Scenario:What would you do?

chadash · Jan 17, 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 have sooo many questions about how this thing works, so bear with me:

Normally, in a non hospice situation, you would not give morphine to someone this hypotensive?

Do you forgo this guideline in hospice? (new rules?)

If someone is actively dying, do you just stop taking vitals and treat the discomfort? Could this actually hasten the process?

I know with hospice you do nothing to prolong life, and you use all palliative measures possible, but is there any ethical conflicts if palliative measures hasten death?

Legally, is the Dr. not liable for wrongful death in these circumstances since apparently the pt had agreed to hospice care and most likely had a DNR?

Just trying to get a handle on how it all works!

leslie :-D · Jan 17, 2006

If someone is actively dying, do you just stop taking vitals and treat the discomfort? Could this actually hasten the process?
I know with hospice you do nothing to prolong life, and you use all palliative measures possible, but is there any ethical conflicts if palliative measures hasten death?

yes, in hospice care you do stop taking vitals, except respers as there are often times parameters on when to hold the mso4; yet often times there are no paremeters whatsover.

and yes, mso4 DOES hasten death.

but as long as your INTENT is to relieve suffering, there are absolutely, positivley no legal ramifications.

i can't count how many cases where the pt's rr was 4 and still grimacing/moaning....and i would give them their mso4, typically their last dose. and it is nothing i struggle with, but rather, feel good that i was able to let someone die in peace.

leslie

mimmiejdm · Jan 18, 2006

If he is a hospice pt, then it was his choice or family choice to send him to the er, other than that comfort measures should be the 1st priority with this pt, I would have given him the pain medication just as the md ordered, and gotten this pt's pain under control, pain control is the real issue here.

FossilRN · Jan 18, 2006

I agree that giving the morphine is correct by why take vital signs if you are not going to treat them? Also, why give the enema to treat the high K? We do have in-hospital hospice care in some situation at my hospital. From my professional (and personal experience) it is difficult for some families to actually accept that is is, in fact, the end even when a patient is on hospice. I can see why people bring their loved one to the ER in what they view as one more crisis. Too bad that they didn't give this family Morphine elixer, suppositories or something at home to help this patient.

chadash · Jan 18, 2006

I agree that hospice home services need to be diligent in explaining to the families what to expect, and how to respond. Sometimes, if the patients condition became a hospice situation suddenly, even with the best efforts to prepare them, they just don't have enough time to absorb the information. People who are going through a crisis in their lives of this magnitude are usually LESS likely to understand what is happening than they would usually.

RnRatchet · Jan 18, 2006

people who are going through a crisis in their lives of this magnitude are usually less likely to understand what is happening than they would usually.

how very true. several times we've spoken with families that got scared and called 911.. but by the time they realize what they did they call hospice and the nurse gets to the house shortly after the ambulance. the family then says they were just scared and decline transport and we call the doc to get orders for whatever symptom changes they've had.

cathiek · Jan 19, 2006

I wouldn't have altered the doctor's order to my comfort level. If the doc wrote down the order for 5 mgs 'till pain gone, if you didn't give what the doc ordered, then it is a med error. That said, the nurse that sent him to ER for the PCA and Kayexallate, should have called to the attending doc and got orders to direct admit him to the floor. There was no reason for him to have to be billed for an ER visit that wasn't necessary. If you weren't comfortable following the doc's orders then you should have requested to have someone else take this patient. If that patient's ER record is audited or someone down the line notices that the doctor's order in the ER wasn't followed, you might be in for some heat from this incident, so be prepared. Next time, follow the doc's order or ask your charge nurse to advise you if you have questions about the order. I personally wouldn't confront the doc, that seems to be a privelege reserved for nurses that have paid their dues and proved themselves to the docs, and that takes years of having a working relationship with them. Yes, it is your licence on the line if a doc's order's aren't correct, but it is your job and your licence that is on the line if you don't follow the doc's orders as written.

I am a registered nurse and practice in new zealand. I find it difficult to understand how morphine can be prescribed as 5mg till pain has gone - in new zealand this would not be an accepted prescription as it would have to have an upper limit that could be given in the included in the prescription.

however like i said i don't practice in your country so am not aware of what the protocols are there. i would be interested to know though

anyway if i feel that a prescrition is wrong or i am not happy giving it i go straight to the doctor concerned cos' at the end of the day it is my registration on the line and after all doctors are humans and not gods and therefore at times need their errors pointing out to them tactfully if you can get your message across or less politely if you feel they are not listening

Carlos Casteneda · Jan 26, 2006

we dont do any routine obs on palliative patients, because we would not act if we found deviations from the norm anyway

babette215 · Oct 7, 2011

I totally agree... I have to ask what sort of nursing do you guys do?? Just because someone is hospice or DNR it does not mean don't treat. The guy has a low sat and it's probably the reason he is hallucinating. He might come around just soon as you put some O2 on him and give him a little fluid. Then his pressure will tolerate the morphine and he will breathe better. You can still work up this guy. If someone comes into the ER, regardless of hx, you do a workup... PERIOD. This covers your ass. And I'm sorry, but when have I ever needed an order to do vital signs?? It's hard to say really whats going on since I can't see the patient, but from what I've heard this is what I would do. I would go up the chain of command if I felt a doctor was not doing something that could technically cause a potential poor outcome for the patient. Patients always come first, not the doctor or us. I've had run ins like this before and if they don't give me what I want then I call the house supervisor or a RAT or just call the ICU doc who is one of our hospitalist. If you want to get the attention of a doctor, get another doctor to do their job and then have them tell them to get their ass is gear. You won't have a problem next time and the patient gets the care they need.

carolmaccas66, BSN, RN · Oct 8, 2011

Haven't read all the posts. We have a morphine protocol that is followed strictly for every patient, given with OBs every 15 minutes, done as per legal rules. What the Dr wants in Oz does not count.

I would do it to pacify the family. I had a woman come in almost with this exact same scenario a few weeks ago: end stage COPD, CO2 retainer, cachectic as. The family wanted more done, she was hospice, we couldn't do anymore except make her comfortable. The family didn't seem to realise & kept wanting us to do more to help her. Family were also rude but just more worried, I think, probly the same in ur case.

Be more proactive & get the Dr to explain we can't do anymore & a hospice team needs to step in. It must be ++ distressing for the patient to be dragged in & out of hospital. They need to be made comfortable to die at home, surrounded by family & loved ones.

This burden should not just be shouldered by you. Talk to ur NUM & the Dr & get them to sort it out.

carolmaccas66, BSN, RN · Oct 8, 2011

Did the OP ever answer the question?

JustBeachyNurse, LPN · Oct 8, 2011

RE: carolmaccas66 Re: Scenario:What would you do?

Did the OP ever answer the question?

Yes she did, on Jan 16, 2006, (this is a reanimated old thread from 5 years ago):

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.