Scenario:What would you do?

[Happy-ER-RN]

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.

[Aneroo, LPN]

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.

[Undecided7]

For Cat III patients I have seen the freq. order, "Morphine gtt- titrate to pain/discomfort". I questioned pharmacy the first time- don't we need more parameters than THAT??? The pharm. explained that in these cases- you medicate based on signs and symptoms of distress and pain- if they die from too much morphine that's okay- it's a side effect of the medication but not the main purpose of giving it. As long as you are giving the medication for the right reason- to ease suffering (as opposed to giving an intentional overdose that would be inappropriate for the pt.'s symptoms) then it is not wrong or illegal. IN THIS CASE, YOU ADJUST THE MED BASED ON S&S, NOT VITALS. THE PURPOSE IS THE LET THE PATIENT DIE IN THE LEAST TRAUMATIC WAY POSSIBLE.

[MomNRN, BSN, RN]

Ditto for the poster who said they would check with their charge nurse and then proceed.

I would ensure doctor wrote out all his orders in plain language. We just today implemented a palliative care caremap.

I agree on only having an initial set of vitals. Why get the family all wigged out by the monitor when you aren't going to be doing anything anyway?

[Marylou1102]

Why take the vitals if the patient is going to die anyway. As someone else posted, take the base set and let it go. You know the person is dying and the vitals are going to drop whether they get the morphine or not. Yes the morphine does decrease the resp. but it also eases respirations. The whole point of pallative care is to make the dying as easy as possible for both the patient and the family.

[Bipley]

The only problem I have with this is the family members. You know the type I refer to, half of them wants Dad to go as peacefully as possible and the other half (or better yet, ONE holding out) wants you to run a code when it happens.

I think you can give the first 5mgs to get the ball rolling and then run it by your sup then document what happened. Point being, get your patient out of pain AND CYA.

[Vanfnp]

I work ER and I think I'm in the minority here. If a pt comes in, we treat. DNR means just that-no resuscitation, not no treatment. Its sad that the families of these pts put them thru these visits, but they do and in this case I'm thinking the MD was suggesting (wink, wink) you might give enough of a dose to send the guy on his way. This puts the deed on the nurse, a very uncomfortable situation. How many times do you get orders to give 5 mg morphine til pain gone? Someone should get a CNS/nurse manager/social worker to identify what the family really wants done by ER before things get more out of hand. Ideally this should have been done by the hospice staff, but as you said in your scenario, it wasn't. No one wins.

[Happy-ER-RN, RN]

Wow! I am really really surprised how many of you would have just given the 5 mg and left it. Here's what I did.

I paced around and thought about it for a little while and came to this conclusion--If I go give this man 5 mg of morphine it is going to kill him. I decided that I am not comfortable killing someone. Many of you may be thinking "but he is dying anyway" ummmm... don't care, I am not killing someone. So, I put the BP cuff back on a took a pressure--it was up to 96/50. I gave him 2 mg of morphine. After about 10 minutes he was so out of it there is no way I could have assessed his pain. I took another BP and it was 70/30, and he was obviously hypoxic w/ shallow resp. Giving him the rest of the morphine definately would have killed him. Would a hospice nurse have just given more morphine? I just didn't feel right about it, I couldn't bring myself to do it. I got him up to the floor where they could give him the PCA pump. I just don't quite understand the logic behind all of this. Of course I don't want anyone to suffer before they die, but are we allowed to give someone pain meds that we know are going to kill them?

I went into this job to save lives, not take them away. Pain control is subjective, life is not. I have to hand it to hospice nurses, you guys are amazing.

[leslie :-D]

i too wonder why this hospice pt was sent to the er....? family ambivalencies?

as long as his code status remains dnr and is under hospice care, i would have give the mso4 until relief of pain accomplished BUT would have been monitoring his rr throughout.

as stated, as long as it is your intent to relieve suffering, then nurses will not be liable for the hastening of death that mso4 can cause.

but sheesh, a damned hospital?????

leslie

[pugmum]

I think its important to remember that patients in hospice or palliative care situations can and do develop acute episodes of pain or resp. distress etc. that are not controlled by the medications that they are on. One poster pointed out DNR does not mean "no treatment", but we need to continue to provide comfort care for these patients.

Pts at end-of-life stages can and do receive what many people would consider to be 'massive' doses of narcotics - the big concern is that it will cause resp. depression. Well, most of these people have been on these doses for a period of time already and do not experience depression. My bigger worry is that they would be denied further medication when they needed it.

Breakthrough pain must be treated in order to keep these patients comfortable. other meds as Ativan are also helpful to anxiety and SOB. Frequent VS are not necessary - in fact, when you are disturbing your patients frequently to do VS, this is not 'comfort care'. If your pt. is dying, keeping them comfortable is a priority of care. I have heard nurses say they do not want to give pts more medication in case they become addicted. What a load of bunk. Addiction should be the least worry!

Often times worried/anxious relatives seem to feel better when they know their loved one is comfortable...for end of life patients we need to help them live their dying, whether it occurs in an ER, on an acute care unit, in LTC, or at home.

Sorry to be so long winded, but it is upsetting to see people in the end stages and not be able to die the peaceful, comfortable death they want.

[Bipley]

Wow! I am really really surprised how many of you would have just given the 5 mg and left it.

