pt safety question, please help pt safety question, please help | allnurses

pt safety question, please help

  1. 0 Ok, the problem that I have is with Hospice and the rules. I am a LVN at a hospital and I had a pt last night that is on hospice. The Dr. and the family is waiting for the guy to die, so at the start of my shift the Dr. had ordered for the pt to receive Dilaudid 1mg EVERY hr PRN. However I did not feel comfortable giving that much and I told the family that it is PRN and the pt was sleeping and VS were all normal. So I gave 4 doses thru out the 12hrs, so he did not die thru the night. The Dr. got there at 5am and noticed the pt had not died yet, he took the charge nurse aside and told him to have the family step out and smother him with a pillow! He in turn told me what the Dr. said and I about freaked at how he could even say such a thing. Anyway, the Dr. came back at 0700 and ordered Dilaudid 1mg every hr (not prn) and adivan every half an hr until death. Of course the Pharmacy called up to clarify the order and told the on coming nurse that she did not have to give that much and to use her judgement with it. She had the same feeling as I did. This is not right and she also said there was no way she would give that much just to speed up his death, and with 5 other pts there was no way to even keep up with it.

    So, what can I do or because he is on hospice it is ok to give him lethal doses to speed up his death.
    P.S I just called to check to see if he had died yet and he is still alive, with good vital signs.
    •  
  2. 20 Comments

  3. Visit  4_Sq profile page
    #1 4
    This sounds to me to be a scary situation, hospice or not.
    If there is validity to the Dr. making a statement like that, I would think it is a
    criminal matter, and I would quit this employment.
    Hospice is a place where people go to die a peaceful comfortable death. It is not
    a place of euthanasia, and this sounds like a place I would not want to work at.

    Be very careful of your practice, it could be jeopardized in such a workplace.
  4. Visit  NayRN profile page
    #2 3
    Really? Because the doc crossed the line of not only euthanasia, but conspiracy to commit murder, and anyone who heard this directive to smother the patient with the pillow is just as guilty as he is if he is not reported. Not that I don't believe you, but your story sounds pretty incredible. I mean, as nurses we often give high doses of morphine and ativan to ease a patient's passing, decrease air hunger, sedate them, etc. but nowhere under any circumstances is is legal to intentionally give lethal doses of a drug (like 50 of morphine) or to mechanically induce death. That's not hospice, it's murder.
  5. Visit  mazy profile page
    #3 1
    I have a very hard time believing this story.
  6. Visit  leslie :-D profile page
    #4 2
    op, i do believe you, as incredulous as it sounds.
    (and that dr. is one stupid man.)
    NO- this is not ok at all.
    hospice never medicates "until death".
    and it is never ok to do so.

    seriously, i would file a report against the dr., submit to nm (with cc to DON) and refuse assignment all together.
    i'm thinking your risks/legal dept would not be ok with this at all.

    get away from this assignment.
    if, after submitting your report, orders remain unchanged, then it's time to get away from employer.

    do not discuss this with anyone except your superiors.
    and worth repeating, put everything in writing (same as what you posted here).
    take action immediately if able.

    let us know how it all pans out.

    leslie
  7. Visit  imintrouble profile page
    #5 0
    The OPs story does not sound far fetched to me.
    Death by morphine, administered by the nursing staff, is not as far fetched as most people would like to believe.
    Last edit by imintrouble on Jan 8, '12 : Reason: Discretion
  8. Visit  KelRN215 profile page
    #6 1
    That the order said "until death" would bother me, but I have had End of Life/Comfort Care patients who were on continuous doses of morphine, dilaudid, versed, ketamine that I'm pretty sure would kill a horse. I had an 8 year old who died last year on 100 mg of morphine an hour. He was on this dose for days (along with continuous ketamine and high dose q 4 hr ativan) before he died. My facility has a very specific protocol for escalating the doses of narcotics and benzos with patients on comfort care. So, OP, no, it is not ok to give "lethal" doses of these drugs for the purpose of speeding up death but in hospice patients, you would often be giving doses of these meds that would be considered lethal in other circumstances. Like, you would never give 100 mg of morphine to a post-op patient. The important thing is to titrate these meds appropriately to keep the patient comfortable.
  9. Visit  nurse12b profile page
    #7 0
    I know it is unbelievable, and I would never believe it myself if it didn't happen. I am off today so I don't know if he passed away or not, I will call my friend that is working in a bit to ask. One thing I can say is that he is a fighter for life. I have made a few phone calls but since it is the weekend no one has called back. I just feel horrible about the whole situation, and this is what happens in America.

    I did not become a nurse to help kill people! I agree with all of you that hospice is supposed to help the pt to be comfortable until the end, not kill the pt.

    I am such a new nurse and didn't know if I could do anything because he is hospice. And my charge nurse just told me to use my nursing judgement on giving the medication and it is up to the family.
    I know I must be careful on how I follow thru with this because I will probably be on my own.

