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.
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.
I could see the pharmacy taking that long to make a medication if it was something that had to come from the pharmacy, but what kind of floor that accepts palliative patients doesn't have narcotics in their pyxis? It would have never taken this long at the hospital I worked at- our oncology MDs were incredibly responsive and every narcotic you could need in the immediate was stocked on the floor. The only time I had to have the pharmacy deliver patient-specific morphine was when I had the patient who was on 100 mg/hr plus 10 mg boluses at end of life and they had to put it in a bag because otherwise we'd have been changing PCA cartridges several times/hour.
That doesn't sound like an unusual length of time for new onset pain. Faster would be better, of course ...but there are other patients the nurse, doctor and pharmacist have to take care of, too. Even doctors who take a while to call back could be returning twenty other calls about twenty other patients before they get to "ours".
I agree that an advance, PRN order would have been appropriate ...but I understand why it might have been left off admitting orders if the patient seemed at peace.
It is a long time however not totally out of the realm of what could be expected depending on many things. How quickly she was able to reach the physician and how quickly he was able to put the order in if that is their policy. There is also a very good chance the RN had other patients whose needs she triaged as more urgent. Perhaps the pixus didn't have the medication ordered. Unfortunately there are so many variables that it there is no way to know for sure. Something for us all to keep in mind when we take over the care of a patient with a diagnosis that is likely to cause pain to make sure we have adequate prns available.
It's not unusual for the orders to be inadequate for end of life patients in the hospital. I have often had to nearly beg for meds that are commonly given in the hospice setting.
The best case scenario to me is once the team has determined a patient is comfort care there should be an "end of life" order set that includes pain, nausea, hallucinations/anxiety, and excessive secretions meds checked. Then the nurse can medicated as necessary.
I'm so sorry to hear that happened. I work on a med/surg oncology floor. That wouldn't happen by me. I can get ahold of the hospitalist fairly easy (10-15 min) and override in the Pyxis if pharmacy doesn't verify quick enough after a phone call to them too.
We see a lot of hospice or comfort care patients on our floor though so we are used to it too.
Every place is different on procedure and protocol of course.
I have worked in a few different settings and I have noticed that the higher acuity units get their meds taken care of faster. If the OP's relative was on a Med-Surg type floor, two hours is a little long but not surprisingly so.
Also, not being a nurse yet, there are probably processes in place that you don't know about yet that take extra time. Here is what typically happens when I need a med order on a regular floor (not ICU):
First, I page the provider. Then wait for the provider to call back and have at least a five minute conversation. Then put in the orders. Then acknowledge/verify the orders. Then wait for pharmacy to verify the medication, which is one of the longest parts of the process. The pharmacist is checking allergies, checking dosages, checking, checking, checking. Then, I acknowledge/verify the new medication on the eMAR. Then, I have to either wait for the medication to be delivered (usually the very longest part of the process), or get it out of the unit's stock meds.
This is when everything goes right the first time and the med is in our formulary and in stock. Often, at least one step in this process has to happen twice with another phone call or two thrown in. If you give an average of five minutes per step (obviously, some steps only take 30 seconds while some can take half an hour), your minimum time is forty minutes. If the provider and/or pharmacy are having a busy day, it can stretch out. Also, pharmacy doesn't notify you when they're done, unless you have called and personally asked them to. The RN has to keep checking the computer, and if the RN gets tied up, the process can stretch out even longer.
As shocking as it may seem, waiting 2 hours for an order is not long in my hospital. Once the pt is admitted, I can no longer ask the ED doctor for an order, I need to call the admitting doctor, which may or may not be the hospitalist. If it's the hospitalist, it will be a quick fix. If it's not, it is almost torturous waiting for an external doctor to call back, some of whom don't for several hours. I have no problem calling someone in the middle of the night for something that should have been initially included in the orders. It's ridiculous, and I feel bad, it's an injustice to my patients who are in pain. Then, by the time you get the order verified, and whether or not it's available in the pyxis, it's just crazy.
Sorry you had to go through this. And as a future note, when you are a nurse, and you're going through the chart if you don't notice a PRN, it's better to call before you need it just to get it on the chart just in case.
I agree PRN pain meds should have been ordered when patient was admitted.
If my patient was in pain and had no orders, I usually escalate things. I place call to MD. If MD doesn't return call in 1/2 hr (per my hospital policy), a second call is placed. If no return, I then get my charge involved. If I do get an order, I usually tell MD I'll input order (I can be quick) and then I'm on phone with pharm to verify order stat. While all of this is taking place, I'm updating family of the progress to ensure them I'm working on the order and not just ignoring them.
I don't know why your loved one wasn't prescribed a PRN pain med upon discovery of the tumors.
However, the two hours is a fairly normal turn around time for units other than ER and ICUs. Those generally have quicker turn around times.
Our Accudose allows us to override the medication orders if need be. I recently had a situation in which a pt suddenly became very agitated, suffering from ETOH withdrawal. I had just enough time to get a telephone order for Ativan from the provider, but there was no way this pt was going to hang out in bed long enough for the order to come through. So I overrode the Accudose, administered the Ativan, then scanned the drug after the order came through.
When you become a nurse, you must use your critical thinking to determine if there is the possibility of a need for pain medication at some point. If you think there is a chance, call the provider, explain your rationale, and ask for a pain med order. Now, if you're working nights, the provider is sleeping, and the pt is not currently in pain, then you should probably hold off on getting an order. But if you have access to a hospitalist or on call provider, go ahead and get an order just in case.
Remember that pain is considered the 5th vital sign, and complaints of pain should always be considered completely true. If a pt has a sudden onset of pain, you should consider it as important as a sudden drop in BP or sharp increase in HR. Knowing if you can override the medication dispensing system if a good step in combating the time consuming process of receiving completed orders.
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xoemmylouox, ASN, RN
3,150 Posts
Unfortunately I'm not surprised at the wait time. I am however disappointed that they did not already have PRNs ordered considering the diagnosis.