Soooo Upset at Palliative Care Doc!

[Jay-Jay, RN]

After browsing the site for awhile, I feel I've calmed down enough to post about this rationally!

I was asked to see a patient tonight who has terminal Ca. It was a first visit for me...though this lady had been on service for awhile, I'd never seen her before. I was to go in and give her Decadron and 2.5 mg. of Haldol.

When I arrived, she was sleeping very peacefully, vitals stable, but resp. rate was only 8. When she awoke while I checked her vitals, she was not able to talk. I went back downstairs, and talked to the family about her history. Apparently, that morning, she had been walking and talking, though in a lot of pain. She'd even gotten up and showered, with assistance. Then, when the palliative care doctor came in, he gave her Haldol and applied a 50 ug Duragesic patch. This was at 2:30 in the afternoon, and she'd been sleeping steadily ever since. She had not even been up to go to the bathroom.

I told them I was concerned that maybe she was a little over sedated, and I was NOT comfortable giving the Haldol without checking with the doctor.

The attending calls me back (after a long wait) and tells me to hold the Haldol, and remove the Duragesic patch. He said to use Dilaudid P.O. for pain, but if that didn't work, to re-apply the Duragesic, but use a 25 ug patch instead of 50.

I carried out his orders. No sooner had I done so than the primary care doc. calls, flaming mad. He told me that what I'd done was totally, totally inappropriate. I should have reassured the family that it was perfectly okay at this point for her to have such a low resp. rate, and not be able to talk or respond to them. I tried to tell him, that YES, I agreed that would be so, if the patient were actively dying. But someone who was walking and talking earlier today, has good colour and perfectly stable VS isn't exactly end stage. He would have none of it, and continued to rake me over the coals. "You should have been reassuring the family, instead of getting them upset about this!" he ranted. "I don't know what kind of training they're giving the nurses, but it's not good! You should know better! Tell them to talk to her softly...it doesn't matter if she can't talk back...."

He then spoke to the family at length, then called me back, and told me to reapply the Duragesic patch, but only half a patch (put Opsite under the other half). As he was about to hang up, I reminded him about the Haldol: should I hold it or give it? "Hold it," he told me. "I gave her some this afternoon, so she'll be okay."

So, palliative and hospice nurses, what would YOU have done? I frankly think he forgot about the Haldol dose. If it hadn't been for that, I probably would have left well enough alone, in spite of the respiratory rate being so low. Right now, I am FUMING over this doctor's arrogance, and the way he treated me. His whole conversation with me took place on the phone, RIGHT BESIDE the patient's bed, with the whole family listening. The family was very understanding, and told me "You did what you though was right, don't worry about it," which makes me feel a little better. Still, it ruined my evening. I had hoped to finish early, and get in a workout at the gym before coming home. Instead, I got home after the gym closed, too angry and too uptight to even think of going to bed.

Arrggh. Gonna go for a nice, long walk with the dog, and try to get over this!

[Tweety, BSN, RN]

I can understand you're being upset. I would be do.

[MikeLPN]

The sum-total of my nursing experience is working LTC eves full-time. Hospice/Palliative is an art. You go with your gut and you more often than not don't have the luxury of time. You were right and plain and simple, over-sedation is wrong and not necessary. Death is just a part of life and symptom management is your priority. Lucidity is a major concern for him and his family. I wonder if the haldol could have been prn.

We had one resident youngish lung ca w/mets and spinal cord cut on a ton of morphine IV. Kept him in a good place w/ativan 1mg IM qd and haldol IM 2.5 mg qod which was pretty much when I was on. I had to do this prn (on a telephone order from an on-call MD) for weeks. I'm not sure of the pharmacology but it worked very well for him and his spouse who was with him every night after work definitely approved.

Appropriate usage of prn meds and dosage adjustments/ranges are very important for hospice/palliative.

Iwould also be interested in any more experienced nurses responses to this thread

[Jay-Jay, RN]

Thanks, Mike, Tweety!

If the haldol had been PRN, none of this would have happened. I double-checked to make sure...nope, no PRN about it. Now, would YOU or any nurse who valued their license, give 2.5 mg. of Haldol to someone with a resp. rate of 8??

I checked my drug book re. the Duragesic. It says, in plain English: call doctor if respiratory rate is under 10. Yup, that's exactly what I recall from all those palliative care courses I took! As a matter of fact, I've even had doctors give written orders to hold narcotics if respiratory rate is less than 10. And this was on patients who were very, very terminal.

