ordered to give roxanol with resp. of 5

[wantsthebest]

I was recently ordered to give a dose of Roxanol to a patient with terminal Alzheimers. I withheld the dose due to the fact that his resp. was 5, there were no s/s of pain, no SOB, and no labored breathing. Pulse was slow and weak. No response from stimuli. The MD said I should give it and (I quote) "you can make it a humane death"

I have a problem with this, I always thought that we first do no harm, isnt giving some one something they dont need harm? No signs of distress, just someone busy dying and not having a problem with it.

[leslie :-D]

i agree that we don't know all the facts.

there are valid concerns with questions, however.

why was this pt made npo if he was gaining wt after being fed by staff?

i do know what end-stage alzheimemer's looks like.

it is a gross cognitive deterioration, not a physical one.

there's nothing in this dx that would lead one to believe that there is physical pain.

no other comorbidities were mentioned.

and yes, it is important that the nurse be experienced in assessing pain.

what kind of nsg judgement is it, if we exercise interventions just for the sake of the family?

i've walked off cases when the pt was being grossly overmedicated as well as grossly undermedicated ("i don't want him becoming addicted").

i've also administered powerful narcotics with a rr of 2....but there were still signs of distress.

suffering persisted.

i think, based on the information we've received, that there is genuine concern about the intent of the morphine.

remember, this pt lost wt when his wife was fdg him.

alzheimer's wreaks havoc on the family structure.

it also evokes alot of undesirable emotions, which inevitably creates guilt and remorse down the road.

i don't see why trudy needs to do any soul-searching.

i found it highly disturbing reading some of these posts.

just because i didn't make a :angryfire face doesn't mean i didn't react.

there is nothing black and white about administering potent drugs, esp at end of life.

there are all sorts of assessments and decisions to be made.

but as long as i continue to use the nsg process in caring for my pts, i'm good to go.....

as are my pts.

leslie

[SueBell]

I have to agree with trudy & earle - something is not clearly right here, I can not make a judgement without me being the actual nurse caring for this patient. What has been posted though sounds like the wife needs to be questioned, or someone contacted regarding this situation. Also, as one of the post previously stated about the financial burdens - Who gives a dang about financial burden - I do not care how much it is/cost - I will/would not starve/dehydrate a loved one or friend just for the cost.........

[RNCRNA2BE]

i agree that we don't know all the facts.

there are valid concerns with questions, however.

why was this pt made npo if he was gaining wt after being fed by staff?

i do know what end-stage alzheimemer's looks like.

it is a gross cognitive deterioration, not a physical one.

there's nothing in this dx that would lead one to believe that there is physical pain.

no other comorbidities were mentioned.

and yes, it is important that the nurse be experienced in assessing pain.

what kind of nsg judgement is it, if we exercise interventions just for the sake of the family?

i've walked off cases when the pt was being grossly overmedicated as well as grossly undermedicated ("i don't want him becoming addicted").

i've also administered powerful narcotics with a rr of 2....but there were still signs of distress.

suffering persisted.

i think, based on the information we've received, that there is genuine concern about the intent of the morphine.

remember, this pt lost wt when his wife was fdg him.

alzheimer's wreaks havoc on the family structure.

it also evokes alot of undesirable emotions, which inevitably creates guilt and remorse down the road.

i don't see why trudy needs to do any soul-searching.

i found it highly disturbing reading some of these posts.

just because i didn't make a :angryfire face doesn't mean i didn't react.

there is nothing black and white about administering potent drugs, esp at end of life.

there are all sorts of assessments and decisions to be made.

but as long as i continue to use the nsg process in caring for my pts, i'm good to go.....

as are my pts.

leslie

Perhaps you should go and recheck on what end stage alzheimers looks like. I highly disagree with you when you say cognitive deterioration and no physical deterioration. Without the brain's ability to process functions all we are left with are reflexes. What about the patient who is incontinent or can't tie their shoes or put their clothes on? Eventally the brain won't be able to support the functions of the systems needed to sustain life. Hence, end-stage. I am out of this discussion, because neither side will be swayed, nor do I wish for that to happen, therefore there is no need for me to debate.

[RNCRNA2BE]

However, it is nice to see a threat last for more than two posts.

