Scenario:What would you do?
- 0Jan 12, '06 by Happy-ER-RNThis 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.
- 0Jan 12, '06 by MIA-RN1still a student here but if the doctor is telling you to go against protocol, I would refuse and go up the chain of command. I wouldn't risk my license because a doctor decided to suddenly change the rules.
EDIT amending post to clarify that I didn't mean holding the meds, I meant as far as doing the vitals. If the doc said not to follow protocol on vitals, then I would go up the chain of command--which would be the NM I guess. (I am interested to read the posts to this; I worry about facing an ethical dilemma myself someday)Last edit by MIA-RN1 on Jan 12, '06
- 0Jan 12, '06 by zacariasIt sounds as if the pt is dying. If the idea is comfort care, then why do vitals? He already has low BP and sats. The morphine will make him more comfortable might drop his BP more and surely his sats while he is dying. Taking vitals seems like "what's the point?" type of thing.
Of course if this was not a hospice pt or a DNR, aggressive care would be appropriate in this instance.
- 0Jan 12, '06 by ClaireMaclAre you joking with us? Morphine is a respiratory depressant and I've seen it happen! Doing vitals after giving it, particularly around 15 minutes after giving it is entirely essential!!!!
Quote from jmgrn65What is the point of doing vitals? if he isn't going to be coded what are you going to do with the info? I would have given the morphine, I don't usually do vitals after morphine anyways.
- 2Jan 12, '06 by Altra GuideQuote from Happy-ER-RNThis infuriates me ... because IMHO, sending someone to the ER is NOT hospice care, unless the patient has spelled out that he/she does not wish to die at home (many people choose to do just that, others don't want their families left w/that memory within the house). In that instance, the pt. should be admitted, ideally directly from home without going through the ER.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).
Hospice care can be so wonderful - it makes me angry when some type of home care has the "hospice" label slapped on it, but what the provider and/or the pt.'s PCP are overseeing is NOT hospice/palliative care. (note: I am NOT knocking home care)
I'll be waiting to read what the outcome was, but this is a perfect example of inappropriate use of the ER.
- 0Jan 12, '06 by mom23RNI had an instance like this many times in ER. First of all, the family sometimes "panics" when their loved one becomes incoherent or unresponsive. This does not mean that they want "heroic" measures taken.
I would make sure that the family is aware of the situation and that death sounds as if it is imminent and what you are doing is trying to control his pain and make sure that he is comfortable.
I do agree that taking vitals in this instance is prohibitive unless you're going to do something with the results. If his oxygen drops or his resps fade are you going to recucitate him? If not, then the family does not need to hear hr slowing, alarms sounding etc.
This is all IF......