Oh, and the clincher? I checked the nomogram for switching from Dilaudid to Duragesic. She was on 2 mg. every 4 hrs. That translates to a 25 ug. patch. Even if she'd been on 4 mg. q. 4 h., that STILL would have called for a 25 ug. patch, NOT 50!!

[Tweety, BSN, RN]

Bottom line. You did what was right. He messed up and wasn't man enough to thank you for covering his ass. He obviously didn't know this patient well enough to properly manage her. He should be thanking you for being his eyes and ears. If she was in pain earlier, I applaud him for dealing with it. But he should be thanking you for your assessment later in the day. What a jerk.

[NRSKarenRN, BSN, RN]

CAn't tell you the number of times doc just odered a Duragesic 50 ug patch--even for opiod naieve patients just cause they were having severe pain only to have your experience----excessive sedation. Especially bad when Duragesic came out ~1990 ---they sure did have great sales personal. Kept telling docs oral route was best for meds unless difficulty swallowing or large dosing.

Had one patient with arthritis flare was only taking Darvocet N and doc ordered Duragesic 50Ug day before, almost passed out on me during my visit when he stood up.

Why the haldol for someone who was assisted up and showered??? Doen't make sense to me.

You did right by questioning this order. Even with correct equivelent analgesic dosing, I've had patients snowed after 12 hours and steady state reached, but family members were grateful that their loved ones pain was releived. Some do better on the second day.

RE respirations of 8:

If this patient was on their ususal drug dose, had been pain free but actively dying, would do nothing for a repiratory rate of 8.

Being pain free is the goal over maintaing life.

In your instance, since it was a new order and patient was alert and talking earlier, I'd have done just like you: call the doc, hold the haldol and ask for lower dose patch. Especially with the elderly due to fentynal's formation, starting with a 25ug patch is best, continue oral med till response to fentynal known then increase strength of patch.

Your nursing instincts were right on in my book. Sorry thi doc was such a pain and ruined your day.

[kids]

Originally posted by 3rdShiftGuy

Bottom line. You did what was right. He messed up and wasn't man enough to thank you for covering his ass. He obviously didn't know this patient well enough to properly manage her. He should be thanking you for being his eyes and ears. If she was in pain earlier, I applaud him for dealing with it. But he should be thanking you for your assessment later in the day. What a jerk.

My thoughts exactly.

[P_RN, ADN, RN]

You know what I think? I think Dr. Personality got his patients mixed up. I know to most families Doc=GOD and they probably never doubted what he did. You did exactly what I would have done. 50 mic duragesic is a whopping big dose for an adult male, but not for a LOL who is being given palliative care.

I also don't think that putting opsite under half the duragesic patch is going to lessen the dose. The fentanyl is floating between the backing and the membrane. If it cant get out of one end, it will just float over to the other.

I also think Dr. Personality might have been embarrassed by his on call having to clear things up.

He owes you an apology.

[pappyRN]

Hello,

I can only speak from my experience as a chronic pain patient but the instructions for using a Duragesic patch specifically say that the patch must be pressed firmly against the pts skin with the palm of the hand for 30 seconds, making sure that the contact is complete especially around the edges. They also states that the system should NOT be altered in ANY WAY prior to application. What's the point of trying to make a half of a patch by covering half with opsite??? That's ridiculous, highly inaccurate and completely goes against what are the recommended instructions for the application of the Duragesic patch. What will he do the next time...ask you to CUT it in half?

I happen to save all the package inserts from any of my medicines and not just those monographs that you get with the prescription from the pharmacist. I guess it's a carry over from my nursing school days and my early days as an RN. I don't know if new nurses do this now, but we were taught to bring our drug box cards to work with us, even after graduation. We had to make an index card lisint drug information for every med prescribed to every pt we took care of while as student nurses. I'm almost embarrassed to say that I still have my file box full of drug information index cards! I add these package inserts to it whenever I remember to tell the pharmacist to give me the pkg insert from the manufacturer, not those monographs. I will share with you what the insert says about Duragesic Transdermal System.

Just skip my post if you aren't interested. I can't get to sleep so I thought it might be helpful if I share what the insert says.

