Got yelled at by MD today

Nurses General Nursing

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my patient started going down hill yesterday. labored breathing, unresponsive to verbal and tactile stimuli, etc.... patient on nrb mask. she has g-tube and used to be on continuous feeding but patient did well on swallowing test and the diet was advanced to chopped diet and the tube feeding was dc'd 2 months ago. patient was dnr/dni/dnh. i came to my shift today and counted rr 40/min.

i called md and requested roxanol order because patient is actively dying. family came to unit and remained with patient. patient stopped eating since yesterday and son asked me about giving tube feeding via g-tube. son was concerned about blood sugar since patient has dm. i told him i will ask the md.

so i called the md and asked about giving tube feeding. he started screaming at me on the phone and said who gave the family an idea about tube feeding and said there was no point of giving tube feeding and that patient is dying already and that he already ordered roxanol for comfort. he asked me if i told the patient's family the risk of giving tube feeding at this stage of the dying process. he said patient would be at risk for aspiration now. i told him i didn't explain the risk to the patient. i raised my voice because i got tired of him screaming at me and told him "you do not have to give me the order for the tube feeding if you don't want to. i am just relaying the family's concern to you." i also told him i told the supervisor (who is also the adon, working ot today) about tube feeding and supervisor agreed about giving tube feeding and told me to just elevate hob during feeding. md said he would only give the order after i call the family and explain to them the risk of starting the tube feeding now and if they agreed, write t.o. as "poa request".

i called family and they agreed not to start the tube feeding. so i did not write order for the tube feeding. so i gave two doses of roxanol during my shift. i went to her room at 10:30pm and just stayed with her until she passed at 11pm.

i do not have much experience with hospice or the dying process and feels like a dummy that i did not know the risk of starting/giving tube feeding at this stage of the dying process. i thought i could just follow the protocol about checking residual every few hours and elevate hob 45 degrees. that is why i consulted with my supervisor and she agreed about giving tube feeding.

wouldn't these patients be in pain or discomfort due to starvation? did i deserve to be yelled at?

Specializes in Wound Care, LTC, Sub-Acute, Vents.
first of all no one deserves to be abused( being yelled at) in the workplace, second i have worked on snf/ltc/ltac and all had morphine and other comfort drips.was hospice involved with this resident? we often used sub-q pumps dont be discouraged all mds are not created equal some are better than others

we don't have any comfort drips or sub-q pumps in my ltc facility. patient was her normal self 2 days ago and started going down hill yesterday. i asked the md also for a hospice eval order, which would have been done tomorrow monday.

i am fine with some md being jerks. i wrote up one when i was a new lpn for screaming his lungs out on the phone which i put in speaker phone so everyone in the unit heard him.

all i know is i did everything i could for the patient and the family. patient was still verbally responsive yesterday and she told her son i was a "good guy" and "good nurse". i almost cried so i left the room.

Specializes in Hospice / Psych / RNAC.

Things happen very quickly sometimes. I commend you for getting the order for comfort. In most cases feedings are stopped to help the actively dying patient. It is actually better in most cases when they are very near the time to go to stop all fluids. It takes a lot of experience to be able to make the call of whether to continue or stop. The MD was out of line but I can understand his frustration.

Take a lesson away from all this and research a bit on end of life care and fluids. You sound like a fabulous nurse.

That is one of the hardest things about hospice to teach... Sometimes dying patients won't eat for quite some time, and it is very difficult for families, especially, to understand that. I can sympathize, but as staff it's good to reassure families that it is part of the dying process and if the pt was hungry and able to eat, they would.

Specializes in Emergency/Cath Lab.

The first time I heard a nurse get yelled at, she yelled right back and put him in his place. It was amazing. He has been nice ever since to us. Now I am not suggesting that but I thought it was pretty funny.

Tone of voice can carry a mix message, you just needed to get louder with him as well. Everything happens for a reason. At least you now have different options if you ever come across a similar situation. Oh by the way love the .....

"I am fine with some MD being jerks. I wrote up one when I was a new LPN for screaming his lungs out on the phone which I put in speaker phone so everyone in the unit heard him."

That's classic!

Now is a great time for you to edu a bit about the dying process. There is good info out there, and now you've got some questions you want answered in your head.

