Hope you all can help me...I've written before about a certain hospice MD that I work with that I have absolutely no respect for. I've witnessed his treatment of some of my patients and have been, at times, beside myself. My latest problem is this: I have a pt with pancreatic cancer with mets in her liver, lungs, lining of her stomach, lymph nodes and a tumor that's wrapped around her mesenteric artery. We have been trying to get this poor woman's pain controlled since she was admitted about 2 months ago. She's comatose now, and on her way to a much better place. She's currently on 18 mg Dilaudid IV/hr plus 4 mg q10min PRN, 1 mg lorazepam q4-6hr, Haldol 0.5 mg q4-6 hr and ABHR gel. I've had many disagreements with this MD on how to treat her pain. He maintains that the tumor around the mesenteric artery makes the artery spasm, and that's what causes the pain, therefore, bolus doses should be used to control it. I maintain she shouldn't been feeling the spasms in the first place if we were adequately controlling her pain! He believes that by, giving bolus doses q10min PRN, we were keeping her pain successfully controlled. She's been on Crisis Care and, depending on the nurse, was getting anyware from 10 to 19+ bolus doses in a 24 hr period. I maintain that she shouldn't have had to awaken in pain or appear in pain when asleep to receive the bolus doses, that we should be keeping her at an adequate level to not need the boluses, expect for a minimal amt of times. She'd be OK with an adjustment in the basal rate for 1 or 2 days at the most, then her pain would escalate again. He just kept wanting to increase the bolus doses and not the basal rate. We went back and forth on it many times. I should say, too, that both the patient and her daughter/POA stated repeatedly to me and to this doctor that she did not want to have any pain and would much prefer just sleeping comfortable. I just spent 2 months of every other day on lectures and questioning my judgement just to how much pain the person was having. Last week he stated she was "just having anxiety" and wouldn't even schedule lorazepam for her...Bottom line? I feel our agency, and I, are doing/did a disservice to this patient and family. I am ashamed that this has gone on like this, and I was a part of it.
My questions, then, are this:
1) Is he correct in his thinking? This guy's got me so rattled, then I get angry. Having a patient rely on bolus doses for adequate pain control seems crazy.
3) It seems this doc won't be leaving this agency anytime soon...I'm thinking I might have to in order to do the hospice care that I'm trained to do and keep my patients comfortable. This is the 3rd or 4th situation I've run into with him, he's our Team doctor and my supervisor is aware, but for political reasons he's staying. So, what do I do? I live out in the country, and the next closest hospice is 50+ miles from me.
Any help would be appreciated. I'm feeling very angry and
down about the whole thing.
PS Sorry this post is long!!
Aug 20, '06
Thanks, everyone. Leslie, I will indeed go to the various web sites and print some articles for him. However, he literally ignores any information that is contrary to his beliefs, especially from a female nurse. He's quite arrogant. I've presented him from information given from an HP pharmacist. It's weird - he just looks at you with a blank look and doesn't respond! As far as an inservice for him? Ha! Our hospice had him do an inservice with us on pain management!!!! Needless to say, I didn't go - what a joke. I also heard that the other teams that had him as a doc didn't go either. Gee, I wonder if mgmt got the message? Also, forgot to mention. I brought up the issue of palliative sedation for this patient in IDT. He looked at me and said "I will not do anything that will depress respirations in a patient, and I will not do palliative sedation at all, any time. It's against my beliefs". He once tried to cut back some morphine on an actively dying patient - she was literally climbing out of the bed. My partner and I sat on that patients bed and held her in our arms for 2 hours until 4:30 when the on-call doc took over, who happened to be our Medical Director. Then we got the orders needed to keep the patient comfortable.
Yes, it seems everyone in this hospice "knows" but will not do anything about it...
Last edit by mc3 on Aug 20, '06