Inpatient hospice patient on a Med-Surg floor

[IdislikeCODEbrowns]

So I work on a med-surg floor with specilization in oncology and are the floor for our contract hospice patients. I picked up an extra day shift this past weekend and at 1745 I get report from our IMU for a patient who is a DNR, comfort care only, possible hospice referral in the AM...she had originally had breast CA with the onset of massive infection and was in multi-organ system failure. The family had, had her extubated over a week before this decision to put her on hospice and she had actually been coded down in vascular surgery the night before when she went in for emergency placement of a dialysis catheter to try to treat renal failure. Anyways, per family's request, she was to be given 2mg Morphine q2hr, alternated w/ 1mg Ativan q2hr, so every hour she would be getting one or the other. I had no problem w/ this b/c I knew she was actively dying, so why not let her be most comfortable, after all, the painful cancer tumors were still present, the fact that she can't 'verbally' express her pain is the only factor missing. The family was refusing vital sign checks on our routine schedule as they didnt want to know what exactly was happening. When I gave report to the night nurse she seemed very uncomfortable with the med schedule that was prescribed for her. When I told her that we were not hastening the patient's death, she quite frankly said, "Yes we are." I am a little upset at her reaction mainly d/t the fact that there is so much mis-information out there about pain control at the end of life and I am concerned that maybe this may have prevented her from providing the meds on the before-stated schedule throughout the night, resulting in great patient/family suffering. I called to check on the patient around 11pm that night and my CN said she was still w/ us but after that I haven't heard any updates. Anyways, what I guess I wanted to clarify was if by 'agreeing' to this med schedule for this hospice pt., was I being 'Nurse Kevorkian'? Last vitals before transferring to our floor was BP 100's systolic and O2 sats in the upper 60's; pt. was unresponsive and agonal breathing when I received her. Any thoughts?

[SHGR, MSN, RN, CNS]

The night nurse's response seems strange. Was she a float from another area? I worked on a unit for many years that sounds very similar to yours. We were pretty liberal with pain and comfort meds, and all on the same page about hospice goals of keeping the patient comfortable and providing support to the family.

If these medications shorten the patient's life by a bit, so be it. All the invasive curative (futile) treatments have been removed. Surely that shortens life too. I would hate to have this nurse making end-of-life decisions for me, though she might be great at med-surg.

[sapphire18]

Following this prescribed med schedule does not make you "Nurse Kevorkian," in any way. The patient was actively dying whether she received the pain and anxiety meds or not. By giving them you at least know that you helped in her suffering.

[eleectrosaurus]

interesting question, to a newbie the ativan dose was alot higher than the standard "im feeling anxious" dose im used to administering, i looked up the ativan and noticed the half life is 9-16hr and the max dose (on iv infusion) is 20mg/hr with nephrotoxic risks. so im not getting how it works for this patient. are we keeping her knocked out at all times?

i'd love to hear more about the pharmacology of the ativan in this situation if anyone knows. thanks.

http://en.wikipedia.org/wiki/lorazepam

http://www.globalrph.com/lorazepam_dilution.htm

[SHGR, MSN, RN, CNS]

interesting question, to a newbie the ativan dose was alot higher than the standard "im feeling anxious" dose im used to administering, i looked up the ativan and noticed the half life is 9-16hr and the max dose (on iv infusion) is 20mg/hr with nephrotoxic risks. so im not getting how it works for this patient. are we keeping her knocked out at all times?

i'd love to hear more about the pharmacology of the ativan in this situation if anyone knows. thanks.

a non-responsive patient can still be anxious and show signs of agitation. (there are many, many nuances to "knocked out at all times" as you put it and that is some of the art of hospice nursing).

ativan is the shortest-acting benzo- it works fast. it potentiates the effect of narcotics for pain and they are often used together. in a patient with multi-organ system failure whose family declines dialysis, nephrotoxicity is a non-issue.

[leslie :-D]

there is absolutely nothing wrong with this med regimen.

1 mg mso4 hourly, is likely not even touching her, it is such a nominal amt.

and to be satting in the 60's, yes, push that ativan...which as stated, has such a short half-life anyways.

the pt needs this, trust me.

when someone is actively dying, this is not the time for nurses to start questioning/withholding(?) meds.

if you people are to receive hospice pts on your floor, it is imperative that ongoing inservices are given.

leslie

[tewdles, RN]

In the acute medical setting it is especially important to document not only the orders for the medications, but also the intent for the medications.

The intent is not to hasten death but to provide relief from pain and suffering. The SE should be discussed with the family and patient and their agreement with the plan should be documented.

Too many health professionals are opiophobic and rather than treating a patient's actual comfort need, they treat their own fears...generally by withholding meds entirely or by prescribing inadequate type or dosing. This is true in and outside of the hospice and palliative care arena.

[Sun0408, ASN, RN]

I have had orders for up to 10mg morphine and 4mg of ativan q1h for comfort care only pts. Trust me, we did not hasten those pts death with those doses. 1mg ativan q2h is nothing and I would not call it a high dose or using it to "keep them knocked out"..

Some nurses are terrified to give ativan or morphine at end of life. They are scared it will be the cause of their death.. The misconception is amazing and sad.

[curiousauntie]

jul 23 by hey_suz

the night nurse's response seems strange

i don't find the response strange. it is one i have heard many times, usually on med/surg floors where we are doing inpatient level of care. hospital nurses many times don't understand why we use the drugs, and the amount of drugs, that we use. i have explained over and over (usually due to 12 hour shifts on the floor, the patient doesn't have the same nurse for more than one day) that the patient may not be able to say they have pain, or anxiety, or feel short of breath, but that does not mean they don't. a patient with end stage cancer will have pain, shortness of breath, and if they are at all aware, are anxious. once i do a mini-inservice, the nurse usually has no problem with the meds and doses and the "morphine now, ativan in 2 hours, morphine 2 hours later..." especially since i am never sure that if the order is a prn order it will be given.

i am having the same type of discussions right now as i am orienting a "new" nurse to hospice case management...she has 25 plus years as a med/surg/er nurse...she was apprehensive about the amount of morphine we used on an actively dying patient until she understood why...then she was so on board. and kind of upset that the docs in the hospital didn't do that for the actively dying patients in the hospital.

[SHGR, MSN, RN, CNS]

Curiousauntie, I meant that her response seemed strange because the OP stated that their floor is the go-to floor for inpatient hospice, so I would hope that all the nurses there are on board with the concept. It would be a typical response for nurses who were not used to working there, as you described.

[IdislikeCODEbrowns]

To give you all an update: the patient died at shift change a day after she was transferred to our floor, I was pleased to learn that the night nurse on the Sat. night shift gave the meds as prescribed. There are so many misconceptions about hospice and even though our floor is the 'go to' floor for contract hospice patients, they are few and far between, b/c as many of you all know, a good percentage of patients/families wait until the last minute or never even enroll in hospice services, so when they come to our floor it's usually b/c they were in ICU and family decided to withdraw care, etc. I would love to pilot a hospice education program on my floor and this would be a perfect example of a common misunderstanding in these types of situations. Needless to say, this sweet lady died a peaceful death so that is all that matters in this instance, however, I would like to put forth more education so more outcomes like this can happen on our floor. Thanks for your advice :)