"Reluctant" hospice doc

  1. I just started a job with a new hospice in a new state. I've tried to give this guy the benefit of the doubt, but I've come to the definite conclusion that he's a horrible hospice doctor. He's turning out to what I consider to be undermedicating of our patients. He's told me various things, but the worst has been "grimacing and moaning in dying patients do not necessarily indicate pain", "restlessness does not indicate someone is uncomfortable" (try telling that to a desperate family", and my "favorite", that "you can't medicate people in spiritual pain"! He also won't approve my requests to medicate someone in pain with morphine every 2-4 hours, he grudgingly will allow q6h. I asked for a pain pump for someone who was in horrible pain, nothing oral or rectal would help, so I wanted a pain pump. He didn't want it because "it doesn't work" and "the nurses don't know how to use it, it always causes problems". He wouldn't order more morphine, either. I'm horrified - most of the nurses I'm working with seem pretty oblivious to this. The hospice MD I worked for in my old job was absolutely an angel. And I was taught that pain is pain is pain - whatever the cause. I just found out that this guy was sued last year by a family for overmedicating a patient (surprise, surprise) so I doubt his behavior is going to change. I may have an opportunity to work on a team with this doc as the team doctor, but I really doubt I can get what I need for my patients when they need it. Should I forget about working on this team, or just go ahead and work my way around him the best I can (I already dread IDT meetings with him...) Also, I'm trying to find good information regarding liability of doctors for undermedicating of pain at end of life. I've tried Medline, PubMed, HPNA and EPERC. I know there have been court cases, but I can't seem to find them. Any and all help would be appreciated.
    :angryfire
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  2. 10 Comments

  3. by   canoehead
    The purpose of hospice is to control pain- I don't see any advantage to the patient being enrolled in hospice if you cannot aggressively treat them. They would be better off in the hospital with a "slow code" better off 50 years ago...

    Is there a medical director? How can the other nurses ignore this?
  4. by   mc3
    Quote from canoehead
    The purpose of hospice is to control pain- I don't see any advantage to the patient being enrolled in hospice if you cannot aggressively treat them. They would be better off in the hospital with a "slow code" better off 50 years ago...

    Is there a medical director? How can the other nurses ignore this?
    From what I'm told, the Medical Director and others know but excuses it with with "he's a good doctor". Also they supposedly have a hard time hiring doctors in the first place, so they tolerate it.
    As far as the other nurses, it's like anywhere else. Some are excellent hospice nurses, others are in it just for the job and can't be bothered. So sad, but true... that's why I'm determined to gather some facts so I can have some backup data. : :stone
  5. by   canoehead
    He's a good doctor...in what sense???

    Sheesh-you have my sympathy.
  6. by   mc3
    Quote from canoehead
    He's a good doctor...in what sense???

    Sheesh-you have my sympathy.
    In his own mind, I think. I really can't explain other nurse's rationale, it's just sad.
    I saw one of his pt's today. The poor lady has inoperable bladder ca, has major fistulas and hemorroids in her rectal vault. She's stopped eating because it makes her move her bowels and she dreads it. She happens to move them 4-6 times/day and is in true agony before and after each movement. He and the Primary MD (who just so happen to be in the same oncology practice) will only authorize methadose 5 mg q6hrs. Nothing long acting. Nothing else. They think she's drug seeking. I am charting each situation that I run into with him very carefully. I'd love to report him to someone outside of hospice but I just don't know who.

    After today, I've decided I just can't work with him, period. I'll get a job with a different group. I hope and pray that someone sues him for undertreatment of pain. Maybe then he'll smarten up, although I doubt it. We wouldn't accept a nurse who wouldn't administer morphine if resp. were under 10, would we? They why is this accepted???
    Still mad! :angryfire
  7. by   Hellllllo Nurse
    Quote from mc3
    In his own mind, I think. I really can't explain other nurse's rationale, it's just sad.
    I saw one of his pt's today. The poor lady has inoperable bladder ca, has major fistulas and hemorroids in her rectal vault. She's stopped eating because it makes her move her bowels and she dreads it. She happens to move them 4-6 times/day and is in true agony before and after each movement. He and the Primary MD (who just so happen to be in the same oncology practice) will only authorize methadose 5 mg q6hrs. Nothing long acting. Nothing else. They think she's drug seeking. I am charting each situation that I run into with him very carefully. I'd love to report him to someone outside of hospice but I just don't know who.