Duragesic is a rectangular transparent unit comprising a protective layer and FOUR functional layers. Proceeding from the outer surface toward the surface adhering to the skin, these layers are:

1) a backing layer of polyester film;

2) a drug reservoir of fentanyl and alcohol USP gelled with hydroxyethyl cellulose;

3)an ethylene- vinyl acetate copolymer membrane that controls the rate of fentanyl delivery to the skin surface; and

4) a fentanyl containing silicone adhesive. Before use, a protective liner convering the adhesive layer is removed and discarded.

If Duragesic is cut or damaged controlled drug delivery will NOT be possible.

Duragesic releases fentanyl from the reservoir at a nearly constant amount per unit time. The concentration gradient existing between the saturated solution of drug in the reservoir and the lower concentration in the skin drives drug release. Fentanyl moves in the direction of the lower concentration at a rate determined by the copolymer release membrane and the diffusion of fentanyl through the skin layers. While the actual rate of fentanyl delivery to the skin varies over the 72 hr application period, each system is labeled with a nominal flux which represents the average amount of drug delivered to the systemic circulation per hour across average skin.

While there is variation in dose delivered among patients, the nominal flux of the systems(25, 50, 75, 100 ug of fentanyl per hour) are sufficiently accurate as to allow individual titration of dosage for a given pt. The small amt of alcohol which has been incorporated into the system, enhances the rate of drug flux through the rate limiting copolymer membrane and increases the permeability of the skin to fentanyl.

Following Duragesic application, the skin under the system absorbs fentanyl, and a depot of fentanyl concentrates in the upper skin layers. Fentanyl then becomes available to the systemic circulation. Serum fentanyl concentrations increase gradually following initial Duragesic application, generally leveling off between 12 and 24 hrs and remaining relatively constant, with some fluctuation, for the remainder of the 72 hr application period.Peak serum concentrations of fentanyl generally occured between 24 and 72 hrs after the initial application period.Serum fentanyl concentrations continue to rise for the first few system applications. After several sequential 72 hr applications, pts reach and maintain steady state serum concentration that is determined by individual variation in skin permeability and body clearance of fentanyl.

After system removal, serum fentanyl concentrations decline gradually,and 17 hours or more are required for a 50% decrease in serum fentanyl concentrations, (range 13-22) hours. Continued absorption of fentanyl from the skin accounts for a slower disappearance of the drug from the serum than is seen after an IV infusion, where the apparent half life is approx. 7 (range 3-12) hours.

Since elderly, cachectic, or debilitated pts may have altered pharmacokinetics due to poor fat stores, muscle wasting, or altered clearance, they should NOT be started on Duragesic doeses higher than 25ug/h unless they are already taking more than 135mg of morphine a day or an equivalent dose of another opioid. Information from a pilot study of the pharmacokinetics of IV fentanyl in geriatric pts indicates that the clearance of fentanyl may be greatly decreased in the population above the age of 60. The relevance of these findings to transdermal fentanyl is unknown at this time. * The recommended starting dose when converting from other opioids to fentanyl is likely too low for 50% of pts.

However, this starting dose is recommended to minimize the potential for overdosing pts with the first dose.

The whole mechanism of Duragesic patches is predicated on the correct application of the FOUR LAYERED transdermal medication delivery SYSTEM inherent to the patch's construction. Each layer works in conjunction with the others. Even the adhesive contains fentanyl so it's important for you to handle the adhesive border as little as possible. ALL layers of the patch contain medication, not just in between the layers that are obvious. Disrupting the intended mechanism of delivery negates the whole purpose of using this steady delivery system. Each layer of the patch, including the adhesive border, is dependent on the correct application for the dose to be delivered in an even manner so hold the patch in place for 30 seconds and be sure the edges of the patch adhere to the skin. Trying to construct a 25mcg patch by rigging it with opsite is questionable at best, most likely very inaccurate and possibly ineffective. As was said by Karen, if the pt was opioid naive, 50mcg would be a very hefty dose. Janssen instructs physicians to always start with a 25mcg patch regardless if the pt is opioid naive or opioid tolerant. Doses higher than 25mcg are contraindicated for an initial dose. Dosing can be titered upwards if need be after determining the pts response to it, but should really only be done after at least two applications of the patch. Steady state is reached after 17 hours with the patch applied and because fentanyl's serum level drops gradually, for any reason if ordered to reduce opiate therapy or switch to a different analgesic, give only half of the equianalgesic dose of the new med 12 to 18 hours after removal. With that amount of time needed to reach steady state and it's slow serum level drop, it seems strange to be ordered to interrupt the medication delivery by removing the patch and then reapplying it later especially if under 12 to 18 hours. Maybe I misunderstood, but is the patch being used as a prn med?

