you are disturbing your patients frequently to do VS, this is not 'comfort care'. If your pt. is dying, keeping them comfortable is a priority of care. I have heard nurses say they do not want to give pts more medication in case they become addicted. What a load of bunk. Addiction should be the least worry!

Often times worried/anxious relatives seem to feel better when they know their loved one is comfortable...for end of life patients we need to help them live their dying, whether it occurs in an ER, on an acute care unit, in LTC, or at home.

Sorry to be so long winded, but it is upsetting to see people in the end stages and not be able to die the peaceful, comfortable death they want.

[Bipley]

Originally Posted by Happy-ER-RN

Wow! I am really really surprised how many of you would have just given the 5 mg and left it.

I don't think anyone here was suggesting you push a mg per second. You start off with the usual lower dose and it doesn't take long to see if they are responding or not.

Also, we don't have access to his records. Pt's like your guy are usually on pretty healthy doses of narcotics anyway and 5mgs wouldn't do to him (typically) what it would to you or me. If his current home management isn't working, he needed something.

My Dad died in pain. Makes me sick to think about it. I flew home to say my good byes and the man was seriously hurting. First thing I did was take a look at all his meds. Poor guy, he was taking meds he had no clue what they were for and certainly didn't need. Also, pain was not being managed. Got an order for Duragesic but those take time to kick in. Requested a morphine drip and hospice said it wasn't necessary. He didn't want to go to the hospital for pain management so what was I do to? He was vomiting every 10-15 minutes so he couldn't keep oral meds down. I was seriously trying to figure out how to crush an Oxy and stuff it up his nose.

Finally talked him into going to ER for pain management. He ended up dying in his front doorway.

Point being, sometimes it is necessary for a hospice patient to go to ER for pain management. If my Dad had gone to ER I would not have cared if the Morphine killed him. I honestly wouldn't, he would finally be out of pain. My sis on the other hand... would have taken that as an opportunity to sue the hospital and if that would have happened, who would the hospital point fingers at? The nurse.

Thus, I stand behind my original statement. Get the patient out of pain AND CYA.

[HLR_RN]

Originally Posted by Happy-ER-RN

Wow! I am really really surprised how many of you would have just given the 5 mg and left it. Here's what I did.
I paced around and thought about it for a little while and came to this conclusion--If I go give this man 5 mg of morphine it is going to kill him. I decided that I am not comfortable killing someone. Many of you may be thinking "but he is dying anyway" ummmm... don't care, I am not killing someone. So, I put the BP cuff back on a took a pressure--it was up to 96/50. I gave him 2 mg of morphine. After about 10 minutes he was so out of it there is no way I could have assessed his pain. I took another BP and it was 70/30, and he was obviously hypoxic w/ shallow resp. Giving him the rest of the morphine definately would have killed him. Would a hospice nurse have just given more morphine? I just didn't feel right about it, I couldn't bring myself to do it. I got him up to the floor where they could give him the PCA pump. I just don't quite understand the logic behind all of this. Of course I don't want anyone to suffer before they die, but are we allowed to give someone pain meds that we know are going to kill them?

I went into this job to save lives, not take them away. Pain control is subjective, life is not. I have to hand it to hospice nurses, you guys are amazing.

I had a similar situation a few years ago when I was a new grad. I had a pt in his 40's severely brain damaged after a MVC and had been living in a NH with a g-tube for years. He was on our Med unit with asp. pneumonia and had been on O2 and triple IV abx for 3 weeks. He was a DNR, no intub., no ICU. So even though he was getting worse everyday there really wasn't anything else we could do.

The night I looked after him it was my first time with him. I walked into his room after report his family was at his bedside and he was very restless and in obvious resp.distress. His BP and Sat's were low (don't remember how low) and he was febrile. I upped his O2, gave tylenol supp, and called the MD to inform him that the pt was still spiking temps even after 3 weeks of abx. Doc ordered a 4th IV abx, like that was going to help . When I went in to give the abx I asked the family if anyone had talked to them about palliative care, of course no one had. I explained to them what it was and they decided that they wanted to do. I called the doc back and had him come up to the floor and talk to the family. It was decided to d/c all meds, iv's, g-tube feeds, everything. I gave the pt morphine at that time and he settled down. But a couple of hours later he was in distress again. I checked his sat, 69%. I thought that if I gave him more morphine I would kill him and didn't know what to do, so I asked the family. I told them that his breathing was really bad and that the morphine would probably make him more comfortable but could also supress his breathing. They wanted him to have morphine and I gave it. I left his room shaking, I thought I had killed him. In nursing school we'd talked bout situations like this in ethics and I always thought that I was ok with giving pain meds if the pt needed them, but to actually do it scared me.

