Got yelled at by MD today

  1. 0
    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?
    Last edit by agldragonRN on Aug 8, '11
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  3. 23 Comments so far...

  4. 21
    I've always been taught that starvation is not painful....and this person sounds like they died from something besides starvation so that's not an issue. The patient died in a couple of hours- you did what you could to make it comfortable.

    No MD should yell at you. (actually, nobody should yell at you unless you're about to step in front of a bus ).


    You didn't do anything wrong. You relayed family concerns- and you learned something. In the future, you can ask someone with more experience at the facility what they usually do in that situation, if it involves active life sustaining care with an actively dying patient. Sometimes, you will still have to call an MD. Other times you won't.

    Doctors can be wonderful- and they can be a.holes....as with anybody. And sometimes they are nice one day, and lousy the next- just remember, you didn't put a gun to his head and make him go to med school, and it's not your fault he's on call

    You'll learn how it all works- and maybe see if there are any policies in the facility about hospice care/actively dying patients... :heartbeat
  5. 0
    Quote from xtxrn
    i've always been taught that starvation is not painful....and this person sounds like they died from something besides starvation so that's not an issue. the patient died in a couple of hours- you did what you could to make it comfortable.

    no md should yell at you. (actually, nobody should yell at you unless you're about to step in front of a bus ).


    you didn't do anything wrong. you relayed family concerns- and you learned something. in the future, you can ask someone with more experience at the facility what they usually do in that situation, if it involves active life sustaining care with an actively dying patient. sometimes, you will still have to call an md. other times you won't.

    doctors can be wonderful- and they can be a.holes....as with anybody. and sometimes they are nice one day, and lousy the next- just remember, you didn't put a gun to his head and make him go to med school, and it's not your fault he's on call :d

    you'll learn how it all works- and maybe see if there are any policies in the facility about hospice care/actively dying patients... :heartbeat
    thanks! yup i learned something new today. and yes i did ask the supervisor who is also the adon and been working there for 20+ years. she even told me the rate of tube feeding to tell the doctor.
  6. 18
    Quote from agldragonrn
    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?
    tube feeding for an actively dying patient? family worried about blood sugars? bizarre. sounds like the physician did not sufficiently educate the family (that is his job). not sure of exact situation, but seems that this patient would have benefited from a morphine drip and dnrcc. no one deserves to be yelled at.
    tvccrn, Debilpn23, glenlorie, and 15 others like this.
  7. 3
    I don't know if its true, but I've heard that at the end of life people do not feel hungry like we do when we are healthy. It was explained to me in reference to my pets (no offense meant!) in how when they are at the end of their life they "go off their food". I've had lots of pets over the years and always noticed that at the end, in old age, they would suddenly turn very gray in their face quickly and then stop eating to the point of refusing food, and then within a couple of days they would leave our Earth. It seems kind of natural that our bodies would not be feeling the need for food when our body realizes that the calories needed to sustain life are not going to be needed.

    It's late, I'm kind of tired & having random thoughts. Guess I'll go to bed. :zzzzz
  8. 0
    Quote from rnccf2007
    tube feeding for an actively dying patient? family worried about blood sugars? bizarre. sounds like the physician did not sufficiently educate the family (that is his job). not sure of exact situation, but seems that this patient would have benefited from a morphine drip and dnrcc. no one deserves to be yelled at.
    i work snf so no morphine drip here. i got the order for roxanol 5 mg via sl today and gave two doses. patient already had a g-tube that is not being used so family asked if we could use it again for tube feeding. i was not sure whether i should call the on call doctor for this so i asked my supervisor (who is also the adon) who has been working there for 20+ years and she agreed about giving tube feeding and she gave me the rate and told me to call md for an order.
  9. 5
    Quote from agldragonrn
    thanks! yup i learned something new today. and yes i did ask the supervisor who is also the adon and been working there for 20+ years. she even told me the rate of tube feeding to tell the doctor.
    wow... then you were basically hung out to dry. i'm sorry you had to put up with that, when you were just trying to get your patient what you assessed them to need, or the family's concerns.

    do you have an affiliation with a local hospice that takes patients that are in the facility? they can be an incredible resource, and handle a lot of the end of life stuff- and teach staff at the facility about active dying- and about not giving food/fluids (that is a huge can of worms, and very individual). they also have a ton of medication ideas for easing the symptoms of dying- congestion, etc- you got the roxanol for the resp rate- so that was great.... it sounds like this also happened pretty quickly.

    if you don't have a relationship with a hospice, maybe your staff education person can set up an inservice with them
  10. 2
    what is DNH?
    Not_A_Hat_Person and barbyann like this.
  11. 0
    Quote from hunnybaby24
    what is dnh?
    do not hospitalize

    i work snf/ltc.
  12. 4
    You did not deserve to be yelled at, no one does. In the future know that in the actively dying pt their systems including the gastric system is slowing down and stopping. This is one of the reasons that they stop eating. By putting down a feeding tube and starting feeding at this point you would be causing discomfort with the insertion. The tube feed itself could cause discomfort and possible pain, as it more than likely will just stay and expand the stomach and not be digested. As muscles are not working optimally during this time there is also an increased risk of aspiration from the tube feed in the stomach when you have to lay the pt flat in order to wash and change the linen. Part of our comfort care protocol is stopping tube feeding and the removal of feeding tubes.
    With that said a lot of families want things done for their family members that are actively dying which will not help the pt but will help the family members feel better. You did nothing wrong with relaying the concerns and ideas of the family members to the doc. Doctors want it both ways, we are not to give out medical advice (what medical orders are needed for a pt) to family members/pt's unless it is convenient for them.

    just posted and saw that they had a GT.
    Last edit by ukstudent on Aug 8, '11 : Reason: added
    tvccrn, GrnTea, turnforthenurseRN, and 1 other like this.


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