Crazy MD orders that caused stress or concern...

[xtxrn, ASN, RN]

One of the lousiest orders I ever got (and the doc was there, charting) was to give Insulin R- 100u IV.. The patient's blood sugar was in the mid 400s (high enough to treat ASAP, but not having symptoms) She had large ketones (don't remember if those were in the blood or urine)... I'd been a nurse for about 5-6 years at that point- NEVER gave that much IV.

I was in charge (no patients) and wasn't going to ask the patient's nurse to do something I wasn't comfortable with (though I told her, and she was glad I dealt with it). I got the insulin and showed the doc- he said yes, that's what he wanted. I drew up the 100units- showed him, and he said yes. I then said "OK, c'mon" and had him come with me while I gave the stuff (figured he could stand there when I had to run for the D50W).

On the way to the room, I asked him why so much.... he told me it was to deal with the ketones more than the blood sugar. We got to the room, and I gave the insulin IV. The patient did fine, and the doc informed me of why he ordered what he did.

Had a nursing home patient who was dying slowly. And not peacefully. I was the sup on W/Es, and they called me to look at the morphine orders...they were reasonable- don't remember exactly what. But, the lady's respirations were 12 (low, but not catastrophic) and labored. She was uncomfortable. And the nurses didn't want to give her something that would do her in- I called the doc, and got parameters for the MSO4...___mg q 4h IM (not so much IV back then) prn pain or respiratory distress; give if respirations >4. I was glad the patient got the relief; the nurses were glad for the parameters, and essentially permission to give the stuff...

[blondy2061h, MSN, RN]

I would never worry about respirations in a patient who was actively dying and a dnr/dni when treating pain.

[Glageman]

I agree.

[NurseLoveJoy88, ASN, RN]

I concur with the above, that is kind of the goal in the actively dying.

[xtxrn, ASN, RN]

Time frame for this- It was not long after all admissions to a hospital or nursing home were required to get advanced directive information, so DNR status, while not new, was not seen as permission to keep someone comfortable to the point of medicating when the vs were somewhat (or a lot) altered. :)

There were several years when the palliative nursing practices were being put in place- this was before that. :)

DNRs were often "do what you think is right" (my instructions from my supervisor at my first job out of school at a nursing home).

Palliative care and hospice were not everyday terminology. :)

And I agree- the lady needed to be comfortable. The floor nurses just didn't want to be the ones to actively 'end it'....and I can understand that. No matter what peoples' beliefs are, euthanasia isn't legal in all 50 states- only OR, and ? other..... :)

[rnccf2007, BSN, RN]

Although this is deviating from the original post, from later comments, just had to share my thoughts and experience on giving morphine and other meds to those who are actively dying. I don't understand why some nurses are afraid to give these meds. It is not euthanasia. As a relatively new nurse, I was caring for a patient who was actively dying. Morphine IVP was ordered q1h prn. The physician specifically told me to make sure that this patient got this med every hour so that he could die with as little discomfort as possible. His NP came in later in the day and stressed this also. I made sure that the patient was given the morphine every hour (as close as I could get with 4 other patients). I was told to pass this information off to the next shift, which I did. I came in the next morning and saw that the morphine had been administered only once during the previous 12 hour shift. I was upset. The nurse caring for this patient (with 20+ years experience) informed me that she was "uncomfortable with killing someone and it is against my religion." To be honest, I was very angry and had visions of tearing her hair out by the roots. Later in the morning, the NP came in and again stressed making sure the morphine was administered q1h and to make sure that the next shift knew this. By then I was fed up, because this was a prn order, so "Ms. Uncomfortable," who would be coming back for the next 12 shift, did not have to give it if she did not feel the need. I asked for my first order for a morphine drip. Granted. Two days later, I came to work and several co-workers thanked my for "my courage." In the end, I actually set a precedent at our facility for those actively dying. I would hope that if I am ever in such a situation my self, someone will have the "courage" to let me die with as little distress as possible.

[RN58186]

I was working an 8 hour night shift on renal transplant. I came on shift, and was told I would be getting a new transplant from the OR and she/she wasn't back yet. Since transplants were (in those days) 1:1 nursed for 24 hours post op, I didn't have any other pts so I started helping out the other nurses. About an hour into the shift the transplant surgeon came to the unit and asked which nurse was going to be getting the pt. I said I would be and asked how the surgery went. He said it went well, and went on to tell me that I was not to check VS at all on this pt overnight (not even on return from the OR) because he didn't want to be called if they weren't normal. (New transplant pts in our facility have VS done q1h x 12 hours, then q2h x 12 hours along with CVP monitoring and I&O.) After I picked my jaw up off the floor, I point blank told this doc that I would be checking VS and I would be calling him if there was a problem. His response? "Well, don't be surprised if I don't answer my pager." Thankfully the pt did well that night, and in the morning the nurse manager and I were having a very intense conversation with the medical director of the transplant program. When the medical director and nurse manager spoke with the surgeon he asked them what he was supposed to do because he couldn't handle all there "aggressive women". (He was Algerian and wanted the nurses to stand when he arrived on the unit, give up their chairs for him and not question what he said.) The surgeon did not get his contract renewed and is now in another part of Canada. They are welcome to him.

