Dilaudid tx for cancer pt

[weavrvirgorising]

I have a 46 yr old client with Multiple Myeloma who has intractable pain. We started him on a Morphine Sub Q drip within weeks of admission but due to long term administration of MS Contin PO, the Morphine did not help with pain relief. The MD then switched him to Dilaudid at 10mg/ml concentration( currently at 8mg/hr, although the MD is saying that is too high of a dose). We have also brought on Naproxyn to assist with potentiation of the narcotic so that he uses less of the Dilaudid...and I think it is working. So, I have been asked to wean him down to 6mg/hr now despite liberal original orders that were given for 2-20mg/hr) Along with this...For the last month, we have seen a marked relief from his pain but with it lots of concern by MD director and owner re: high cost of medication. Now the nurse director wants me, a registered nurse to find costsaving ways to avoid the $868/100ml bag cost. One suggestion has been for me to draw the Dilaudid out of a vial, premixed and insert into a empty bag without sterile conditions despite pharmacy's concern that there is no hood being used for sterile procedure. Also suggesting that I might want to mix Dilaudid with another drug like Ketamine for better relief. I am a new nurse(two years) and in addition; my director is also fairly new herself(three years as registered nurse). We really don't have anyone but a long-distant owner who has experience with such options for pain relief. Am I crazy to wonder why I should do what is being suggested when there is noone experienced around who can guide me through this? My director has said she would draw it up for me...but I have a bad feeling in my gut that she does not realize the danger in doing this without proper guidance. What do you think? Ready to bolt...Maggie

[leslie :-D]

this is totally nuts and illegal!!

only your pharmacist should be mixing/compounding medications.

while ketamine is a good idea, the doctor should be ordering the dosages with the pharmacist's collaboration.

your instincts are serving you well.

listen to them.

and i hope your pt remains the priority here.

leslie

[tencat]

Do NOT go ahead and do what they are suggesting you do. Very dangerous for patient and for your license. Do you have access to a pain specialist? In my job I have access to one through the pharmacy we use for medications. I have used them a couple of times. I would continue being a noisy advocate for the patient as the pain is under control and that should be the most important issue here.

[morte, LPN, LVN]

why is the cost an issue? is this patient uninsured? and the dose isnt at all "too high" if it is working and the patients is still breathing.......the MS may still be an option it simply needs to be titrated up more.....there are graphs or whatever that tell you how much iv = po.....prob not started on enough iv.geesh

[leslie :-D]

it really stinks when a hospice's med'l director is not experienced in pain control.

and there are many of them out there.

being a 'regular' md is not sufficient.

you really have to know your meds and their many different labeled and unlabeled uses.

i'd recommend methadone as well, as it is effective and inexpensive.

but from reading your post, i'm afraid this doc doesn't know what he's doing.

please, continue being a voice.

and listen to those instincts.

leslie

[Whispera, MSN, RN]

It also sounds as if the doctor is on of those who worries about addiction more than he worries about pain...?

[Berkshire1995]

This doctor needs to learn pain control. Why is cost an issue? Does this pt have severe bone pain? I would assume so. Try Motrin 800 mg q 8 and try Motrin Speed gel (compunded by the pharmacy). This all sounds crazy to me. I have had patients on 30 mg dilaudid per hour via a pump. And, they were still alert.