Doc that hinders pain management

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I will try to summarize this as shortly as possible-

I am new-ish to ICU (6months in) and have 2 years total in nursing. There is this doc that works in our ICU that gives all new ICU nurses a "hazing" period... But I swear he is giving me a run for my money!

First situation- young 30-somthing old male dying of advanced liver disease due to alcoholism. Was a DNR and actively dying. He was on pressors- but his POA wanted those turned off and let him go peacefully. He was moaning with every breath he took was in a coma, tachycardic and diaphoretic. He had NO pain meds ordered. I asked this Dr if there was anything we could do to make him more comfortable and stated my observations. I was told by the Dr that I needed to be more "objective"........???? I was like *****! He said "He's been that way since he got here"............ummmmm- that doesnt mean he is not in any pain!! Needless to say- I went my whole 12 hour shift without giving this person anything for comfort. He died the following day on another nurses watch- but I felt horrible- how am I supposed to be an advocate in a situation like this??

2nd situation-

Older patient. Was a full arrest a few days prior with approx 30-60min in asystole. Follow up EEG showed minimal brain function. Patient was extubated and placed on comfort measures which was a whole 2mg morphine q2h.

When I called the SAME doc for additional meds to make him more comfortable (pt was guppy breathing, gurgling and family was demanding for some relief) he said "your doing this again......" and carried on about how people dont die in their sleep- I was irritated enough I wasnt listening at this point. Anyhow, he increased the order to 4mg q2h. THEN proceeded to call the charge nurse to have HER assess MY patient and call him to basically validate my assessment skills. He also told her to make sure that I know "that we dont give meds to kill people"......

EXCUSE ME! I was HOT.

I know I am a good nurse, yes I have things to learn and I am eager to learn, but come on now. I was an aide on a hospice unit prior to nursing and death is not new to me.

I just feel like he is almost punishing me bc I am new to ICU... or maybe punishing the patients (like the alcoholic who basically gave himself the disease, etc)...

But am I wrong for feeling upset about this? I need some guidance. An event report was placed about the first incident. The second just happened.

What orders have you all seen for end of life care comfort measures? What are your hospitals policies, etc? I am at a loss here. I want to have a sit down with him and see what the heck I did to make him dislike me so much (as these are only a few minor things that he has said/done to me).

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Wow just wow! I work in a facility that basically gives out PCAs for everything just to cover their butts with the HCAP (I know that abbreviation is missing a letter or 2 but oh well) scores. We also have a separate service for Palliative care patients with standard pain medication orders to keep people comfortable. I don't care if the patient did this to themselves or not keeping someone comfortable through the death process is just the right thing to do

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Specializes in Acute Care, Rehab, Palliative.

Our patients go on PCA pumps with a continuous morphine or Dilaudid delivery plus a bolus that we can use.We can generally titrate up until the patient is comfortable. Or we get a SC order, usually 1-10mg morphine q 15 minutes.

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Im glad I am not the only one who thinks this is BS. I am still irritated. But I am also on the ethics committee at my hospital and this will be brought up. I have also notified the charge nurses and event reports have been filed. I just think this is crap.

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I ran into this issue when I worked neuro stepdown. I had a patient with terminal cancer that was metastatic to basically everywhere. Constant pain. The combinations of meds the attending wrote for were not enough to get it under control. The patient belonged to our hospitalist service and the hospitalist who the patient had sucked at their job. Would not put the pain management consult in. Things were worse for the patient (pain control wise) who really wanted pain control and to go home on hospice. I checked in on the patient before getting report and set my plan into action. I'd had enough and figured a way around it.

Our pain management service was in house 0800-1900 most days. The attending from the hospitalist service that a patient was assigned to got any/all questions/requests/issues from 0700-1900, 1900-0700 was the on call hospitalist/intensivist coverage who got it. I looked at who the hospitalist on call coverage was (it was one of our favorites). So I paged the pain service pager with the extension for our unit, they called back, I tell them I have a patient for them, but need about 10 minutes before the order will be in. They agree to come up, and see the patient before leaving.

While I was getting report at 1900 I page the hospitalist on call who called back basically immediately. I explained the situation about my patient's pain, that nothing we'd tried was helping. The on call asked what I thought would help my patient, so I explained that I really felt the pain service might be a good resource for this patient. The on call asked why pain service wasn't already involved, and I explained that the attending the patient was assigned to had refused to put the order in. The on call attending put the order in for me. Pain management saw the patient, adjusted meds and we FINALLY got the patient's pain under control.

The next morning, I had 4 coworkers to give report to, and was still on the unit when the assigned hospitalist rounded on this specific patient. They were furious we'd gotten the pain service involved. Yelled at me. It's not like I cared - I did my job. The on call from the night before had come up to check on that specific patient, and was on our unit at that time. It's not a surprise, the doc who'd been on call the night before ended up professionally taking my (and the other nurses' side). He explained I'd done my job by relaying a patient concern and his judgement was that the patient needed to be followed by the pain service.

I've since moved on to another job elsewhere. I still talk to nurses from my old unit, and as it would turn out, this incident is part of how this doctor (the assigned hospitalist for days) was gotten rid of.

There is probably a way around it, you may just have to be creative about finding it. The other issue is, and you have to be careful how you handle it, but you can go above an individual attending physician's head. You can't do it for piddly things (not liking so and so) but you can and should follow your facility's policy/guidelines about attendings who are not meeting patient needs/providing safe care/etc. You need to figure out what the policy is at your facility because there may legitimately be times where you have to go above Dr. So-and-so's head to protect your patients, yourself and your license.

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I was so worked up about your experience and sharing mine...I missed your last paragraph about orders etc for patients.

When I worked neuro stepdown we had two sets of orders for comfort care/hospice patients that were pretty standard. The first was for Morphine, Ativan and Robinul as frequently as q30 minutes (generally a little higher dose than the recommended dose would ordinarily be). The second was for Morphine, Ativan and Robinul as frequently as q15 minutes. Frequently there were other orders related to what made the patient comfortable - if a patient struggled with nausea - there were orders for zofran and phenergan. If a patient had been on a PCA or continuous pain medication infusion, they were left on that. We left patients on oxygen if they/the family desired it. Most of our docs wrote for meds to treat whatever else may have made patients uncomfortable in any way (ex steroids etc). Informally, we did vitals every shift or as requested by the family (and/or skipped them as refused by the family). We tried to do as much of an assessment as possible each shift, but again, depends on the family's wishes. We did (or at least offered) other things like turning/repositioning, baths, mouth care, and spending time with patients/families - but that's part of our jobs anyways.

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