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Discussion

Help!!

Help!!!!!

I recently had a pt admitted with an large fungating SCC of the face. When he was handed over to us via the community pall care CNC we were told that the pt would die within two days. This would be either to his palate collapsing and occluding his airway, or to drowning in his own blood. She handed us a med chart with an order for a huge dose of parenteral morphine and gave us the instruction to administer that and the dose of midazolam immediately that happened to him. The dose of morphine was greater than 50mg. The pt had never taken narcotics, hadn't even had acetaminophen. We were uncomfortable with this Stat order. As she made it clear the intent of giving the dose was to immediately end the patient's life it made us even more uncomfortable.

We are used to caring for terminal patients. We average two deaths a week. We have no problem administering meds when required to alleviate suffering, when the orders are legal. All the research we did indicated this was an illegal order. We asked the physician if he could change the order to smaller doses, administered at frequent intervals for the alleviation of suffering. Even an order for sedation. He refused.

Our NUM said she'd have no trouble giving the dose and would do it herself. The juniors on our staff, aware of legal and ethical obligations, were fearful about losing their registration if they were coerced into being a witness to the administration of the dose.

I asked our pharmacist for help and he consulted many specialists who all said it was an illegal order and amounted to euthanasia. He discussed it with the physician and the response was for the order to be rewritten and underlined.

I believed I had an ethical and legal obligation to act so documented all of this in the patient's notes.

I was called to see the DON. She said she had no problem with the orders and if she lost her registration for administering the dose, so be it. She told me she was giving me the first warning for documenting inappropriately in the patient's notes about 'political issues.' If I do it again I will be terminated. She said the concerns about the dose had nothing to do with the patient's care.

Please...........can I have some feedback about this?

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    Oh dear. That is quite the conundrum. You say that you have proof from the pharmacist that this is an illegal dose? It sure seems that way to me, but I am no pharmacist.

    Personally, I would NOT have anything to do with this case. You may lose your license or you may also have criminal charges brought against you if it is, in fact, illegal. I can't believe your NUM is being so harsh. If she wants to put her license on the line, she can. But to tell you that you can't document what you are witnessing is in effect, falisifying charting.

    I have not read your profile, but it seems from your statements that you are not in the US. I don't know what the laws are in other countries regarding this very serious matter. I have a hard time believing that the NUM is ok with administering a lethal and illegal dose to a pt. Moreover, I have a very hard time with the fact that she is basically threatening you with the loss of your job if you do not comply. Is there a legislative board that you can contact regarding this?

    What does the pt want? Family involved?

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    If I had received an order like that I would have refused to give it and promptly called the supervisor, director, manager or whomever is ultimately in charge. I would not have charted anything about it though. Was the patient even complaining of pain?

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    Joss, I think that the point of the gi-normous dose of MSO4 was to end his life. I don't think it had anything to do with pain at all. Scary, huh?

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    Joss, I think that the point of the gi-normous dose of MSO4 was to end his life. I don't think it had anything to do with pain at all. Scary, huh?

    Oh I realized that. 50mg of Morphine would kill a horse! Therefore I said I would refuse to give it and contact the person in charge. My question was merely coincidental. Was the patient even in pain in the first place?

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    • Author

    It was the NUN and the DON. They didn't say I had to administer it, just that they would themselves. It is a stat order on his chart, to be administered when he does deteriorate.

    've had lengthy discussions with him and his loved ones. He agrees to a plan for sedation. He wants to live for as long as he can. He is a very strong, very courageous man. The centre of his face has eroded away. When you connect with the incredible being he is, you don't notice his appearance.

    I didn't chart in his notes that I refused to give the dose, I charted the results of discussions with international pall care specialists, a legal nurse consultant, and the pharmacist. I wrote only what their advice about the order had been. The order was written by the medical director of the health service and this isn't the first time.

    Last night I emailed the DON and said I don't feel supported to practise in a manner that is ethical and legal, therefore I don't feel safe.I've asked to be moved to a nonclinical area. I love working with patients.

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    • Author

    No pain, incredible considering the SCC was tracking along his trigeminal nerve.

    60 mg morph,20mg midaz

    Euthanasia is illegal in Australia.

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    Off to work now.

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    Does this not warrent the involvement of the authorities (the police)? If in a country where euthanasia is illegal how is this not homicide?

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    Oh I realized that. 50mg of Morphine would kill a horse! Therefore I said I would refuse to give it and contact the person in charge. My question was merely coincidental. Was the patient even in pain in the first place?

    Oh, sorry!:chair:

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    I would'nt have done it if I wanted to kill people I would have become a hitman that's crazy I think you did the right thing I would have told the DON to do it if she was so okay with it.

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    I am going to say something here... get ready for it.

    Something makes me see mercy in this, albeit hard to wrap my brain around in practice. Have any of you seen someone die emergently in this way. It's an awful horror. Makes me want to cry, this situation, it really does.

    OP is tracking right though, we all agree that this is some heavy ****. One of those times when you must keep your head. And one in which you must be ready to work fast.

    OP, sending you calm and peace.

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    Onaclearday-yes, I have. It was my mother. She aspirated to death. She had end stage renal small cell carcinoma. She died at home, under the care of a wonderful and giving hospice care team. I tried to make her as comfortable as possible, I gave enough meds for her to be sedated, but did not go over the prescribed dose written by her hospice care doctor. I watched her turn blue and then die. It was the most horrible memory of my life. I still have nightmares about it.

    I think that there is something to be said about making someone as comfortable as possible in their last days. But to purposefully mainline a syringe with a lethal dose of medication is clearly unethical, illegal, and amounts to being an executioner. I am all for palliative care...within our scope of practice, and within the confines of the law. As hard as it is to witness, this is the realm that we must live with, and practice within.

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