I don't think anyone here was suggesting you push a mg per second. You start off with the usual lower dose and it doesn't take long to see if they are responding or not.

Also, we don't have access to his records. Pt's like your guy are usually on pretty healthy doses of narcotics anyway and 5mgs wouldn't do to him (typically) what it would to you or me. If his current home management isn't working, he needed something.

My Dad died in pain. Makes me sick to think about it. I flew home to say my good byes and the man was seriously hurting. First thing I did was take a look at all his meds. Poor guy, he was taking meds he had no clue what they were for and certainly didn't need. Also, pain was not being managed. Got an order for Duragesic but those take time to kick in. Requested a morphine drip and hospice said it wasn't necessary. He didn't want to go to the hospital for pain management so what was I do to? He was vomiting every 10-15 minutes so he couldn't keep oral meds down. I was seriously trying to figure out how to crush an Oxy and stuff it up his nose.

Finally talked him into going to ER for pain management. He ended up dying in his front doorway.

Point being, sometimes it is necessary for a hospice patient to go to ER for pain management. If my Dad had gone to ER I would not have cared if the Morphine killed him. I honestly wouldn't, he would finally be out of pain. My sis on the other hand... would have taken that as an opportunity to sue the hospital and if that would have happened, who would the hospital point fingers at? The nurse.

Thus, I stand behind my original statement. Get the patient out of pain AND CYA.

[Helori]

Wow! I am really really surprised how many of you would have just given the 5 mg and left it. Here's what I did.

I paced around and thought about it for a little while and came to this conclusion--If I go give this man 5 mg of morphine it is going to kill him. I decided that I am not comfortable killing someone. Many of you may be thinking "but he is dying anyway" ummmm... don't care, I am not killing someone. So, I put the BP cuff back on a took a pressure--it was up to 96/50. I gave him 2 mg of morphine. After about 10 minutes he was so out of it there is no way I could have assessed his pain. I took another BP and it was 70/30, and he was obviously hypoxic w/ shallow resp. Giving him the rest of the morphine definately would have killed him. Would a hospice nurse have just given more morphine? I just didn't feel right about it, I couldn't bring myself to do it. I got him up to the floor where they could give him the PCA pump. I just don't quite understand the logic behind all of this. Of course I don't want anyone to suffer before they die, but are we allowed to give someone pain meds that we know are going to kill them?

I went into this job to save lives, not take them away. Pain control is subjective, life is not. I have to hand it to hospice nurses, you guys are amazing.

I had a similar situation a few years ago when I was a new grad. I had a pt in his 40's severely brain damaged after a MVC and had been living in a NH with a g-tube for years. He was on our Med unit with asp. pneumonia and had been on O2 and triple IV abx for 3 weeks. He was a DNR, no intub., no ICU. So even though he was getting worse everyday there really wasn't anything else we could do.

The night I looked after him it was my first time with him. I walked into his room after report his family was at his bedside and he was very restless and in obvious resp.distress. His BP and Sat's were low (don't remember how low) and he was febrile. I upped his O2, gave tylenol supp, and called the MD to inform him that the pt was still spiking temps even after 3 weeks of abx. Doc ordered a 4th IV abx, like that was going to help:confused: . When I went in to give the abx I asked the family if anyone had talked to them about palliative care, of course no one had. I explained to them what it was and they decided that they wanted to do. I called the doc back and had him come up to the floor and talk to the family. It was decided to d/c all meds, iv's, g-tube feeds, everything. I gave the pt morphine at that time and he settled down. But a couple of hours later he was in distress again. I checked his sat, 69%. I thought that if I gave him more morphine I would kill him and didn't know what to do, so I asked the family. I told them that his breathing was really bad and that the morphine would probably make him more comfortable but could also supress his breathing. They wanted him to have morphine and I gave it. I left his room shaking, I thought I had killed him. In nursing school we'd talked bout situations like this in ethics and I always thought that I was ok with giving pain meds if the pt needed them, but to actually do it scared me.

He settled down after the morphine. And I continued to give him morphine every couple of hours the rest of the night even though he appeared comfortable (I wanted to prevent him from getting into distress again). I never once checked his vitals, we weren't going to do anything about them anyway. Toward the end of my shift I went in to say good-bye to his family, his mother, brother and sister were asleep but the SIL was awake. I told her I was off for a few days and that I would be thinking of them, I knew he wouldn't still be there when I came back. About 10 min later, the pt's mother came the the nursing station and found me. She hugged me and thanked me for what I had done for her son. Then about they called the nursing station to say he wasn't breathing. (everybody dies at change of shift )

Some people probably think I killed this pt. I actually count this as one of the proudest moments of my nursing career. I made helped make him comfortable which is what he and his family wanted and needed. I no longer think that I killed him. It was the illness that killed him, I just made him comfortble when he died. (sorry for the long post)

[kersti]

Some people probably think I killed this pt. I actually count this as one of the proudest moments of my nursing career. I made helped make him comfortable which is what he and his family wanted and needed. I no longer think that I killed him. It was the illness that killed him, I just made him comfortble when he died. (sorry for the long post)

I have never been in this kind of a situation myself, but I like to think that being a strong patient advocate, that is how I would respond. Ther's no rule of thumb though for something like this, each situation is unique and needs to be dealt with on an individual basis.