Scenario:What would you do?

leslie :-D · Jan 15, 2006

that's a given, to follow your unit's protocols. but if someone ends up on your unit erroneously and/or inappropriately, it's up to the nurse to question said protocols to the md, and let the md write orders customized to pt's condition and code status.

leslie

thatoneguy · Jan 15, 2006

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.

this is what i was commeting on. is not a matter of should you question the protocals. its a matter of CYA. the doc just turns the monitor off and says give the med forever if needed and implies forget about the protocals. no, thats not the way to do it. the doc needs to write new protocals. if not it did not happen. you acted on your own.

"let the md write orders customized to pt's condition and code status."

thats my whole point. this needs to be done before you start applying new protocals

leslie :-D · Jan 15, 2006

this is what i was commeting on. is not a matter of should you question the protocals. its a matter of CYA. the doc just turns the monitor off and says give the med forever if needed and implies forget about the protocals. no, thats not the way to do it. the doc needs to write new protocals. if not it did not happen. you acted on your own.
"let the md write orders customized to pt's condition and code status."
thats my whole point. this needs to be done before you start applying new protocals

i agree 100%.

i would never administer any med or dc any treatment w/o a written order.

leslie

austin heart, BSN, RN · Jan 15, 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.

Are you saying that you do not believe in palliative care in the ER? Protocols or no protocols, everything that roles through the door is a different story and not 2 peeps will ever be treated the same. Do you treat all your chest pains the same way no matter what symptoms they present with just because it is "protocol"? Let's hope not as someone might end up dead sometime due to standard protocols.

It is quite clear that there are several nurses here that do quite grasp the concepts of Hospice and palliative care. sickandtired made an excellent post earlier. I don't think that ER nurses have to deal with this situation as the ER is an inappropriate place for the folks, but this type of situation is handled totally different than your average pain patient. Morphine is not just a pain medication. It is also used for anxiety, relieving pulmonary edema and it decreases myocardial O2 demand. Hospice patients already receiving Morphine at home quickly adjust to any effect that it may have on their breathing. It is prescribed in small initial doses then gradually increased if it is needed. So rarely do breathing problems occur, they are usually not even listed as side effects. In fact morphine is a drug of choice for breathing distress in people with end-stage heart or lung disease: it makes their breathing more comfortable. When administering morphine in these situation in an ER I would follow MDs orders take base line vitals and monitor respers when giving the morphine. What are you ganna do with all those vitals? If the patient is Hospice they are ganna come in with a butt-load of paper work stating what they want and don't want to have done. Are you going to go against the patiants wishes just because it is "protocol" in an acute care setting? If it where me or my loved one I would say bring in the drugs and keep me or my loved one comfortable.

Bipley · Jan 15, 2006

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.

This is something that seriously bothers me on a personal level. Giving morphine to a person and you pretty well know it will be their last dose but damn! They are still hurting.

I've given MASSIVE doses of Fentanyl through the spine, 1mg/1ml. I'm not even going to state the rate because I doubt anyone would believe me and the guy didn't die. He was STILL in pain!!!!!!!!!!! The doc ordered Diprovan and honestly, I felt like he was still in pain but unable to react to the pain. I've never seen anyone experience pain like that man.

I will do whatever is necessary to get someone out of pain. ANYTHING. But that doesn't mean it doesn't haunt me later. What do you do? You have a patient in serious pain and one more dose of narcs and they will die. Do you let them suffer or do you admit you just killed that man? Sure, we can all say the disease killed him but the bottom line is that last dose of morphine sure sped up the death process.

After the Fentanyl patient (above) I knew in my heart I did the right thing, the man WAS in pain, period. I'll never forget the order, I saw it and chuckled to myself that the doc obviously made a mistake. I called him and he said nope, that's what he ordered and that is what he wanted. I knew for sure pharmacy would catch it and call me and sure enough, pharmacy called requesting clarification. I explained I had the same reaction and called the doc, that's what he wanted. I don't think pharmacy believed me. They called the doc too. I thought that would end the order, but it didn't. Soon here comes a 500ml bag of straight fentanyl. Holy crap! Never seen that much straight Fentanyl in my life.

