Scenario:What would you do?

NFuser · Jan 14, 2006

Interesting discussion.

As a nurse who receives an ever-growing number of patients in this situation from ER, I see the issues presented here as part of a larger issue that before long will bite our health care system in the proverbial backside. We are accustomed to curing and extending life with cutting-edge technology; but we are woefully inadequate at caring for those whom we cannot cure (IMHO).

Another poster wrote that folks in this situation should not come to the ER; but they do, and for many reasons. In hospitals without palliative/hospice care initiatives in place (and/or staff accustomed to dealing with these issues), quite often the hospitalization becomes an upsetting, painful, complicated ordeal for patients, families and staff. Vital signs, narcotic doses/routes and enemas aside, there are no pat answers, no perfect protocols, no "rules set in stone" that prepare us to care for terminally ill patients, except to explain what we can do and ask how we can make them comfortable. Palliative/hospice care is holistic nearly to an extreme (in many ways, but also) in that it involves family and other caregivers...all have valuable input to be considered. Complex? Yes, but ultimately rewarding.

As a nation, and as a health care system, we are on a major learning curve, folks. In our area (as in most areas of our country, I suspect), hospice and palliative care have begun to have some impact, but there are gaping holes in continuity. My hope is that we get this right, and soon. The number of patients that could served by hospice/palliative care is growing rapidly (at least by what I see in my practice).

Until we do get this right, we trudge on prayerfully; respecting our patients and following their wishes. When I'm in doubt, I ask myself, "will my actions help my patient to live well, and in comfort?"

Food for thought.

dian57 · Jan 14, 2006

First, let me apologize if I repeat something already posted. I have not read all the previous posts.

Palliative Care is a relatively new concept in our country; a country that is accustomed to fixing everything. We tend to white-wash illness and death, banishing our sick family members to the sterility of a hospital. Many are not comfortable with the ultimate defeat--death, albeit a perfectly natural ending awaiting us all.

The first things to consider in a terminal illness situation are the wishes and expectations of the patient. Open communication is needed so they can make their own informed decision on how and where they want to die. The family needs to hear these things. The team (patient/family/healthcare workers) needs to work together toward the same goal--a comfortable and dignified death.

Do they want to continue diagnostic testing, including bloodwork and vitals? Do they want aggressive treatment or just enough analgesia to remain comfortable? Do they want artificial hydration or nutrition? Do they want 02, even though hypoxic narcosis is a much more humane condition for the dying? Do they want to stay home or die in the hospital? Someone must explain these things in plain language so the patient and family can make informed decisions.

In Palliative Care, there is something called The Doctrine of Double Effect that says, in essence, a patient can be given pain meds to control their pain, even though the dose may hasten death. I would venture a guess that many experienced nurses have been in the position of administering that last dose of morphine to a terminally ill patient with respirations at or below 8.

I believe communication is the key in these situations. In a perfect world, people would all spell out their wishes in a Living Will and appoint a Health Care Proxy and NOT leave a fractured family to anguish over doing the right thing or not.

The patient in the original post had no business in the ER, that was an unnecessary indignity that should have been handled by Hospice at home.

Just MY 2 cents.

leslie :-D · Jan 14, 2006

Right you are.
I am a charge LPN at a nursing home, and I see plenty of dying people. I have actually had MDs write actually write orders NOT to take vitals on certain patients. It makes no sense not to take vitals, if for no other reason than covering yourself and being able to show that you were taking care of them. On other patients who are dying and have no orders to stop vital signs, we take vitals on them at regular intervals. Taking vital signs is a basic nursing assessment and a nursing judgement, is it not?

if you choose to do so, then yes, it's a nsg judgement.

the only vital i monitor is their respirations only because there are usually parameters on when to hold the mso4.

but if a pt. is actively dying, what are you going to do about their vitals?

that's why hospice nurses don't take them.

sometimes i'll take an ap because if a pt is tachycardic and if there's anything i can do, i will. but mostly the tachycardia is r/t dehydration which there's nothing one can do about that.

leslie

thatoneguy · Jan 14, 2006

This happened to me this week.
A hospice pt. comes in to the ER. He has end-stage renal cancer and is here for a PCA morphine pump and a Kayexalate enema. (good hopice huh). So the guy is pale as a ghost and hallucinating, I can't get an accurate O2 but it's somewhere around 75%. His BP is 82/40 his family is very rude and demanding. The Dr. comes in and tells me to give him 5 mg of morphine, repeat it until pain is under control, then takes him off the monitor. Another nurse tells him we have to take his vitals if giving morphine. Dr. says--well, new rules.
What would you do? I'll tell you later what I did.

