Question on pancreatic ca

  1. Hi,
    Hope you all can help me...I've written before about a certain hospice MD that I work with that I have absolutely no respect for. I've witnessed his treatment of some of my patients and have been, at times, beside myself. My latest problem is this: I have a pt with pancreatic cancer with mets in her liver, lungs, lining of her stomach, lymph nodes and a tumor that's wrapped around her mesenteric artery. We have been trying to get this poor woman's pain controlled since she was admitted about 2 months ago. She's comatose now, and on her way to a much better place. She's currently on 18 mg Dilaudid IV/hr plus 4 mg q10min PRN, 1 mg lorazepam q4-6hr, Haldol 0.5 mg q4-6 hr and ABHR gel. I've had many disagreements with this MD on how to treat her pain. He maintains that the tumor around the mesenteric artery makes the artery spasm, and that's what causes the pain, therefore, bolus doses should be used to control it. I maintain she shouldn't been feeling the spasms in the first place if we were adequately controlling her pain! He believes that by, giving bolus doses q10min PRN, we were keeping her pain successfully controlled. She's been on Crisis Care and, depending on the nurse, was getting anyware from 10 to 19+ bolus doses in a 24 hr period. I maintain that she shouldn't have had to awaken in pain or appear in pain when asleep to receive the bolus doses, that we should be keeping her at an adequate level to not need the boluses, expect for a minimal amt of times. She'd be OK with an adjustment in the basal rate for 1 or 2 days at the most, then her pain would escalate again. He just kept wanting to increase the bolus doses and not the basal rate. We went back and forth on it many times. I should say, too, that both the patient and her daughter/POA stated repeatedly to me and to this doctor that she did not want to have any pain and would much prefer just sleeping comfortable. I just spent 2 months of every other day on lectures and questioning my judgement just to how much pain the person was having. Last week he stated she was "just having anxiety" and wouldn't even schedule lorazepam for her...Bottom line? I feel our agency, and I, are doing/did a disservice to this patient and family. I am ashamed that this has gone on like this, and I was a part of it.

    My questions, then, are this:
    1) Is he correct in his thinking? This guy's got me so rattled, then I get angry. Having a patient rely on bolus doses for adequate pain control seems crazy.
    3) It seems this doc won't be leaving this agency anytime soon...I'm thinking I might have to in order to do the hospice care that I'm trained to do and keep my patients comfortable. This is the 3rd or 4th situation I've run into with him, he's our Team doctor and my supervisor is aware, but for political reasons he's staying. So, what do I do? I live out in the country, and the next closest hospice is 50+ miles from me.

    Any help would be appreciated. I'm feeling very angry and down about the whole thing.
    Thanks,
    mc3
    PS Sorry this post is long!!
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  2. 7 Comments

  3. by   doodlemom
    I disagree with this doc - it is always better to KEEP the patient comfortable instead of waiting for the pain to escalate and have to take frequent bolus doses. Unfortunately I don't have much of a recommendation for you since it appears that you are stuck. Is your supervisor's supervisor aware of the problem? If you think you are going to have to quit at some point, I would take it as far up the ladder as you can - what do you have to lose?
  4. by   leslie :-D
    this doctor does not have experience in hospice/palliative care.
    the sad thing is he's not receptive to feedback-it's going to be his way.
    clearly chasing a pts pain is anxiety-producing for the pt, and time consuming for the nurse.
    no one wins.
    yes, the basal rate should be titrated upwards but it seems like a moot point.
    what if you printed off some concrete articles (2-3) about managing ca pain.
    cdc, nih, who, jcaho, all have references; as well as the many hospice organizations.
    once you presented some hard evidence that negates his, how would he react?
    how would he respond to some mandatory inservices for all employees, himself included?
    you said your pt is in a coma now?


    leslie
  5. by   grace,joy
    The ENTIRE point to hospice is comfort care the bolus is for BTP, and I agree the dose should reflect need at all times. If there is no one near how will she get her BTP med's? The doc needs an inservice review. Hang in there you sound like a great pt. adv.
  6. by   EmptytheBoat
    How about a home visit from your doctor to let him witness first hand
    your patient's anguish?
    Titrate the basal rate based on the amount of bolus doses, you mentioned
    10-19+, in 24 hour period, it's not rocket science. You may want to
    have your pharmacist speak to the doctor; at 19+ doses, you're looking at
    another 3-4mg/hr added to the basal rate; make sure you are keeping accurate records. May also want to use some morphine/oxycodone concentrate SL prn.
    I would also suggest you increase the lorazepam.
    You are a wonderful advocate for your patient, don't give up until
    your patient is comfortable. Take care!
  7. by   doodlemom
    Quote from grace,joy
    The ENTIRE point to hospice is comfort care the bolus is for BTP, and I agree the dose should reflect need at all times. If there is no one near how will she get her BTP med's? The doc needs an inservice review. Hang in there you sound like a great pt. adv.
    This may sound stupid, but what does BTP mean?
  8. by   grace,joy
    BTP is break through pain. I agree with all the users in methods to teach the doc and increase the meds. Your the kind of nurse I would likwe to take care of my own family. GOD bless you.
  9. by   mc3
    Thanks, everyone. Leslie, I will indeed go to the various web sites and print some articles for him. However, he literally ignores any information that is contrary to his beliefs, especially from a female nurse. He's quite arrogant. I've presented him from information given from an HP pharmacist. It's weird - he just looks at you with a blank look and doesn't respond! As far as an inservice for him? Ha! Our hospice had him do an inservice with us on pain management!!!! Needless to say, I didn't go - what a joke. I also heard that the other teams that had him as a doc didn't go either. Gee, I wonder if mgmt got the message? Also, forgot to mention. I brought up the issue of palliative sedation for this patient in IDT. He looked at me and said "I will not do anything that will depress respirations in a patient, and I will not do palliative sedation at all, any time. It's against my beliefs". He once tried to cut back some morphine on an actively dying patient - she was literally climbing out of the bed. My partner and I sat on that patients bed and held her in our arms for 2 hours until 4:30 when the on-call doc took over, who happened to be our Medical Director. Then we got the orders needed to keep the patient comfortable.
    Yes, it seems everyone in this hospice "knows" but will not do anything about it...
    Urggh!
    Last edit by mc3 on Aug 20, '06

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