I explained to the patient what was going on, I TOLD him what the drug was, what it would likely do. Did he want the med. He cried. Okay, so he wanted it. I hung it, held my breath and waited. He was still in pain. That was enough narcotic to kill 12 horses.

Long story short the dose was increased, Diprovan was added, and the man died. For days I sat by my livingroom window waiting for a police car to show up. I seriously did. I charted my little heart out but I still know what killed that man.

That's the most obvious case I've ever had but even with the less obvious cases, it haunts me. I question if I had the right. I firmly believe patients have a right to call the shots regarding their own fate. It is THEIR body, my personal beliefs, my choices, ... it matters not. *I* am not the one suffering, it just isn't my call. So is it the call of the family if the patient cannot answer? I think so. But that doesn't mean it doesn't haunt me for days and days.

leslie :-D · Jan 15, 2006

bipley,

i know that many doses i've given, have been 'the' lethal dose.

but since it bothers me more to see one suffer, it would haunt me for days if this person's remaining time was spent suffering.

i actually feel good that i was able to relieve one's pain, even if it did hasten their death....one of those quality vs. quantity issues. a pt's quality of life is greatly improved in the absence of pain vs. cutting one's life short by a week or 2, writhing, screaming, crying for relief. and having been a hospice nurse for 10 yrs., i have seen and heard the relief and gratitude for alleviating one's suffering.

leslie

Bipley · Jan 15, 2006

bipley,
i know that many doses i've given, have been 'the' lethal dose.
but since it bothers me more to see one suffer, it would haunt me for days if this person's remaining time was spent suffering.
i actually feel good that i was able to relieve one's pain, even if it did hasten their death....one of those quality vs. quantity issues. a pt's quality of life is greatly improved in the absence of pain vs. cutting one's life short by a week or 2, writhing, screaming, crying for relief. and having been a hospice nurse for 10 yrs., i have seen and heard the relief and gratitude for alleviating one's suffering.
leslie

I agree with what you are saying but it still bothers me knowing I am the one that did the dirty deed.

I've had patient families approach me and request I do the dirty deed. Just give him enough to end it!!!!! In my mind I'm thinking YOU give him enough to end it! Why is this my job? Not to get the patient out of pain but to actually kill them?? That isn't what I went into nursing for.

It's not a religious thing with me, it really isn't. Heck, I'm an atheist for goodness sakes. So my religion is not getting in the way of the decisions of a patient but it still haunts me knowing I'm the cause for that death at that moment. It isn't a belief issue with me in any possible way, I firmly believe it is the patient's choice. I still hate being the one to do it. It doesn't stop me from doing it, instead it just haunts me for days.

I'd be a compassionate and effective hospice nurse but OTOH, I'd be an emotional wreck. After all these years that one job just bothers me a great deal. Regardless if the patient is clear they want WHATEVER it takes to get out of pain, it still bothers me a great deal. There is a part of me that is screaming that I just don't have this right. The other part is screaming I don't have a right not to do it.

I suppose we all have our issues within nursing, something that is a challenge and that is mine. I don't want to make it sound like I keep the patient in pain while I decide, it isn't like that. I do what I have to do, it just simply bothers me later.

leslie :-D · Jan 15, 2006

it would definitely haunt me if i actively assisted in killing them, just for the sake of ending it.

but since we know their outcome is inevitable death, i NEED to know that i did everything humanly possible to ensure that they die peacefully.

it is not my intent to undermine your ambivalencies; it's just something i can't relate to. the relief of suffering and your involvement in it, is a noble and honorable act.

how do you think you would feel if you knew a pt. died w/agonizing pain and needlessly suffered?

i know too many nurses that are afraid to use mso4, dilaudid, fentanyl, in fear of causing their death.

i think end of life care should be taught and mandated in all healthcare facilities.

leslie

Bipley · Jan 15, 2006

it is not my intent to undermine your ambivalencies; it's just something i can't relate to. the relief of suffering and your involvement in it, is a noble and honorable act.

Maybe that is the issue, I'm just not there yet. Honorable and noble. I can't really voice what my issue is. I know I am doing the right thing, I've done it many many times over the years. I'll continue doing it every bloody time it is necessary. But there is this haunting feeling in the back of my mind that I don't have this right.

I don't know, perhaps it is the "recovering Catholic" in me. Not really sure.

how do you think you would feel if you knew a pt. died w/agonizing pain and needlessly suffered?

