Moral dillema

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Hi. I just started back working at a very small town hospital - you know the one, where everybody knows everybody elses personal lives, the Docs all have the buddy system and meet at the country club on Wed's for golf. I work with a lot of (much) older nurses who still think that if the Doc orders it, they have to do it. (huh?). There is one Doc known for her "euthenasia" efforts. I had an 82 yo nsg home pt who was on his last leg. Diagnosis: aspiration pneumonia, old age, etc.. she writes an order for Morphine 2mg IV q4hrs prn for pain. They guys bp stayed around 84/42 even without morphine. She convinced the family that he needed something for pain so that he could rest better. He was comatose! There was no way I was giving him morphine. the family got upset and I get called into the managers office the next day for refusing to carry out a Dr.'s order. It was just a slap on the wrist, but come on. The week before, she had made one of my elderly pts a no code. In the chart she wrote that she talked to the family and my coworker was present. I asked her about it and she got so upset, she said that she never witnessed that conversation - and when asked, the family knew nothing about it. All she could do was make a note in the chart. I cant believe this stuff still goes on.

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Specializes in Med-Surg.

Writing a DNR order on a patient without consulting the family, and lying about having a conversation with a nurse, is not only unethical it's illegal false documentatiion. Sad the your facility thinks they are so powerless to do anything about this doctor, all she could do was leave a note in the chart. Sad that that won't because one day it's going to bite them in the butt big time.

I don't mind giving pain meds on end stage people with a low BP, provided they are DNR comfort measures. Otherwise, the BP should have been addressed and efforts made to increase it.

Good luck.

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Specializes in pure and simple psych.

the Medical Practice Board would be interested in the behavior of Ms Doc. Make note of the patients, dates, ect. But don't be afraid of medicating end stage patients. Coma may not be comfort.

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the Medical Practice Board would be interested in the behavior of Ms Doc. Make note of the patients, dates, ect. But don't be afraid of medicating end stage patients. Coma may not be comfort.

I agree with Tweety and Sanctuary - especially about medicating patients at the end of their lives.

However, I can certainly understand your hesitation to trust this particular doctor and her assessment skills.

I too have held morphine in a patient who was obviously not having any pain.

steph

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Specializes in ED, ICU, Heme/Onc.

Have given it PRN - so if the guy was not in any pain - objective OR subjective (elevated BP, HR, moaning -etc.) then I would not have given it. Morphine helps blood flow to the lungs as well as being a pain killer - pneumonia hurts though - even when you are old and "comatose".

Perhaps the family needs a little PRN something-something?? (I say this partially in jest)

Like the others have said, document, document, document.... someone is bound to sue this doc and will get access to their chart. Having a DNR signed illegally is worth an anonymous tip to the police - especially if it ends with the patient's premature demise. Perhaps the patient did tell the doc that's what they wanted. We get many, many cases where the patient does not want all the interventions and the family insists on a full code, just so they can be shocked into sinus rhythm, only to die in a week of their disease.

That being said, I wouldn't withhold pain meds from an intubated/sedated patient who can't communicate. But thankfully they are usually good about this although sometimes you get someone who "forgets" or thinks they are "too sedated" on the vent!

Your description reminds me why I love teaching hospitals....

Blee

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i agree about reporting the doctor!!:madface:

re: the elderly patient, i've seen many md's talk to family re: dnr status on an elderly patient. sometimes i think it's justified, others i don't.

what was the pt's rr? i imagine they would be elevated with asp pneumonia. so ms04 2mg iv would bring comfort. if the pt is comfort care, then let him be comfortable.

if he's not comfort care, then get some parameters initiated.

good luck.

leslie

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Specializes in Variety of experience including Telemetr.

I work in a LTC facility as a CRNP and often times I am in charge of the end of life issues even if I order hospice. I have had the scenario of an elderly 80's something patient with aspiration pneumonia on almost a weekly basis. If the antibiotics have not worked early in the course of the illness, they are not going to. I routinely give all my dying patients orders for Roxanol which is liquid morphine sublingually or a Morphine Drip. This helps them die comfortably and in peace without gasping for their breath which is an awful thing for the family to watch. As for the B/P, I do not take the B/P at all but rather use tachycardia or tachypnea as markers for medicating these patients.

Re the DNR without having spoken to the family---this is illegal and should be reported.

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