Comfort care med protocol??

Blee O'Myacin, BSN, RN · Sep 30, 2007

70 year old pt CHF, ESRD on a vent with dyspnea , b/p 70/30 currently on comfort care only. Dr ordered ativan 4mg/ morphine 4 mg IVP . Due to the difficulty in breathing I gave the morphine dose but was leery of giving the high dose of ativan also. I as afraid of pushing him over the edge with such a low bp. I realize the vent would breath for him but was nervous giving both meds at the same time. Was I wrong in feeling this way? Is this a normal practice with comfort care only pts?

Why was he still on the vent if he was "comfort care"? I would have given the ativan if there were no parameters. By your reasoning, I could say the inverse, why should his remaining time be filled with anxiety and agitation due to the difficulty in breathing and being intubated without a drip? Sounds pretty cruel to me. I'd have given the ativan and investigated why the meds were PRN and not routine or drips.

Blee

leslie :-D · Sep 30, 2007

for a geriatric pt w/esrd, i wouldn't give more than 2mg ivp.

off the vent, i would reassess dosages r/t anticipated struggling.

leslie

nrsang97, BSN, RN · Sep 30, 2007

Since the pt was comfort care I would have given both. But I would have questioned the pt still being on the vent. Where they going to be doing a terminal wean? A lot of times we give meds during a terminal wean from the vent. Usually we give a bolus of morphine then start a drip and can titrate per pt comfort.

I also totally agree with Blee.

leslie :-D · Sep 30, 2007

i've had many pts who weren't weaned.

it was their choice.

there's no such thing as universal comfort measures.

they should be as individualized as the pt.

there is nothing 'comforting' about the thought of gasping for your last oz of air.

in the event this pt is to be weaned, then ms04 and ativan should be given generously.

but while she's on the vent, why give 4 mg of ativan?

esp where renal function is next to nil, giving half the dose will be equivalent to giving the full 4 mg.

if pt still seems anxious, then you give another 2mg.

but to give meds just for the sake of snowing someone, is being presumptuous at best.

and irresponsible, at worst.

leslie

Tweety, BSN, RN · Sep 30, 2007

Is she experiencing dyspnea while on the vent? Perhaps the settings are too low.

Leslie said it best. There are no "protocols" or "normal practice"for comfort care. I also agree that 4 mg of Ativan is a bit much, depending on tolerances, etc. and I might start out lower.

It's not unusual to give both meds together, but I probably wouldn't have given them both together. I might have given one or the other and assessed if they needed the other. This way I have another option if one was not effective.

At this point patient comfort is more important than a drop in BP, so while I would watch it as part of my assessment I wouldn't let it hold me back in giving the meds since comfort is the goal.

starcandy · Oct 1, 2007

Is she experiencing dyspnea while on the vent? Perhaps the settings are too low.
Leslie said it best. There are no "protocols" or "normal practice"for comfort care. I also agree that 4 mg of Ativan is a bit much, depending on tolerances, etc. and I might start out lower.
It's not unusual to give both meds together, but I probably wouldn't have given them both together. I might have given one or the other and assessed if they needed the other. This way I have another option if one was not effective.
At this point patient comfort is more important than a drop in BP, so while I would watch it as part of my assessment I wouldn't let it hold me back in giving the meds since comfort is the goal.

This is what I did I gave the morphine and pt was sedated resps decreased from 30's to low 20's. It was ordered q 1 hr prn. I know the goal is to maintain comfort but I did not want to be the one to speed up her impending death. I assume terminal weaning wwill be discussed very soon.

nuangel1, BSN, RN · Oct 1, 2007

i worked icu for 12 yrs i would have given both .pts comfort care seems uncomfortable i would definetly give meds.regardless of vs and i wouldn't have worried about hastening death.comfort care to me means keep pt comfortable.unfortunately as with hospice pt the med can effect the vs as well .but the point is to make pt as painfree and comfortable as poss.in my exp pts who are comfort care would not be kept on the vent -pt would be extubated.

leslymill · Oct 1, 2007

I had a pt like that with narcotics ordered Q2 hrs, unconscious and DNR. Family in more pain than they were.

The doctor called right after I received report and asked,

"Is she dead yet?"

That changed my perspective.

I was a traveler, I looked up the charge nurse and told her if you want this drug given she would have to administer it herself or find someone compfortable with it. I could care for them, but could not give the drug due to ethical issues.

I told her what the doctor had called and asked, and added it made me feel like an angel of death, why not just put the pt. on a continuous drip,I could manage that.

She went to give the IVP drug...stopped... changed her mind , called the doctor and got an order for a continuous analgesic drip, a much more peaceful way to go IMHO. I have encountered this a a few times and I find no dignity in that kind of dead. I don't mind giving Ativan if they are bucking a vent, but with a B/P like you describe, I too would be thinking the dosage would push them into the afterlife. I seriously have issues with these orders, so I have no reservation in refusing them. I'm not God and I am not called to his line of work..

starcandy · Oct 1, 2007

I had a pt like that with narcotics ordered Q2 hrs, unconscious and DNR. Family in more pain than they were.
The doctor called right after I received report and asked,
"Is she dead yet?"
That changed my perspective.
I was a traveler, I looked up the charge nurse and told her if you want this drug given she would have to administer it herself or find someone compfortable with it. I could care for them, but could not give the drug due to ethical issues.
I told her what the doctor had called and asked, and added it made me feel like an angel of death, why not just put the pt. on a continuous drip,I could manage that.
She went to give the IVP drug...stopped... changed her mind , called the doctor and got an order for a continuous analgesic drip, a much more peaceful way to go IMHO. I have encountered this a a few times and I find no dignity in that kind of dead. I don't mind giving Ativan if they are bucking a vent, but with a B/P like you describe, I too would be thinking the dosage would push them into the afterlife. I seriously have issues with these orders, so I have no reservation in refusing them. I'm not God and I am not called to his line of work..

I agree with you. :lol2:They don't pay me enough for this job:lol2:

leslymill · Oct 2, 2007

If I liked that kind of work I would work in Corrections giving letal injections to death row inmates. I hear that kind of nurse has a high turnover rate.

leslymill · Oct 2, 2007

If I liked that kind of work I would work in Corrections giving letal injections to death row inmates. I hear that kind of nurse has a high turnover rate.