Don't we all know how that feels? You come to work and someone is in horrific pain and the nurse that was taking care of him out and out states she didn't want to manage pain because she didn't want a death on her shift? I want to smack those nurses hard enough to inflict the same pain they just inflicted on their patient. It's very difficult to manage pain when it has become that level. Soooo much easier to stop it dead in its tracks vs. undoing a shift of ... nothing.

I know too many nurses that are afraid to use mso4, dilaudid, fentanyl, in fear of causing their death.
i think end of life care should be taught and mandated in all healthcare facilities.

Agreed. But in my case I'm not sure it could be something that is learned. I think I need to figure out what my issue is and deal with it head on. It isn't something that can be learned, instead I think it is something I need to deal with. Not sure if that makes sense.

I do what I am supposed to and I can honestly say that I am a mega patient advocate when it comes to pain management. I do what needs to be done, period. The difference between those without my "issues" and me is that it haunts me for days afterwards.

juliebean4u · Jan 15, 2006

"Pain Crisis" is a legit reason to squad a hospice patient to the ER/hospital. No, it's not really necessary to take vitals, but an experienced nurse will know that if bp and pulse up, pt is probably still in pain. If bp down and pulse up, pt is approaching the end and the heart is speeding up to accomadate the low bp.

pugmum · Jan 15, 2006

I was an ER nurse for nearly 20 years (until recently), and have seen countless pts. at the end of their lives come in through the emergency department. Discussions of palliative pts. in the ER, comfort care and pain control have and always will continue to be issues.

The problem? It is the culture of the ER department itself... it exists to treat emergencies, initiate rapid treatment, and prolong life. In the ER, we are accustomed to "doing something". Palliative care is often seen as "doing nothing"...no further tests, monitoring, vital signs, no need to see surgeons, internists, etc all of the things we do for our acutely ill pts. The purpose of hospice/palliative care nursing is to assist the person to comfortable/painfree death...so the challenge is to put the ER stuff aside for this patient and provide the nursing care that is needed.

Education for nurses in the ER includes drugs, interpreting ECGs, defibrillation, ACLS protocols, appropriate dosages of pain medications,rapid head to toes assessments, Trauma protocols, etc. etc. etc. Very little about end of life care, and as a consequence thoughts on pain control for palliative pts. seem to be based on assumptions of what is appropriate for an acutely ill pt.

I took a hospice/palliative care course because I realized I had a serious knowledge gap. I had a pt. with intractable pain come in to the ER and was dismayed because the physician was ordering a dosage that I "knew" would kill the pt. The pt was admitted to hospital, then discharged home 2 days later once the pain was under control again. It was like being hit over the head with a ton of bricks - I realized I knew zip.

We all know our population is aging. We can expect an increase of palliative pts. arriving in the ER. It does no good to say that palliative pts. have no business in the ER. They will continue to arrive with acute episodes of pain or crises that they or their families cannot deal with at home. Even if those pts. are hospice pts or have a nurse with them, you can bet your bottom dollar that they will show up. We need to ensure that we can provide the type of care these pts at end of life need. Even if that includes administering pain medications in high doses (as compared to what is appropriate for an ER) pt. Education was a key for me, and that is reason I mention it and encourge everyone who has not had the benefit to take a course or two, no matter your area of speciality.

leslie :-D · Jan 15, 2006

It does no good to say that palliative pts. have no business in the ER. They will continue to arrive with acute episodes of pain or crises that they or their families cannot deal with at home. Even if those pts. are hospice pts or have a nurse with them, you can bet your bottom dollar that they will show up.

i agree that education is paramount in effectively treating hospice pts in acute pain.

what i'm not so sure about is that hospice pts will always end up in the er.

there are reputable hospices and not so reputable.

but if you have a hospice nurse that is astute in pain assessment, pain prevention, sound pharmological knowledge base and a medical director who is receptive to suggestions, is an expert in pain mgmt as well as liberal in their scripts, there is no need for hospitalization.

in my 10 yrs experience, i have never sent anyone out.

but i've worked in in-pt hospices- not home health.

but again, if you know your stuff and have a doc that equally knows their stuff, then i don't know why a hospice pt would need hospitalization.

leslie