Feeling a little blue (kinda long)

[jessiern, BSN, RN]

Ya'll, the last two days have been killers. We have one of our regulars in the hospital. She has always been so sweet, and the nurses love her and her family. Only this time, she is in the process of dying. And it is very painful.

She was sleeping peacefully when I first saw her on Monday. At 10 the family called me in the room. She was jerking in the bed, moaning, and crying out in pain. Every muscle in her body is tense. She was so obiviously in severe pain. And she looks for frail. The only thing she had for pain relief was morphine 2 mg IV. After 20 minutes, she was showing no relief. I call the doc. All he'll do is give 1 more mg. And that cycle continues for 4 hours till it is time for another 2mg. then the cycle starts again. The whole time this woman is in pure physical torment. I try everything I can think to do. Repositioning (causes more pain), heating packs, ice packs (no help, since we really don't know where she hurts), rubbing her tense muscle (doesn't seem to help). I'm at a loss. We end up just holding her hand, me and her daughter. We tried singing to her, and that seemed to calm her some. Finally, by 5:30 that night she calms down. I don't know if she finlly got pain relief, or if she is just too exhausted to keep on fighting. The doc also came at 5, and sees that I am not crazy, and what I said was true. Ups her morphine to 7mg hourly prn. HELLO! Morhpine isn't helping. Can't we try something else. Well my shift was over. I called around midnight (surprise, I can't sleep), and she started back right after I left, and has yet to settle.

The next day, the nurse reports to me that she has had to output since 3 yesterday. She is wraithing in pain when I go in the room...I do a quick assessment, and I find that her bladder is distended. So I put in a foley (with hopes that the doc will give me an order for it). Immediately has 950 cc out. And she comes down. So I think God, and think that was the source of her pain. Her relief lasted till about 1100 that day. And I spent the rest of the day the same way as before. 7mg of morphine every hour. By 6 she is calmed again, but her resp are 12. I'm not giving any more morphine.

The doc is trying to find out what is wrong, but the family doesn't want any test or anything done that will cause her pain. They begin by 12 yesterday refusing to let me turn her. They are wonderful, and just can't stand to see her hurt so badly.

I have never hated nursing as much as I do right now. At one point, we have me, two hospice nurses, and a sitter (a retired rn) at her bedside, and could do nothing for her. All that education, all the skill, and there was nothing we could do for her. Just hold her hands and pray, and at least hope that she realized we where there with her. I feel awful.

[bigsyis]

I am really surprised that the the Hospice Nurses hadn't assumed control of her care. They have their own orders for pain meds and comfort measures that can be adjusted based on their assessments. Please be sure that you check w/them first, and forget that MD. He obviously isn't interested.

Also, I am sorry that this lady is experiencing so much pain, but with the Hospice comfort measures that should ease considerably. You did everything a good nurse should do to help her become comfortable. I will tell you now that there will be times when all you can do is hold the pt's hand and talk, or pray, or sing with them. Or, it may be a family member that you have to help through this as the pt passes. All of these things are Nursing measures. We can never know for sure how much they help a dying pt, but if she eases or quietens any at all, it is likely because she is getting comfort and some kind of relief from your presence and the care that you are giving her.

[TigerGalLE, BSN, RN]

Have you tried ativan? Sometimes ativan + morphine helps calm them down.

[leslie :-D]

what the heck did the hospice nurses say during all of this???

it sounds like she needed a heck of a lot more morphine as well as a sedative.

and if she was still in pain w/rr 12/min, i would have fought like a banshee to give her more (if there were parameters to hold).

2 hospice nurses and no interventions????

that sounds criminal...:angryfire

leslie

[jessiern, BSN, RN]

Have you tried ativan? Sometimes ativan + morphine helps calm them down.

Can't try that without a docs order. And believe, I spent all day on the phone trying to get something else.

2 hospice nurses and no interventions????

that sounds criminal...:angryfire

She isn't currently under hospice care during this admission. This admission diagnosis is not related to her hospice diagnisis. They just came by to check on her, but she is not under their care at this time. We are talking to the doctor about readmitting her to hospice.

[leslie :-D]

who have you been contacting regarding better pain mgmt?

the same doctor?

it's time to get the nm, or DON (if need be) involved.

either one should advise you as to who you should pursue, in terms of advocating for this pt.

but please, do not stop fighting for this lady.

time is wasting away while she writhes in pain.

also, make sure you thoroughly document your pt's responses to the morphine- the moaning/groaning, restlessness, grimacing, etc.

please jess, don't give up on her.

turn your "blues" into spittin' mad.

this will afford you to take some much needed action.

leslie

[CrunchRN, ADN, RN]

This is really awful. Can the family call the MD and demand that either he prescribe medication for comfort care or change her to hospice status so the hospice MD can take over an d arrange appropriate medication management?

I am so glad she has you as I can tell you are a very compassionate nurse.

[jessiern, BSN, RN]

Well, she has been changed to hospice this am. They have d/c the IV morphine, and started different types of pain management. She is more comfortable now. I feel a little better. She's still hanging in there.

[crissrn27, RN]

Thank goodness they have readmitted her to hospice. Bless you for caring enough to fight for better pain control for her.

[CrunchRN, ADN, RN]

Well, she has been changed to hospice this am. They have d/c the IV morphine, and started different types of pain management. She is more comfortable now. I feel a little better. She's still hanging in there.

This is wonderful. Good job!

[anonymurse]

You probably already did this, but I've seen a lot of interns lately d/c'ing meds on admission that old folks have been on for YEARS and have become dependent on for comfort, particularly benzos. So when I have an older pt with discomfort, I check the admission med rec to see what got d/c'd and by whom. I also ask relatives if something may have been left off the admission med rec (how well it got filled out frequently depends on who was available to take the pt to the ER).