He settled down after the morphine. And I continued to give him morphine every couple of hours the rest of the night even though he appeared comfortable (I wanted to prevent him from getting into distress again). I never once checked his vitals, we weren't going to do anything about them anyway. Toward the end of my shift I went in to say good-bye to his family, his mother, brother and sister were asleep but the SIL was awake. I told her I was off for a few days and that I would be thinking of them, I knew he wouldn't still be there when I came back. About 10 min later, the pt's mother came the the nursing station and found me. She hugged me and thanked me for what I had done for her son. Then about they called the nursing station to say he wasn't breathing. (everybody dies at change of shift )

Some people probably think I killed this pt. I actually count this as one of the proudest moments of my nursing career. I made helped make him comfortable which is what he and his family wanted and needed. I no longer think that I killed him. It was the illness that killed him, I just made him comfortble when he died. (sorry for the long post)

[kersti]

Originally Posted by HLR_RN

Some people probably think I killed this pt. I actually count this as one of the proudest moments of my nursing career. I made helped make him comfortable which is what he and his family wanted and needed. I no longer think that I killed him. It was the illness that killed him, I just made him comfortble when he died. (sorry for the long post)

I have never been in this kind of a situation myself, but I like to think that being a strong patient advocate, that is how I would respond. Ther's no rule of thumb though for something like this, each situation is unique and needs to be dealt with on an individual basis.

[jimthorp]

Originally Posted by MLOS

This infuriates me ... because IMHO, sending someone to the ER is NOT hospice care, unless the patient has spelled out that he/she does not wish to die at home (many people choose to do just that, others don't want their families left w/that memory within the house). In that instance, the pt. should be admitted, ideally directly from home without going through the ER.

Hospice care can be so wonderful - it makes me angry when some type of home care has the "hospice" label slapped on it, but what the provider and/or the pt.'s PCP are overseeing is NOT hospice/palliative care. (note: I am NOT knocking home care)

I'll be waiting to read what the outcome was, but this is a perfect example of inappropriate use of the ER.

Just my

This was my initial thought. However, there is not enough information for me to form a solid opinion. I've been a nurse for only a short while. To me hospice means DNR, no return to hospital, and comfort measures only. Are there different interpretations of what hospice is/does?

Where was this patient's hospice nurse/case manager? Was she/he the one who had him sent to the ER or was it a panicing family? I have to wonder why he was not already on pain management meds and why his hospice nurse could not communicate with the doctor if these meds needed to be changed for good pain management instead of putting him through the trauma of a ride to the hospital. The enema, well, that doesn't sound like hospice care to me.

[RnRatchet]

This was my initial thought. However, there is not enough information for me to form a solid opinion. I've been a nurse for only a short while. To me hospice means DNR, no return to hospital, and comfort measures only. Are there different interpretations of what hospice is/does?

I'm a hospice RN, This is a common opinion of many nurses who aren't hospice nurses. We have several patients that aren't DNR's. You cannot force a family to choose DNR just because they are on hospice. It's still the pt / family right to choose. Although often times after we've been able to work with a family and pt and educate them on the dying process they change their minds.
Without knowing the pt and family story it's hard to say why this pt was sent to ER.
He could've had morphine SL or done a SQ infusion instead of going to hospital for PCA. Maybe this family just needed some more education and support from the hospice and they would've kept him at home and worked with the hospice for comfort care.
We often times have inpt hospice orders for a morphine gtt and "may titrate for comfort" so the staff can increase by 1 mg increments every hour or so untill the pt is comfortable. Like another previous poster said.. many times these pts were on narcs at home that dwarf what we see at "normal" doses.

[carolinapooh]

Originally Posted by kersti

I have never been in this kind of a situation myself, but I like to think that being a strong patient advocate, that is how I would respond. Ther's no rule of thumb though for something like this, each situation is unique and needs to be dealt with on an individual basis.

I wish they had done that for my father. He ended up in the hospital with staph pneumonia that no one had known he’d had, but the pulmonologist said he’d had it for weeks. (Daddy had severe peripheral neuropathy – of unknown origin, as he had neither diabetes nor liver disease – and was on 100 mcg fentanyl patches every other day and Tylenol 3 as needed. He probably either didn’t notice he was in pain or chalked it up to neuropathy.) He’d been vented for a week, in the hospital for two, and there had been no change, so we decided to let him go. They said he didn’t know what was happening but I don’t believe that. They took him off the vent, put an oxygen mask on him, and kept him medicated with Ativan and occasional morphine. We watched him struggle so hard to breathe for about five hours that every breath made him arch up off the bed and the hospital bed would shake. Finally it was over. I knew what morphine does and wished I could have asked for more of it for him. Maybe they DIDN'T give it to him for fear of being sued for killing him. Maybe they couldn't give it to him - I don't knoe enough to know. I wish they could have asked, because believe me, there was nothing DEPRESSED about the ventilations I saw. It looked torturous.

