comfort care order med dilemma

[adra]

Hello everyone,

I am having an issue I hope my fellow nurses can help me enlighten. I am a beginner in my nursing practice and have been working night shift on a busy intermediate intensive care floor for less than a year now. A few days ago, I have been asked to give metropolol IVPB to a pt with a terminal dx recently switched to comfort care. The problem? No cardiac monitoring, no blood pressure monitoring (part of comfort care measure). Our protocol for med administration do require cardiac monitoring for such a med, yet MD was not understanding that. After much discussion, IVPB was switched to metropolol iv push which I administer with MD at the bedside while monitoring BP. Eventually we had to switch back pt to DNR/DNI and not comfort measures anymore because family was not aware of what comfort measures really meant and wanted IVPB metropolol to be administered. This happened at night time with a covering MD. The day after, primary team came to complain to charge nx regarding the fact I refused to give med as initially ordered and that as a result, the code was changed.

I guess my question is first: what would you have done? In your unit do you have pt with comfort care order set? Do you give med other than med supposed to alleviate symptoms?

FYI: at time of administration, BP and HR were within normal range, rational per MD to give med was to prevent recurrence of SVT that occur the night before while pt was on cardiac monitoring..)

Thank you for your input :-)

[heron, ASN, RN]

One of the hardest parts of end-of-life care is watching abnormalities develop and refraining from treating. The order in question makes sense if the patient was uncomfortably symptomatic during previous episodes of svt. If that's not the case, then the md was treating himself, not the patient.

Treatments are often used if the condition being treated, i.e. pulmonary edema, painful infections like uti or sinusitis, is likely to cause significant discomfort.

[Double-Helix, BSN, RN]

Eventually we had to switch back pt to DNR/DNI and not comfort measures anymore because family was not aware of what comfort measures really meant and wanted IVPB metropolol to be administered.

Can you explain what you mean by this? Palliative care (comfort measures”) involves providing relief from the symptoms, pain, physical and emotional stress of an illness. While palliative care can be rendered to any patient- whether the goal is curative treatment or not- is most commonly offered in conjunction with a DNR/DNI order. I'm not understanding why the patient would have been switched back from comfort measures to DNR/DNI."

Whether a cardiac medication that could potentially cause bradycardia/hypotension should be administered to a patient who isn't receiving continuous cardiac monitoring should be discussed by the family/POA and the palliative care team. If the SVT has caused instability/discomfort in the past and the cardiac monitoring would be too disruptive to the patient, it may still be the best decision to give the metoprolol without monitoring and accept the potential risks. It would be no different, in my opinion, than administering morphine to a patient with a low respiratory rate who is having pain. The goal is to provide the most relief from discomfort possible.

[coffeetalker]

I totally agree with Double- Helix and would add that comfort care is a part of end of life care; DNR/DNI status can mean that up until the moment when a pt stops breathing/ heart stops, everything else is done to treat the medical condition. Also, in this situation the question of if the pt was symptomatic with the SVT should have been asked.

[Here.I.Stand, BSN, RN]

I agree with the others. Our docs generally d/c everything and order a bunch of prn's -- usually morphine, ativan, atropine drops/scopalomine patch (to help reduce secretions), and I want to say Tylenol supps for fever and Dulcolax supps for constipation. I don't think they use an order set because the doses vary.

Now as the PPs said, metoprolol can be continued if d/c'ing it would result in discomfort. If the pt is on palliative care though, you're not going to need to worry about the cardiac monitoring; the monitor serves no comfort-promoting purpose. You can always clarify why it is being continued, and then just give it as ordered.