Scenario:What would you do?

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Specializes in Emergency.

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). So the guy is pale as a ghost and hallucinating, I can't get an accurate O2 but it's somewhere around 75%. His BP is 82/40 his family is very rude and demanding. The Dr. comes in and tells me to give him 5 mg of morphine, repeat it until pain is under control, then takes him off the monitor. Another nurse tells him we have to take his vitals if giving morphine. Dr. says--well, new rules.

What would you do? I'll tell you later what I did.

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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)

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Specializes in CCU,ICU,ER retired.

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

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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?

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Specializes in cardiac/critical care/ informatics.

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.

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Specializes in tele, stepdown/PCU, med/surg.

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.

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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

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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.
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Specializes in Emergency & Trauma/Adult ICU.
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 :twocents:

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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......

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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.

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Specializes in LDRP.

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?

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