I certainly don’t believe in KILLING people, but after seeing Daddy struggle, I have no problems with high doses of morphine.

God bless the nurses who have carried out these orders and made these decisions. I agree - THE ILLNESS IS WHAT KILLS in this situation, NOT YOU.

[Happy-ER-RN]

Thanks to all of you for your replies. If I were dying I would want to be given morphone non-stop until I died. Maybe if the family hadn't been so hostile I would have felt more comfortable with the idea of giving this man more morphine, but honestly I was concerned about legal (and moral) ramifications of my actions directly causing the death of this man. Perhaps there needs to be clearer policies in our hopitals or nursing practice regarding these issues. Hospice is a wonderful institution when it comes to these issues however. This case was just a bad situation--the man had been using a fentanyl patch but it wasn't controlling his pain so the hospice Dr. ordered a morphine PCA pump--the hospice nurse said she was unable to get the PCA pump until the next morning so she sent the pt. to the ER--she called and told us that he needed a PCA pump and a Kayexalate enema. Well, we don't do PCA pumps in the ER so he ended up being admitted to the hospital. The man was near his death and was not being allowed to stay at home as he had wished due to a technicality. I just think there had to have been a way to keep him at home and still take care of his pain--one of the primary goals of hospice care is pain control right? So why was he sent to the ER for pain control of all things, this should be something the hospice should have worked out, that's why I have an attitude about this situation.

I think people should be allowed to choose how they want to die, for example, if I had a traumatic brain injury and little chance of regaining my previous function, I would want someone to assist me in passing along peacefully. It is so terrible that people have to suffer because of a few sue happy people that have ruined it for the rest of us.

[caroladybelle]

Several problems with the scenario.

Is the patient a DNR? And if so, is he a full active treatment or a comfort measures only? Just because a patient is on hospice does not mean they are DNR (it is illegal in several states to require hospice patients to be DNR, silly and irrational but true). And just because the patient is a DNR does not mean that they are comfort care only.

DNR does not mean do not treat...in and of itself.

Problem two, patients on Hospice/DNR - comfort measures only should not have to come into the hospital for a PCA or a Kayelexalate enema. Both of these are easily set up at home or in an office. Putting such a patient in the local ER is an inappropriate use of the ER and unduly stressful to the patient. It also (as noted in this case) may expose the patient to excessive treatment or regulations on the pain med that are not appropriate for a patient on comfort measures only.

Problem three, why is a hallucinating incoherent patient being on PATIENT CONTROLLED ANALGESIA? A drip, or the patch, etc. would be more appropriate.

Problem four, why would they put this patient through the discomfort of an enema, if he were comfort measures only? Renal failure is part of dying, the electrolytes will be out of whack. Unless it is painful, there is little reason to correct it. For that matter, why are they even drawing labs on a patient if they are merely on comfort measures.

There is a rule from "The House of G-d", that goes, "Don't take a temperature unless you want to treat a fever". Why take vital signs if you are not going correct any problem that they show?

The ER is a place for correcting acute resolvable disorders and have many rules that apply to this. The patient is dying, presumable on comfort measures, does not have a resolvable disorder (other than ending in death)and many of the standard rules do not apply.

I would not take followup vital signs if the patient is comfort measures only/DNR. Because they do not matter. You ask the patient if he is in pain, and if so, you give the appropriate and ordered med to relieve it. If the patient continues to have pain and clearly indicates this, you give meds as ordered or contact the MD as appropriate. If you are uncomfortable, you refer the situation to the Charge Nurse, and/or MD. He is dying of a disease and you are treating the only thing that can be treated, the discomfort.

But quite honestly, this should not have occurred in the ER because the aforementioned reasons.

[Marylou1102]

Reading these posts I have two comments to make. 1) When Happy-ER-RN gave only two mg. of the Morphine, did you have a doctors order to do it that way? If not you could be sued for not following doctors orders. It is not our place to change the orders of the physicians, no matter how terrible you think they might be. If you feel uncomfortable with an order, you can talk to the physician about it or you can go to your supervisor and let him/her know that you do not feel comfortable giving it. You can refuse to do something you don't feel comfortable doing, I have.
2.) The other comment I want to make concerns something another poster said. She mentioned that a patient that has been on pain medication for a long time grows used to it and requires periodic increases to maintain effectiveness. I once had an A&O CA patient who was receiving 262mg MS/hr. My pharmacist told me he had one receiving over 300mg/hr.