Paramedics and palliative care

[Countrynurse17]

Hi everyone :) i am looking for some

insight on a situation i ran into lately. Im a rural visiting nurse, and have palliative care training etc. but this was something new for me.

This client is at a retirement residence, in which there is a UPC in charge over the weekends - my understanding of this facility is that the nurse manager must delegate the meds and all that to this worker. Anyways besides the point. I have been caring for a lady who is palliative, PPS 30 %, symptom relief kit and orders in the home, DNR signed and expected death folder filled out. She expirienced respiratory distress over the weekend, tachypnea, so i was called in to administer palliative care meds from the symptom relief kit - all very normal for us so far, nothing out of the ordinary. The relief kit orders are standard, and we have hydromorphone 0.1-0.3 ml ordered SC q1hr as required for pain relief and dyspnea. So i started a SC line and administered the lowest dose, 0.1ml, which works out at 1mg - sat with her a while, then asked the staff at the home to continue checking on her and call me back if no relief expirienced. So a little over and hour i recieved a phone call asking me to come back as she was still tachypnic. She looked just as bad as the first time i was in, so i reassessed, and administered 0.2ml this time, as covered in her orders. These are the bare

minimal orders, i have seen higher for those who could not achieve lain relief, but there is how we always start off and ive never had any issues. So i stayed with her again, until she was comfortable, she was able to talk again, short answers but enough to say no pain, and breahing was becoming easier. So i reported back to the upc and told her to call me again if she has any problems. I got a frantic phone call about 2 hours later from her asking me to confirm the dose i gave, as she panicked and called the EMS as when she checked on the client last her resps had dropped to 8 and her pupils dilated... The paramedic got on the phone and immediately started accusing me of overdosing her! I read him the orders and there was a copy in the home also, told him exactly what i gave and what time along with my assessment at each visit... So my question is do paramedics do much training with palliative care situations? I dont believe the ambulance should have been called. Its a normal effect of the hydromorphone to slow her respirations to where she is comfortable and unlaboured so she can rest. My only intention was to minimalize her pain and resp distress. So needless to say my stomach dropped when he said i overdosed her. Ive spoken with a palliative care nurse educator as well as the manager on call that day and both of them tell me i did absolutely nothing wrong. I understand the hydromorphone may have hit her a little harder than expected, i absolutly did not intend to snow the poor lady, but the orders were correct, extremely common, and not questionable dosing. Any thoughts? Anyone else had a similar expirience they dont mind sharing?

And i should mention im in northern ontario. Just incase anything conflicts with something in someone elses jurisdictions :)

[Laurie52]

If you had overdosed her with a narcotic her pupils would have been constricted. She was probably dying which must had been expected if she was palliative.

[acuriousnurse]

Don't take it personally. He was probably uncomfortable with the situation and took it out on you. I've noticed that paramedics (or was he and EMT?) tend to get really jumpy if they aren't familiar with hospice patients. You did nothing wrong.

[brownbook]

You did nothing wrong. I assume it is a small rural area and you may run into this paramedic or situation again. Maybe you or your manager could bring up this issue with the EMS provider to prevent problems in the future. Do some educating?

[akulahawkRN, ADN, RN, EMT-P]

A very normal side effect of hydromorphone use is pinpoint pupils, not dilated ones. I also wouldn't expect that a patient's resp drive to slow to 8/min from a hydromorphone administration (even if 2mg of the stuff), subcutaneously, 2 hours ago. That patient has been out of your direct care for probably close to that long so... who knows what happened in the meantime.

Oh, and no, Paramedics aren't very familiar with palliative care as that's not their focus. They don't expect to be called to deal with palliative patients. If you get a Paramedic that IS familiar with palliative care, they probably won't be very happy about having to follow protocols that do NOT often recognize patients in such a program any differently than any other pre-hospital patient. It's worse if there's no DNR or POLST that limits the care to be provided by EMS.

[offlabel]

The medic is not qualified let alone trained or experienced to make the determination he did. If that happened again or if that person were to have any questions, refer him to his medical director for any questions or concerns.