I hope the family of this pt didn't want the pt to be snowed with drugs after seeing the pt was up and interacting earlier in the day. What was the doctor's major malfunction? Was he just trying to hasten things and keep the pt quiet so he would be called less and wouldn't have to deal with the pt? What in the heck was he thinking? Did he even know if this pt was actively dying? Sounds to me like he was robbing the pt's family of valuable time together with the pt interacting and the family conversing with the pt. Was the doctor a pain and palliative care specialist? IF it was my parent, I'd be livid that he was either trying to speed things up OR dosing too heavily when obviously the time wasn't quite right yet and the pt not imminently terminal or expectant. It's one thing to be made comfortable but quite another to be rendered out of it and unable to communicate. I'd guess that he screwed up by applying a 50mcg patch instead of a 25mcg patch but also by giving her the Haldol. It also sounds like he was embarrassed because you caught his mistake and he got busted by you in front of the family and so he tried to make himself look important and in control by raking you over the coals and then having such a long conversation with the pt's family to reassure them that HE was right and YOU were wrong.Sound a little like he was trying to talk his way out of his mistake when he was speaking to the family? Hopefully, the pt's family was smart enough to see what was really going on. He got caught messing up!

Based on a pharmacokinetic model, serum fentanyl concentrations could theoretically increase by approx. one third for pts with a body temperature of 104 due to temperature- dependent increases in fentanyl release from the system and increased skin permeability. Therefore, pts wearing Duragesic who develop fever should be monitored for opioid side effects and the dose should be adjusted if necessary. All pts. should be advised to avoid exposing the Duragesic application site to direct external heat sources such as heating pads or electric blankets, heat lamps, saunas, hot tubs, and heated water beds etc. while wearing the system. There is a potential for temperature-dependent increases in fentanyl release from the system.

Duragesic should be applied to non-irritated and non-irradiated skin on a flat surface such as chest, back, flank, or upper arm. Hair at the application site should be clipped NOT SHAVED prior to system application. If the site of application must be cleansed prior to application of the system, do so with clear water. Do NOT use soaps, oils, lotions, alcohol, or any other agents that might irritate the skin or alter it's characteristics. Allow the skin to dry completely prior to system application.

If the pt experiences any breakdown from the patch or from it's adhesive border, spray the skin with either Azmacort, Flonase or Beconase nasal spray to help to prepare the skin and prevent the rash that occurs frequently with Duragesic. Of course, let it dry before attempting to apply the patch! The drug company, Janssen, will NOT continue to supply the pt with free bio-occlusive dressings if you or the pt reports that there is ANY skin breakdown no matter how minor. They are instructed to discontinue ordering these dressings for a pt if they know about a rash or blisters and those bio-occlusive dressings are very expensive. Care should be taken not to reapply a patch to that area until it is well healed.

The concomitant use of other central nervous sytem depressants may produce additive depressant effects. When such combined therapy is contemplated, one or both agents should be reduced by at least 50%.

Duragesic is supplied in sealed transdermal systems which pose little risk of exposure to health care workers. If the gel from the drug reservoir accidentally contacts the skin, the area should be washed with copious amounts of water. Do NOT use soap, alcohol, or other solvents to remove the gel because they may enhance the drug's ability to penetrate the skin.

To dispose of Duragesic, the system should be folded so that the adhesive side of the system adheres to itself, then the system should be flushed down the toilet immediately upon removal.

Like I said, my perspective is from that of a very ill chronic pain patient as I haven't been able to practice nursing for the last seven years. I just found out a few weeks ago that it is very likely that I am also now diabetic on top of having RSD, TOS, fibromyalgia/CFIDS etc. I am just sooo sick of being sick!

Hope I wasn't out of line for expressing my opinion. Please excuse me if I have repeated certain information. I have not been to bed since Wednesday night due to insomnia and really bad pain levels. It is extremely cold here with a lot of wind. The cold is very hard for me and the Reflex Sympathetic Dystrophy/Fibromyalgia/TOS. My rt arm and rt leg is rather cyanotic and cold even though the heat is on and I am wearing long sleeved and long pants pajamas with slippers. It is just the vasomotor effects from the disease. I don't know how to describe my pain except that it is deep, hard searing bone pain with very severe bouts of hard lightning like jolts that occur anywhere it wants to. I think if you think about experiencing "brain freeze" when you eat very cold food such as ice cream and the roof of your mouth screams out in pain. That is almost a dead ringer for what I feel on the entire rt side of my body with the characteristic of 'burning' added to it.I am hoping beyond hope that this doesn't represent diabetic neuropathy on top of everything else that is wrong with me.