wow alot of replies went way off the deep end here. ok here is my take on it. first would check to see if he was a DNR. if not, have the doctor write the "new rules" as a order. then if you still feel uncomfortable following his orders go to the charge nurse and tell her/him of your concerns and ask to be removed from the care of that patient. or just tell the doc na i dont think that is in the patients best interest. if you want to give the morphine go on, i dont believe its safe to do so and will chart it accordingly. we have to be safe care givers, and we know we must take vitals before giving such a med. if you give it with out takeing the vitals its your fault. sounds to me like the patient should be intubated, dont know his ABG's but O2 sat of 75 and unresponsive to giving O2 not good signs and with that BP. after intubation you can give all the morphine you want with little worries. but still need to take vitals before giving. my thinking is the doc wants to intubate just waiting till his respirations are depressed enough to do so. our jobs as RN's is very straight foreword. if pallitive care is to be done and what exactly it consists of is not our decision to make. instead, if ordered, its our responsiblity to make sure the family and patient have been informed and question about it are answered and of course understand what it means and agrees with it. thats it. to do routine vitals or not is up to them the doc or patient, but doing vitals for PRN meds like in this case is a indepentent nurseing action. its your responsiblity and no one elses.

leslie :-D · Jan 14, 2006

sounds to me like the patient should be intubated, dont know his ABG's but O2 sat of 75 and unresponsive to giving O2 not good signs and with that BP. after intubation you can give all the morphine you want with little worries. but still need to take vitals before giving. my thinking is the doc wants to intubate just waiting till his respirations are depressed enough to do so. our jobs as RN's is very straight foreword. if pallitive care is to be done and what exactly it consists of is not our decision to make. instead, if ordered, its our responsiblity to make sure the family and patient have been informed and question about it are answered and of course understand what it means and agrees with it. thats it. to do routine vitals or not is up to them the doc or patient, but doing vitals for PRN meds like in this case is a indepentent nurseing action. its your responsiblity and no one elses.

this patient is question is already receiving hospice care, therefore you would not intubate....no invasive procedures. there is no reason why he ended up in the er in the first place. all of this could have been easily managed from home. if hospice was waiting for an infusion pump, he still could have been receiving mso4 po, sl, im , sc until the infusion pump arrived. this entire scenario is disturbing to say the least and totally unnecessary.

leslie

celeste7767 · Jan 14, 2006

This happened to me this week.
A hospice pt. comes in to the ER. He has end-stage renal cancer and is here for a PCA morphine pump and a Kayexalate enema. (good hopice huh). So the guy is pale as a ghost and hallucinating, I can't get an accurate O2 but it's somewhere around 75%. His BP is 82/40 his family is very rude and demanding. The Dr. comes in and tells me to give him 5 mg of morphine, repeat it until pain is under control, then takes him off the monitor. Another nurse tells him we have to take his vitals if giving morphine. Dr. says--well, new rules.
What would you do? I'll tell you later what I did.

I was an AFTER HOURS Telephone Triage RN for VITAS, a nationwide hospice. I worked in Houston. Every hospice patient should have an emergency contact number to their hospice; our patients were not allowed to go the ER (and would be discharged from hospice if they did) unless they contacted either their Primary RN on days, or me on nights. If they went to an ER on their own, the ER staff would call us and we would contact the Hospice MD on call who would interact with the ER docs. Hospice patients are cared for under standards that vary considerably in many cases from that which is given in acute care and/or long term care settings.

celeste7767

fergus51 · Jan 14, 2006

Thank God for good hospice nurses... If I am dying and in pain, I want as much morphine or whatever it takes to get my pain under control and you better not be trying to take my blood pressure. Count resps if you want, but I wouldn't want you bothering me with a bp when I am dying anyways.

thatoneguy · Jan 14, 2006

this patient is question is already receiving hospice care, therefore you would not intubate....no invasive procedures. there is no reason why he ended up in the er in the first place. all of this could have been easily managed from home. if hospice was waiting for an infusion pump, he still could have been receiving mso4 po, sl, im , sc until the infusion pump arrived. this entire scenario is disturbing to say the least and totally unnecessary.
leslie

true but i never go by what should have or could have happend, i focus on what is happening. the patient ened up in the ER under your care. thats all i need to know. hospice does this or that but the patient is in the ER. the doc will determine what will be done from this point. my job remains the same. sure he could have been given mso4 at home but thats not what happen. as a ER nurse i believe you should give every patient in the ER the same consideration, wheather they come from hospice or not. to me it dosent matter how they got there or where they came form, maybe they changed their minds about hospice care, who knows but my care will follow the same protocals as always. let the doctors talk to eachother about long term care, i am here for acute care and thats where the patient is now and should be treated as such.

scenario unnecessary, perhaps. but i comes down to the here and now in the ER. should of could of's are for someone else to deal with, in the ER we need to deal with what did's, and deal with that.

leslie :-D · Jan 14, 2006

Thank God for good hospice nurses... If I am dying and in pain, I want as much morphine or whatever it takes to get my pain under control and you better not be trying to take my blood pressure. Count resps if you want, but I wouldn't want you bothering me with a bp when I am dying anyways.

for my first few yrs as a hospice nurse, i always struggled with those pts who had a rr of 8 but were still in alot of pain. i would call up the docs and they were petrified of being held liable if i were to administer more. so i called my state's nsg association and was told by the director, that as long as your INTENT is to relieve suffering, then a nurse will never be held accountable.