    After today, I've decided I just can't work with him, period. I'll get a job with a different group. I hope and pray that someone sues him for undertreatment of pain. Maybe then he'll smarten up, although I doubt it. We wouldn't accept a nurse who wouldn't administer morphine if resp. were under 10, would we? They why is this accepted???
    Still mad! :angryfire
    As a former inpt hospice nurse of 4 years, I feel your pain, pardon the pun.

    Seriously, sounds like a horrible stressful situation for you and the pts. I agree w/ you: I'd leave that group. Allowiing pts to suffer is accepted in a doctor because they are so powerful. A nurse who was my mentor when I was in hospice told me about a night when the medical director was away, and a doc who was notoriously miserly w/ pain meds was on call. A pt was in severe pain, and he would not treat. My friend tells me she will never forget the pt screaming "help me, help me!" and calling my friend's name.

    She went through all the channels and finally got the pt properly medicated, but it was a horrible ordeal. Years ago, I read about a case of a nurse being sued for "wrongful pain and suffering". The article stated that the pt was a hospice pt in a nursing home and the ltc nurse was not educated on palliative care and refused to give the pt his ordered ms. I do not know if this was a real case, or just written for teaching purposes, but I remember reading about it.

    I feel bad for your hospice doc's pts, but glad for you that you've decided not to stick with him.
  8. by   aimeee
    This is a physician that actually works for the hospice? Unbelieveable!
  9. by   JennInColumbus
    My parents have published extensively about the undermedication of hospice patients. Try a search for Karl Miller, MD and Martha ( or Marti) Miller RN if you are looking for journal articles on the topic.

    Hope this helps.
  10. by   ray2512
    My first advice would be to go to your CEO, if that doent work go to your board of trustees. This is an outrage. You should also consider recommending him to go to NHCPO conferences where he can learn something. If all else fails go back to the board and suggest his dismissal. After all this is what hospice is all about!
  11. by   mc3
    Hi everyone,
    Just to update you all...I've just been so busy I haven't even had time to look at this board...
    I did change teams with a different hospice MD. But, guess what. Shortly after I got there, they changed MD's and guess who is the new team MD? However, our team manager is well aware of the situation. Currently working on getting our facts together. Lately? We have a COPD pt who has major anxiety issues (no surprise, poor thing). Has significant SOB, esp. when anxiety increases (which happens at the drop of a hat). She's been getting neb tx, etc. as well as PRN morphine and ativan 2-4x day (mostly 4x). Primary wants to schedule it. MD says no. Why? (I was there, I heard it..) "because she smokes so much. If she'd stop smoking, she'd be fine" Not the first time he's made smoking comments about this pt, either. Un____believable!!! Am also finding pain management difficult here in FL, even with hospice MD's, is terrible. Will order MSIR q6-12 hrs (duh, peak is at 4 hrs!!!). Love to order Darvocet, I've never seem an order for Percodan/set. Will order methadone only for pt w allergy to MSIR. And use methadose for end of life. I was taught gold standard for EOL was MSIR c Ativan for pain AND SOB! Was told titration of methadone was "too difficult". What's difficult about monitoring closely especially at "Day 5"? If you can't do the conversion (and you should know how) call your MD or your pharmacy or HP. Difficult??? I get very discouraged alot of times. Are all FL hospices like this? Perhaps it's because I come from the north where they seem to be much more progressive in this area.
  12. by   canoehead
    Morphine nebs might be useful. He's a real stinker.

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