Ok, the problem that I have is with Hospice and the rules. I am a LVN at a hospital and I had a pt last night that is on hospice. The Dr. and the family is waiting for the guy to die, so at the start of my shift the Dr. had ordered for the pt to receive Dilaudid 1mg EVERY hr PRN. However I did not feel comfortable giving that much and I told the family that it is PRN and the pt was sleeping and VS were all normal. So I gave 4 doses thru out the 12hrs, so he did not die thru the night. The Dr. got there at 5am and noticed the pt had not died yet, he took the charge nurse aside and told him to have the family step out and smother him with a pillow! He in turn told me what the Dr. said and I about freaked at how he could even say such a thing. Anyway, the Dr. came back at 0700 and ordered Dilaudid 1mg every hr (not prn) and adivan every half an hr until death. Of course the Pharmacy called up to clarify the order and told the on coming nurse that she did not have to give that much and to use her judgement with it. She had the same feeling as I did. This is not right and she also said there was no way she would give that much just to speed up his death, and with 5 other pts there was no way to even keep up with it.
So, what can I do or because he is on hospice it is ok to give him lethal doses to speed up his death.
P.S I just called to check to see if he had died yet and he is still alive, with good vital signs.
If such is really the case than orders need to be clarified, the ultimate goal is comfort. 1mg per hour dilaudid with some benzo's for an actively dieing hospice patient is a minimal dose and when you say vital signs are good....were you taking VS on a hospice patient every hour? Yes the pillow comment is way out of line and I would report that. As far as the medicine being a PRN order....than you gave it PRN and that was fine. The fact that the order actually read "until death" is inappropriate and I have never met a hospice/palliative/ or intensivist that would ever actually use those words in an order and have a hard time believing the order was written that way albeit the thought was there, but if true than that needs to be reported. As a previous responder noted hospice does not medicate "until death" but to comfort. I am not surprised that pharmacy called to clarify the ativan order but for them to suggest to the RN that she did not have to give the med as ordered....I have never met a pharmacist who would suggest that to an RN and it crosses a line for them to suggest that. If the pharmacist has issues with the order than they can hash it out with the MD. There is a lot of problems with this whole scenario and if such is actually the case then I would step out of that assignment as well....sounds like a jeopardizing situation.
I have never heard of dilaudid q1 hr for use in hospice. As long as you documented every hour comfort and stability of the pt, a nursing medication hold can be justified clinically. I would have challenged and called the legal dept. To cover yourself. Hospice is comfort for a natural death not drug overload that's why they use morphine. Fast in and fast out of the systerm. Dilaudid half-life is not the same by any means. That physician is questionable, I would have reported him.
I agree with most of the comments, except for refusing assignment. I would take the assignment and ensure that I do everything within my power to be this patient's advocate and safety, as it seems the doctor does not have his head screwed on right. Good luck!
Just an update the pt is still alive. The order has been D/C'd since it was taking so long, the family was getting aggravated that the Dr. kept say this it it and everyone would come up to visit him and nothing would happen.
Specializes in Med-Surg/Neuro/Oncology floor nursing..
I would definitely check out the comment the doctor made about smothering the patient with a pillow. It's hard to believe the doctor was serious in what he said. Of course the comment should be taken seriously, BUT...a lot of things are said during the heat of the moment. I would certainly make sure that the doctors supervisors are aware of what he is said(and make sure he watches his mouth in the future). As for the medication orders, I do have to say they are bizarre in the way they are timed to be given and the dosage. 1mg of dilaudid seems to me that it isn't enough. If the patient isn't alert enough to be able to use a PCA, then why not use fentanyl TDS with another narcotic used for break-through pain? I know not all medications are effective for EVERY patient..but when my father was on hospice(he had pancreatic cancer which everyone working in healthcare knows is EXTREMELY painful) his doctor but him on fentanyl TDS with 10-12mgs of IV morphine PRN(he wasn't able to have oral medications because he couldn't swallow during the end). My dad responded pretty well with the medication orders. He also was on a benzo(I just don't remember which one). I mean 1mg of dilaudid every hour as well as ativan every half hour is a little ridiculous...who has the time to go medicate a patient every 30 minutes?
I am not surprised that pharmacy called to clarify the ativan order but for them to suggest to the RN that she did not have to give the med as ordered....I have never met a pharmacist who would suggest that to an RN and it crosses a line for them to suggest that. If the pharmacist has issues with the order than they can hash it out with the MD.
i disgree, in that it is perfectly appropriate for a pharmacist to tell a nurse they don't have to follow a (questionable) order.
we don't know if pharmacy addressed concern with physician or not.
but s/he was certainly not out of line.
just like it wouldn't be inappropriate for any other licensed professional to offer same type of input.
Document, document, document.
I agree with most of the comments, except for refusing assignment. I would take the assignment and ensure that I do everything within my power to be this patient's advocate and safety, as it seems the doctor does not have his head screwed on right. Good luck!
i only suggested refusing assignment because of the (il)legal implications in assisting someone in murder.
i was writing/thinking from a defensive point of view.
if no one questioned this now scheduled order, and had indeed, administered meds til death, then nurse would have been held just as liable as the prescribing physician (if it went to court).
if nurse refused assignment, s/he would document refusal in nsg notes, with subsequent explanation and intervention...
i.e., "nm/don notified and aware".
that type of intervention, is the advocacy the pt needs.
but to remain in a situation that is dangerous, subjects the nurse to being incriminated as well.
Sorry but I feel that this is a frustrated family member rather than a nurse. "Adivan'"and "D\C" make me wonder.
The OP has some eyebrow-raising language. First the order that was written to medicate "until death," something I have never seen written on a TO, in addition to the comment about smothering the patient with a pillow.
I cannot imagine a scenario where a dr. would put his license in such jeopardy as to make comments like that. Why would a dr. be that invested in a patient death?
iceecat
3 Posts
If such is really the case than orders need to be clarified, the ultimate goal is comfort. 1mg per hour dilaudid with some benzo's for an actively dieing hospice patient is a minimal dose and when you say vital signs are good....were you taking VS on a hospice patient every hour? Yes the pillow comment is way out of line and I would report that. As far as the medicine being a PRN order....than you gave it PRN and that was fine. The fact that the order actually read "until death" is inappropriate and I have never met a hospice/palliative/ or intensivist that would ever actually use those words in an order and have a hard time believing the order was written that way albeit the thought was there, but if true than that needs to be reported. As a previous responder noted hospice does not medicate "until death" but to comfort. I am not surprised that pharmacy called to clarify the ativan order but for them to suggest to the RN that she did not have to give the med as ordered....I have never met a pharmacist who would suggest that to an RN and it crosses a line for them to suggest that. If the pharmacist has issues with the order than they can hash it out with the MD. There is a lot of problems with this whole scenario and if such is actually the case then I would step out of that assignment as well....sounds like a jeopardizing situation.