Pain medication and the dying patient

[khall7398]

I'm sorry, but I have to vent. Recently, a loved one of mine was admitted to the hospital with tumors covering his liver. He was given days to live. He was not initially given pain medication due to the fact that he was not complaining of pain. However, after a few days, he began moaning from severe pain. He was in an altered state of consciousness, but it was clear through his expressions that he was in pain. Confusion had set in and he had trouble communicating it verbally; however, he indicated he was experiencing pain. Several members of my family, including myself, informed the nurse immediately that he was showing signs of being in pain. It took 2 hours to get pain medication for this individual. It was awful having to watch someone I love suffer for that long during their final hours of being alive.

I am not placing any blame on the nurse because, although she was busy, she made getting this medication a priority. However, getting the physician to write the order and the pharmacy to send it to the floor took that long...

I have only completed one semester of nursing school and may be naive, but this seems like an excessive amount of time to get pain medication to an individual who is receiving end-of-life and comfort-based care. Is it not acceptable for physicians to prescribe prn morphine orders for somebody who has liver cancer?

I do not like speculating so I would appreciate any feedback from experienced nurses on this situation. It was very upsetting to have to experience this and I would appreciate any advice that can help me prevent something like this happening when I am practicing as a nurse.

[dudette10, MSN, RN]

I am so sorry about your loved one.

Unfortunately, anything we say about the situation would also be speculating. We weren't there, we don't know the hospital, unit, doctors, or nurses.

Again, I'm sorry you are going through this. Best wishes.

[Red Kryptonite]

This kind of thing is why end of life comfort care is probably not best delivered in the hospital. That's not really their strength. Nothing can change what happened, and it sounds inexcusable, but maybe others can learn from it.

Was he on hospice? If so, why did he go to a hospital? If he wasn't, why not?

[ICURN3020]

I can believe that it took two hours for the nurse to contact the physician, get the order, pharmacy to process the order and the patient to finally be administered the drug. Personally, I don't think this time frame is excessive and I've had patients have to wait much longer than that, unfortunately.

I think the problem stems from the fact that the patient's pain (or possibility of) should have been addressed PRIOR to the patient developing the need to be medicated for it. As this was apparently a terminally ill, comfort care patient, why was this not addressed when admission orders were obtained? Someone didn't think ahead and realize that a diagnosis such as his could be expected to cause pain. It wouldn't have hurt to have a prn pain med ordered even if he didn't end up needing it.

[khall7398]

He was taken to the ER after a fall and it was noticed that he had jaundice, tests were done and it showed the tumors so he was admitted. Unfortunately he passed away the day before he was scheduled to begin receiving hospice care.

I appreciate your responses and understand what you are saying about not having answers because every circumstance is different. This experience has shown me the importance of advocating for my patients and their families.

[dudette10, MSN, RN]

Was he on hospice? If so, why did he go to a hospital?

Let's clear up this myth. Hospice patients can go to the hospital for emergent symptom management. As long as the hospice company is notified so billing can be worked out, a hospitalized hospice patient can avoid losing the hospice benefit.

[Red Kryptonite]

Let's clear up this myth. Hospice patients can go to the hospital for emergent symptom management. As long as the hospice company is notified so billing can be worked out, a hospitalized hospice patient can avoid losing the hospice benefit.

I never said he couldn't....patients can go if they feel the need. But I know my employer works hard to have alternative options in place for urgent needs, like 24 hour triage nurse availability who can usually get to the home in an hour or less, or being admitted to one of our inpatient units. I didn't perpetuate any myth.

OP, I'm sorry it all went down as it did. Sounds like it was all very fast, except the one thing that needed to be and wasn't. Hopefully your family can take good care of each other as you mourn.

[khall7398]

Thank you. It was fast. I was just curious about the pain meds being available as prn orders and now I realize how different every situation is. I appreciate the responses- it helps me to learn about things I can expect when I finish school and begin practicing as an RN.

[loriangel14, RN]

I think that 2 hours is ridulous.It wouldn't take that long where I work. Our pallaitive patients usually have pain prescribed right away as PRNs in case it is needed.

[CVeyeseeyou]

I'm sorry you and your loved one had to endure those 2 hours of misery. A pain remedy in a hospital setting shouldn't be so complicated but unfortunately, that's the reality sometimes...not all the time or even most of the time...but too often just the same. It seems this unfortunate experience has at least underlined for you, the responsibility of your chosen career path. When possible, I suspect your future patient's will be spared the pain your uncle endured.

[VANurse2010]

It is "ok" that the patient had to wait 2 hours? No.

Is that an abnormal turn around time for a new medication order? No.

[Libby1987]

OP, I'm sorry for your family's situation.

Whether it's realistic or not, what's messed up is that I can and have gotten a hospice nurse, my patient transitioned and medicated out here in rural home health faster than a hurting would be palliative patient can be medicated in a hospital.