i shared this info with any/all docs involved-gave them numbers to call. eventually they dropped their parameters until there were none. so if i had a pt whose rr was 4 but groaned and grimaced w/ea breath, then i would give more (qh, q2h....).

i recall 1 pt who we received to our unit. end stage breast ca w/mets to bones, lungs, brain. the nm told the doc that her pain was well controlled and did not need all of these narcotics he had ordered. so all narcs were dc'd and she was only on apap. when i heard this, i flew to this pt's bedside and her pain was excruciating. i reported the nm to the medical director- she was fired...and the medical director (after conferring w/the pt's pcp) was put on a very reasonable cocktail of various narcs, anxiolytics, scheduled and prn. i had such a hard time getting her pain under control but the next day, she was losing consciousness but thanked me. even as she slept, i could still tell she was in pain. i gave her the last dose of mso4 and she died 1 hr later. to this day, i do not feel i killed her- i relieved her suffering. and i continue to do whatever it takes, to get a pt's pain under control.

leslie

leslie :-D · Jan 14, 2006

true but i never go by what should have or could have happend, i focus on what is happening. the patient ened up in the ER under your care. thats all i need to know. hospice does this or that but the patient is in the ER. the doc will determine what will be done from this point. my job remains the same. sure he could have been given mso4 at home but thats not what happen. as a ER nurse i believe you should give every patient in the ER the same consideration, wheather they come from hospice or not. to me it dosent matter how they got there or where they came form, maybe they changed their minds about hospice care, who knows but my care will follow the same protocals as always. let the doctors talk to eachother about long term care, i am here for acute care and thats where the patient is now and should be treated as such.
scenario unnecessary, perhaps. but i comes down to the here and now in the ER. should of could of's are for someone else to deal with, in the ER we need to deal with what did's, and deal with that.

with all due respect, don't you consider that rather robotic? if you're dealing with the here and now, why even bother obtaining pmh's? i find it very relevant that the er know that this pt was receiving hospice care-it was already clearly communicated that he was there until hospice's infusion pump arrived. so there was no question re: ending hospice care. and that is to be respected. and although somewhat vague, the doctor's orders were most appropriate. at least he had the sense and understanding NOT to treat this man but rather, keep him comfortable.

leslie

fergus51 · Jan 14, 2006

for my first few yrs as a hospice nurse, i always struggled with those pts who had a rr of 8 but were still in alot of pain. i would call up the docs and they were petrified of being held liable if i were to administer more. so i called my state's nsg association and was told by the director, that as long as your INTENT is to relieve suffering, then a nurse will never be held accountable.
i shared this info with any/all docs involved-gave them numbers to call. eventually they dropped their parameters until there were none. so if i had a pt whose rr was 4 but groaned and grimaced w/ea breath, then i would give more (qh, q2h....).
i recall 1 pt who we received to our unit. end stage breast ca w/mets to bones, lungs, brain. the nm told the doc that her pain was well controlled and did not need all of these narcotics he had ordered. so all narcs were dc'd and she was only on apap. when i heard this, i flew to this pt's bedside and her pain was excruciating. i reported the nm to the medical director- she was fired...and the medical director (after conferring w/the pt's pcp) was put on a very reasonable cocktail of various narcs, anxiolytics, scheduled and prn. i had such a hard time getting her pain under control but the next day, she was losing consciousness but thanked me. even as she slept, i could still tell she was in pain. i gave her the last dose of mso4 and she died 1 hr later. to this day, i do not feel i killed her- i relieved her suffering. and i continue to do whatever it takes, to get a pt's pain under control.
leslie

And thank God for that! My aunt is a hospice nurse and has often said that pain control is the most important part of her job. It sickens me to think that anyone would leave a dying patient suffering, especially if the reason they came to the ER was for pain control! I'm not saying we shouldn't treat those patients, we should treat their pain.

thatoneguy · Jan 15, 2006

with all due respect, don't you consider that rather robotic? if you're dealing with the here and now, why even bother obtaining pmh's? i find it very relevant that the er know that this pt was receiving hospice care-it was already clearly communicated that he was there until hospice's infusion pump arrived. so there was no question re: ending hospice care. and that is to be respected. and although somewhat vague, the doctor's orders were most appropriate. at least he had the sense and understanding NOT to treat this man but rather, keep him comfortable.
leslie

well not really. is it not robotic to give whatever to a pt in the ER just because they came from hospice care. i am not saying that the docs orders where wrong but you have to follow the protocal of the area the pt is in. if the doc wants to change those protocals for that pt he must order it correctly. the rule is you must check the resp. and other vitals before giving, there is no unless the pt came from hospice. if the doc wants to change the values we go by for that patient ok, but there is a correct way to do it. if nothing is written than your acting on your own. just because the pt was receiving hospice care dose not mean you automaticaly go by there protocals. you must follow the protocals in your setting until otherwise ordered. why would you tell someone to do something that could put their lic in jeporty. you should never disregaurd the protocals set. yes knowing the pt was receiving hospice care is very relevant, but only to help you understand the doc orders and reasons for the type of care, not to disregaurd your areas protocals.