    Being a real nurse is nothing like nursing school, or being an EMT. I can honestly say that I am afraid!!
    I keep going over in my head,"did I document enough" most likely I didn't.
  10. Visit  KelRN215 profile page
    #8 0
    Quote from nurse12b
    I know it is unbelievable, and I would never believe it myself if it didn't happen. I am off today so I don't know if he passed away or not, I will call my friend that is working in a bit to ask. One thing I can say is that he is a fighter for life. I have made a few phone calls but since it is the weekend no one has called back. I just feel horrible about the whole situation, and this is what happens in America.

    I did not become a nurse to help kill people! I agree with all of you that hospice is supposed to help the pt to be comfortable until the end, not kill the pt.

    I am such a new nurse and didn't know if I could do anything because he is hospice. And my charge nurse just told me to use my nursing judgement on giving the medication and it is up to the family.
    I know I must be careful on how I follow thru with this because I will probably be on my own.

    Being a real nurse is nothing like nursing school, or being an EMT. I can honestly say that I am afraid!!
    I keep going over in my head,"did I document enough" most likely I didn't.
    Honestly, I don't worry about my documentation with a hospice patient as much as I do with any other patient. On hospice/comfort measures, you're not doing VS and you're basically just managing meds to keep the patient comfortable and dealing with the family. When a patient is on hospice, the outcome is fairly certain- the patient is ultimately going to die. I know that no one reads anything I document and that the only time it would really matter would be if a case were to go to court. Of course, I document on all patients as thoroughly as possible always aware that that could happen but with a hospice patient, it's not something I'd stress about.

    I would also suggest not getting too wrapped up with this patient when you are not currently on duty. I used to call in to check on my patients (especially the dying ones) all the time but I find I'm much more effective at my job if I only worry about it on days when I'm there. My patients die... it happens and it's going to continue to happen. My days off are for me to do things for myself and to not worry about work.
  11. Visit  vic_rn profile page
    #9 2
    I have never worked for hospice, but have provided end of life care for hospital patients. Feel free to correct me if I'm wrong, but 1 mg of dilaudid and ativan, while a large dose in a general patient population, does not seem out of line in an end of life situation. When I've worked with these patients, we always use continuous infusions of narcotics and benzos to ensure comfort, with additional PRN doses if needed. Is it possible the doctor was concerned for the patient's discomfort if not receiving these doses? Has he watched other patients suffer due to a failure to provide appropriate medication? Was he trying to prevent an onset of discomfort that may be difficult to overcome once it has begun? As for the comment, I have said and heard many statements in moments of frustration. Things you would never say to a family member or patient, but say to a colleague to vent. It does not make it right, the comment you mentioned is way out of line, just something to consider. If in fact, he truly wanted to speed death and not assure that the patient encounters a peaceful end... scary!
  12. Visit  mazy profile page
    #10 0
    I agree that the way narcotics are dosed in hospice care can be startling and confusing to someone who is not familiar with how hospice works. And as KelRN pointed out, a dose that would be lethal for a patient in post-op would be acceptable for a hospice patient, especially if those drugs, in a best case scenario, were being monitored closely and titrated to need.

    So it's really hard to make a judgement call about the med angle of this scenario.

    What I am having trouble believing is that the dr. told a nurse to smother the patient with a pillow.
  13. Visit  heron profile page
    #11 3
    I agree with Leslie that the OP as written is completely wrong, wrong, wrong.

    But, I'd be interested in hearing more about the context. What did the patient need to stay comfortable before he became unresponsive? Are these new dosages or an approximation of what the patient was previously taking?

    We have no way of knowing what a patient feels if he is not able to talk to us. Vital signs are not always a clear indicator.

    Euthanasia is not part of the hospice mission. Period.

    That being said, hospice caregivers do most of our work in the gray areas of medicine ... blanket statements about "death by morphine" are a profound distortion of what we do and why we do it.

    ETA: I have had a number of patients, primarily end-stage COPD, who could not be awake at all without being in a panic as they felt themselves strangle. I gave meds precisely to make sure they stayed asleep as it was the only way left to give them any peace at all.

    It's all about context.
    Last edit by heron on Jan 9, '12 : Reason: added point
  14. Visit  iceecat profile page
    #12 0
    If such is really the case than orders need to be clarified, the ultimate goal is comfort. 1mg per hour dilaudid with some benzo's for an actively dieing hospice patient is a minimal dose and when you say vital signs are good....were you taking VS on a hospice patient every hour? Yes the pillow comment is way out of line and I would report that. As far as the medicine being a PRN order....than you gave it PRN and that was fine. The fact that the order actually read "until death" is inappropriate and I have never met a hospice/palliative/ or intensivist that would ever actually use those words in an order and have a hard time believing the order was written that way albeit the thought was there, but if true than that needs to be reported. As a previous responder noted hospice does not medicate "until death" but to comfort. I am not surprised that pharmacy called to clarify the ativan order but for them to suggest to the RN that she did not have to give the med as ordered....I have never met a pharmacist who would suggest that to an RN and it crosses a line for them to suggest that. If the pharmacist has issues with the order than they can hash it out with the MD. There is a lot of problems with this whole scenario and if such is actually the case then I would step out of that assignment as well....sounds like a jeopardizing situation.

close