The family is reacting normally. They know about DM and of course would wonder if the s/s have something to do with DM and not death. About the eating thing, I have seen patients (obese) that live and are sometimes intermittently alert after over a month of not eating more than maybe a bite every few days if that. Eating is sometimes a comfort measure, but the patient needs to still be able to eat PO and be able to convey that it is comforting to them, and it does require an order and explanation of the risk. Not sure if that is too well explained, but when eating and "comfort measure" are used together that is more of what the discussion is in hospice. It's not that you are going to cease intake for all patients on hospice. Its assessing and reassessing disease process and ability and risk for traumatic results of eating.

As others have said, making the call to active dying can be tough. Calling the MD is what you have to do no matter what mood, remember if you don't, you go down that road of avoidance and soon you are practicing beyond your scope without realizing it. MDs are funny little people at times. More often than not, they have a brain freeze when a patient is no longer on active intervention mode for them. These MDs sort of put the patient on the shelf and get irritated to be bothered even for CC orders. This PMO when I was a case manager. I've been told, "I don't want to be getting calls from a hospice nurse" --excuse you!! Then you better get ready to write a whole slew of contingency orders for me right now. That can be hard too as some just don't want to be writing open orders for Morphine all the time (understandable). But they then must be immediately available because I WILL page their behinds. I remember trying to make the family think the whole interaction for hospice was a smooth one, when it certainly is not for ya sometimes as a case manager.

Specializes in Oncology.

There is a really great course that I took in nursing school that deals exclusively with care of the dying patient. It's called the ELNEC (End of Life Nursing Education Consortium) Training Program. It was offered through my actual nursing program as an elective, and I will tell you that I've never cried nor learned so much in a course. I was surprised by so many of the things I learned, and the withdrawal of food and fluids at the end of life was one of the biggest shockers. I consider it an invaluable experience, and it made me realize my passion for pediatric palliative care that never would have surfaced otherwise. As students we do not get near enough education on end of life care in our typical program. There were a total of 6 students in my class, and it provided for lots of fantastic, sometimes teary discussion. I really wish it was available in such a small class to everyone. I can't praise the class enough and it's a part of my resume that I'm proud to list and tell future employers about.

Here is a description of the course: http://www.ncbi.nlm.nih.gov/pubmed/17579303

Here are links to information/course offerings: http://www.aacn.nche.edu/ELNEC/

You sound like a great patient advocate, and thank you so much for listening to the patients and relaying their message to the doctor. It's so important for them to be involved in the process and to feel like they made the best choices they could for the patient. That MD was out of line completely. Good luck in the future, and I hope that this information will be helpful.

Specializes in Wound Care, LTC, Sub-Acute, Vents.

thank you everyone! all good info! and yes i will have to research more about end of life care so that i will be more knowledgeable in the future. :)

What was your supervisor/ADON's reaction to this?

wouldn't these patients be in pain or discomfort due to starvation? did i deserve to be yelled at?

your patient went only one day without food, correct? starvation was no issue here.

and no, you did not deserve to be yelled at.

think about times you have been really sick (a bad case of influenza perhaps). you had zero appetite, remember? you were not uncomfortable or in pain from not eating-you had no desire to eat. this is similar to what happens with the dying patient. if eating would make them feel more comfortable, they would eat. that simple.

you sound very conscientious and that's great that you are going to do more research about end of life issues. some day you will be the one who is sought out by a new nurse for advice!

Specializes in Telemetry, Oncology, Progressive Care.

I love to talk with hospice and palliative care nurses. I always learn wonderful things from them. There are many things we do as nurses that actually interrupts the dying process. It was explained anything you do that is not necessary actually is painful for them and interrupts the process of actively dying.

Sorry you were yelled at. I've been yelled at by a couple of doctors and it's no fun. The last time I was yelled at (well not really yelling but it was clear he was upset) he apologized to me. He is one of the nicest docs and everyone told me that was so out of character for him. He did tell me he was having a very bad day so I don't hold it against him.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

If I had a dime for everytime a MD yelled at me I'd be richer than Warren Buffett! :D

End of life is a difficult subject for every one and even harder to be the person the famlies look to to be reassured it's ok to let go. You have been given so excellent resources to help you and as nurses we learn everyday. YOu were to the best of your ability and knowledge advocating for your patient and that's something to be proud of..........:hug:

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