[xtxrn, ASN, RN]

I was working an 8 hour night shift on renal transplant. I came on shift, and was told I would be getting a new transplant from the OR and she/she wasn't back yet. Since transplants were (in those days) 1:1 nursed for 24 hours post op, I didn't have any other pts so I started helping out the other nurses. About an hour into the shift the transplant surgeon came to the unit and asked which nurse was going to be getting the pt. I said I would be and asked how the surgery went. He said it went well, and went on to tell me that I was not to check VS at all on this pt overnight (not even on return from the OR) because he didn't want to be called if they weren't normal. (New transplant pts in our facility have VS done q1h x 12 hours, then q2h x 12 hours along with CVP monitoring and I&O.) After I picked my jaw up off the floor, I point blank told this doc that I would be checking VS and I would be calling him if there was a problem. His response? "Well, don't be surprised if I don't answer my pager." Thankfully the pt did well that night, and in the morning the nurse manager and I were having a very intense conversation with the medical director of the transplant program. When the medical director and nurse manager spoke with the surgeon he asked them what he was supposed to do because he couldn't handle all there "aggressive women". (He was Algerian and wanted the nurses to stand when he arrived on the unit, give up their chairs for him and not question what he said.) The surgeon did not get his contract renewed and is now in another part of Canada. They are welcome to him.

Yikes

I had a doc not order accucheks on a pt admitted with hyperglycemia because he "didn't have to deal with things he didn't know about'.... the pt got checked anyway.... I reported it to the ethics committee. Fortunately the patient did ok....no thanks to his doc.

[xtxrn, ASN, RN]

Although this is deviating from the original post, from later comments, just had to share my thoughts and experience on giving morphine and other meds to those who are actively dying. I don't understand why some nurses are afraid to give these meds. It is not euthanasia. As a relatively new nurse, I was caring for a patient who was actively dying. Morphine IVP was ordered q1h prn. The physician specifically told me to make sure that this patient got this med every hour so that he could die with as little discomfort as possible. His NP came in later in the day and stressed this also. I made sure that the patient was given the morphine every hour (as close as I could get with 4 other patients). I was told to pass this information off to the next shift, which I did. I came in the next morning and saw that the morphine had been administered only once during the previous 12 hour shift. I was upset. The nurse caring for this patient (with 20+ years experience) informed me that she was "uncomfortable with killing someone and it is against my religion." To be honest, I was very angry and had visions of tearing her hair out by the roots. Later in the morning, the NP came in and again stressed making sure the morphine was administered q1h and to make sure that the next shift knew this. By then I was fed up, because this was a prn order, so "Ms. Uncomfortable," who would be coming back for the next 12 shift, did not have to give it if she did not feel the need. I asked for my first order for a morphine drip. Granted. Two days later, I came to work and several co-workers thanked my for "my courage." In the end, I actually set a precedent at our facility for those actively dying. I would hope that if I am ever in such a situation my self, someone will have the "courage" to let me die with as little distress as possible.

This was when this was all very new. Once it became more common, they relaxed a bit, and understood that morphine wasn't just for pain but to also ease respiratory distress. :)

[Ruby Vee, BSN]

years ago i worked at a teaching hospital in the midwest in the micu. patient was nasally intubated (they all were in that institution at that time -- don't know if they still are or not) and had been on a vent for a week. he kept asking for gum. doctor wrote an order to give him gum . . . . i refused and doctor tried to have me fired.

the next night i came in and they were bronching him to get out a piece of gum . . . .

[leslie :-D]

This was when this was all very new. Once it became more common, they relaxed a bit, and understood that morphine wasn't just for pain but to also ease respiratory distress. :)

this is true.

however, there still remain a boatload of nurses who resist in giving prn mso4, fearing they'd cause the death.

if drs/nps are that adamant about pt giving it qh, then let them order it scheduled.

leslie

[leslie :-D]

ok, the only orders i outright refuse, is r/t legality and if pt will suffer.

working inpatient hospice, i've gotten orders to give ________mg of morphine s/ivp qh, until respirations cease. (usually 50mg+).

there is one incident that i refused to do.

an elderly lady who had a gtube, was put on hospice, and refused to take anything via gtube.

pt told dr she wanted cookies.

dr wrote order to "eat as desired", noting that food is a pleasure of life.

i refused.

the first nurse that gave her something to eat (cookies), pt aspirated and later died.

a pleasant death, for sure....not.

food is a pleasure, IF one can eat it w/o aspirating.

otherwise, it's a nasty way to go.

leslie