[Kymmi]

The ethical/legal issue is not withholding life support measures on anyone that is terminally ill however withholding food/water on a patient that is capable of eating/drinking without any medical reason or risk of aspiration is what I question. The OP stated until he became so sedated from the morphine he was able to function without any artificial means. Technically we are all terminally ill.....however just because it might be a fiancinal burden or we can no longer control our bladder/bowels or remember what we had for dinner last night doesnt mean that starvation and sedation is a option. If we used that therory then where do we draw the line? What about the 9 year old child that for whatever reason cant control his/her bowel/bladder or feed himself or remember the day before or get out of his/her wheelchair because of limitations ...do we starve and sedate them because they are fiancinal burdens or require to much of our time and attention.....I dont foresee one person answering yes to that because its a child we are talking about however other than age the elderly and the child might have just the same cognitive and physical abilities or inabilities.

Life supportive measures are well defined.......withholding food/fluid from people that cant eat/drink on there own is one thing because in order to feed these people it has to be by artificial means however withholding from someone that doesnt require artificial means is ethically and Im thinking legally wrong. The same with the oversedation .......there are people in this world that live with chronic pain due to numerous reasons however do we sedate them to the point of unresponsiveness?

I understand what people are saying about the disease process of Alzheimers however if we start starving and sedating just because then where do we draw the line?

[DJRRN1992]

Ok_ I'M WITH YOU! I myself have been quoted that I am going to have a DO NOT ADMIT tattoo placed on my chest, let alone a DNR. ( with stipulations for haunting attached!!) Life is precious. We must take care of that. Death is part of life, and I feel we have a responsibility to that. Respirations of 5 still means that the heart is beating, and you are right... we must assume that there is pain. Technology brought this man to this place. Meds were given for his disease process, I'm sure. Why wouldn't you give? It sounds like a physician who has a heart. I could go on and on re this subject. I am a quality vs. quantity person, especially when it pertains to life.

[caroladybelle, BSN, RN]

Ok_ I'M WITH YOU! I myself have been quoted that I am going to have a DO NOT ADMIT tattoo placed on my chest, let alone a DNR. ( with stipulations for haunting attached!!) Life is precious. We must take care of that. Death is part of life, and I feel we have a responsibility to that. Respirations of 5 still means that the heart is beating, and you are right... we must assume that there is pain. Technology brought this man to this place. Meds were given for his disease process, I'm sure. Why wouldn't you give? It sounds like a physician who has a heart. I could go on and on re this subject. I am a quality vs. quantity person, especially when it pertains to life.

Sorry, but there is no reason nor evidence to "we must assume that there is pain".

In what way did technology bring the patient here? There is no indication that there has been undue technology used. The development of dementia may occur naturally.

Nor is your belief of what is "quality" the same as everyone else.

I work with plenty of terminal cancer patients who will tell you that they do not always have pain. And others that take pain meds for comfort but still do not want to be "snowed" because they want to know what is going on. They can also get quite peeved when everyone treats them as delicate flowers that "must" be hurting. While many patients hurt, not everyone hurts, and even fewer want to be snowed.

We can no more "assume" that there is pain, or that there is not pain. We must review the patient's history and behavior/symptomology for that or we are doing a disservice to them. Because if they are still cognizant, they have their own beliefs and preferences - we cannot assume that ours are the same.

I have also taken care of many dementia patients. Pain is not an automatic presumption. For that matter, they more often have fear or anxiety that trouble them. And there are plenty of meds and also care techniques to alleviate that.

There is absolutely no indication in the posts that there was a pain issue being treated to begin with. From what has been posted, the patient was stable, prior to ordering NPO for no apparent reason. And during that time, Roxanol was ordered to be given without consideration to the patient's health.

There is no evidence of pain issues necessitating this, the "disorder" of this patient would not necessarily create pain, there is no indication that the patient had pain when fully cognizant.

There is evidence, though, that inappropriate orders may have resulted in further impairing the patient's health and ability to properly communicate. And that the roxanol is impairing the patient's respiratory function.

As there is nothing indicated the need or benefit of this med at the time to the patient, and there is evidence that a dose would cause the ultimate damage, the drug must be ethically held. There is no appropriate reason to give it.

What you or I might want for our final exit is irrelevant. What we "feel" is right based on OUR preferences and beliefs are not acceptable. We cannot just give drugs because we "assume" based on OUR needs is not ethical. We need to base our care in the patient's history, medical condition, physiological issues, behavior and prior wishes. And not forget legal requirements. The OP is doing that and held the drug.