If you have any spare prayers will you please keep me in mind and send them my way? I also just found out lsat night that my nephew is dying from Kaposi's sarcomas in both lungs. Yes, he is HIV positive. He also has malignant melanoma. He's 35 years old and a wonderful nephew. I am saddened beyond my ability to think. Sorry if I have babbled too much.

Thaks for allowing me to get so much typing practice.lol

Warm personal regards,

PappyRN

[renerian, BSN, RN]

I have seen people with respies at 8 with narcs in comfort and some in pain. I have seen people get tons of MS04 and be still miserable. I would have called about the haldol too only because she may have been snowed. I want people to be comfortable but going from a walkie talkie to a snow is to fast on the meds, I think. I also have seen people deteriorate very fast as well.

I have had conversations with docs about that as well. In the end I just say I have to call. It is what is it.

renerian

[hospicenurse]

Jay-Jay

I just found these forums, and this post caught my eye. I've been a hospice nurse for 15 years (Yikes!). I agree with all the responses you've received so far. I'm especially sorry that it all had to occur at the patient's bedside, embarrassing you and involving the family. I feel the sedation was caused by the Haldol, not the Duragesic, which takes roughly 14 hrs to get into the system, and I often don't see the full effect for 24 hrs or more. My question to the doc would be why was the Haldol given? It is sometimes used in palliative care to relieve nausea that hasn't responded to Compazine or Phenergan. Of course, it's used for confusion and agitation, too, but it doesn't sound like that was the case. Regarding the dose of Duragesic - when a patient is in a lot of pain, it's not unusual to start at a dose higher than the recommended conversion rate, assuming the patient is not narcotic naive. One of the big disadvantages to Duragesic is the inability to fine tune the dose. And I've seen a lot of variation in absorption/metabolism of transdermal drug vs. po., and found that knowledgeable palliative care docs tend to have their own idea on what is the best conversion. So, I'm less likely to question the Duragesic - EXCEPT - the order to cover half the patch with opsite - that's completely innapropriate - I've never even heard of it before - and I have had docs tell me to cut the patch in half. (Also wrong). That in itself makes me wonder if that doc knows what he is doing.

Without knowing this patient, I can't say for certain how terminal she was. It's not unusual in hospice to see a patient deteriorate over a few hours. As someone else stated, we don't get too concerned over respirations, we focus on the patient's comfort. However, if I felt the patient's sedation was completely due to the drugs, I would have held the Haldol too. I might have waited to see what the Duragesic did, but maybe not - that's the nursing judgement piece that I would need to be in your shoes that night to know for sure. I think you did the right thing by calling both physicians and expressing your concerns. The palliative care doc was wrong to treat you that way. It's not typical of the collaborative team approach most palliative clinicians use. So, I'll say it too: what a jerk!

Gail

[Jay-Jay, RN]

Pappy: WOW!!!

MOST impressed by your post, but also saddened beyond words by the end of it. Don't worry, you indeed have my prayers for what you and your nephew are suffering. Ande excuse me for the typos...it's kind of hard to reead the screen through my tears for you.

This doc IS a very well know palliative care specialist. He has been questioned before about the 'half a patch' thing, and gotten all huffy over having his judgement questioned. (Do you get the impression that MAYBE he has a bit of an ego problem?? ) I just finished a very excellent palliative care training course, and in the pain module, one of the things they stressed was that doctors often misuse Duragesic. They use it too soon on patients who are opiod naieve, or not yet in enough pain to really need it. I had this same doc. prescribe it for a lady who wasn't taking anything other than the occasional Tylenol #3 for her pain. Needless to say, it made her miserably sick, and she will never, ever want to use it again. Too bad. She may really need it, once her disease progresses far enough. She has a paralysed arm due to Ca. of the breast. Tumor growth is affecting both the nerves and the circulation.

I have to work this a.m., so I cannot respond to this in as much detail as I'd like. Perhaps more later, when I've finished battling the icy, snowy roads out there... Maybe you could say a prayer for my safety today, Pappy?

Thanks! :kiss God bless!