Scenario:What would you do?

still a student here but if the doctor is telling you to go against protocol, I would refuse and go up the chain of command. I wouldn't risk my license because a doctor decided to suddenly change the rules.

EDIT amending post to clarify that I didn't mean holding the meds, I meant as far as doing the vitals. If the doc said not to follow protocol on vitals, then I would go up the chain of command--which would be the NM I guess. (I am interested to read the posts to this; I worry about facing an ethical dilemma myself someday)

We have a new thing here called pallitive care. and what the doc did is in the scope of care.

I don't think there's enough info there to make a decision - are you giving him morphine or is he getting a PCA pump?

What is the point of doing vitals? if he isn't going to be coded what are you going to do with the info? I would have given the morphine, I don't usually do vitals after morphine anyways.

It sounds as if the pt is dying. If the idea is comfort care, then why do vitals? He already has low BP and sats. The morphine will make him more comfortable might drop his BP more and surely his sats while he is dying. Taking vitals seems like "what's the point?" type of thing.

Of course if this was not a hospice pt or a DNR, aggressive care would be appropriate in this instance.

first up id talk to the nurse in charge and see what they say. second i wouldnt give anything until the Dr had written down the specific morph order

Are you joking with us? Morphine is a respiratory depressant and I've seen it happen! Doing vitals after giving it, particularly around 15 minutes after giving it is entirely essential!!!!

What is the point of doing vitals? if he isn't going to be coded what are you going to do with the info? I would have given the morphine, I don't usually do vitals after morphine anyways.

This happened to me this week.

A hospice pt. comes in to the ER. He has end-stage renal cancer and is here for a PCA morphine pump and a Kayexalate enema. (good hopice huh).

This infuriates me ... because IMHO, sending someone to the ER is NOT hospice care, unless the patient has spelled out that he/she does not wish to die at home (many people choose to do just that, others don't want their families left w/that memory within the house). In that instance, the pt. should be admitted, ideally directly from home without going through the ER.

Hospice care can be so wonderful - it makes me angry when some type of home care has the "hospice" label slapped on it, but what the provider and/or the pt.'s PCP are overseeing is NOT hospice/palliative care. (note: I am NOT knocking home care)

I'll be waiting to read what the outcome was, but this is a perfect example of inappropriate use of the ER.

Just my

I had an instance like this many times in ER. First of all, the family sometimes "panics" when their loved one becomes incoherent or unresponsive. This does not mean that they want "heroic" measures taken.

I would make sure that the family is aware of the situation and that death sounds as if it is imminent and what you are doing is trying to control his pain and make sure that he is comfortable.

I do agree that taking vitals in this instance is prohibitive unless you're going to do something with the results. If his oxygen drops or his resps fade are you going to recucitate him? If not, then the family does not need to hear hr slowing, alarms sounding etc.

This is all IF......

As I read this I had to wonder, why did they even have to go to the ER??? Poor communication with their hospice company, maybe hospice just started, who knows, but the meds he needed should have been in his home and the nurse called. As far as the med order, I would give the medication as ordered, probably one dose only needed here to settle things down. I would get a set of vitals after for my charting. Because you stated the person was incoherent, how else could you assess relief of pain anyways? Family would need to be educated better on hospice and its role here.

Was he actively in pain? Did he already have a PCA?

I'd have given it. The patient is terminal. In pain. Going to die. Why not make him more comfortable in his final days/hours? Morphine might slow his resps, sure, but he's going to die anyways, right? Isn't in preferable to die comfortably than to die in pain?

This infuriates me ... because IMHO, sending someone to the ER is NOT hospice care, unless the patient has spelled out that he/she does not wish to die at home (many people choose to do just that, others don't want their families left w/that memory within the house). In that instance, the pt. should be admitted, ideally directly from home without going through the ER.

Hospice care can be so wonderful - it makes me angry when some type of home care has the "hospice" label slapped on it, but what the provider and/or the pt.'s PCP are overseeing is NOT hospice/palliative care. (note: I am NOT knocking home care)

I'll be waiting to read what the outcome was, but this is a perfect example of inappropriate use of the ER.

Just my

Bingo. Had this happen recently- it made me so mad, and so sad for the patient. DNR, end stage CA with multi mets. Came in for unresponsiveness. Her h/h was low, family agreed to transfuse her. Thank goodness we didn't get it started before she got a bed upstairs. Except she died in the elevator on the way to the floor. God, it peeved me off. Three hours- this lady could have stayed at home and died in her own bed in her own house, surrounded by her family there. Instead it was her husband and a CNA in a damn elevator.

Rambling... If you were going to do something about those vitals, then yeah, I'd hold the morphine and recheck. But if you're giving the morphine to a DNR to help ease their respirations and to ease their pain, then why put them thru the added vitals mess- let them rest as much as possible.