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.

[jimthorp]

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

This was my initial thought. However, there is not enough information for me to form a solid opinion. I've been a nurse for only a short while. To me hospice means DNR, no return to hospital, and comfort measures only. Are there different interpretations of what hospice is/does?

Where was this patient's hospice nurse/case manager? Was she/he the one who had him sent to the ER or was it a panicing family? I have to wonder why he was not already on pain management meds and why his hospice nurse could not communicate with the doctor if these meds needed to be changed for good pain management instead of putting him through the trauma of a ride to the hospital. The enema, well, that doesn't sound like hospice care to me.

[RnRatchet]

This was my initial thought. However, there is not enough information for me to form a solid opinion. I've been a nurse for only a short while. To me hospice means DNR, no return to hospital, and comfort measures only. Are there different interpretations of what hospice is/does?

I'm a hospice RN, This is a common opinion of many nurses who aren't hospice nurses. We have several patients that aren't DNR's. You cannot force a family to choose DNR just because they are on hospice. It's still the pt / family right to choose. Although often times after we've been able to work with a family and pt and educate them on the dying process they change their minds.

Without knowing the pt and family story it's hard to say why this pt was sent to ER.

He could've had morphine SL or done a SQ infusion instead of going to hospital for PCA. Maybe this family just needed some more education and support from the hospice and they would've kept him at home and worked with the hospice for comfort care.

We often times have inpt hospice orders for a morphine gtt and "may titrate for comfort" so the staff can increase by 1 mg increments every hour or so untill the pt is comfortable. Like another previous poster said.. many times these pts were on narcs at home that dwarf what we see at "normal" doses.

[carolinapooh, BSN, RN]

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.

I wish they had done that for my father. He ended up in the hospital with staph pneumonia that no one had known he'd had, but the pulmonologist said he'd had it for weeks. (Daddy had severe peripheral neuropathy - of unknown origin, as he had neither diabetes nor liver disease - and was on 100 mcg fentanyl patches every other day and Tylenol 3 as needed. He probably either didn't notice he was in pain or chalked it up to neuropathy.) He'd been vented for a week, in the hospital for two, and there had been no change, so we decided to let him go. They said he didn't know what was happening but I don't believe that. They took him off the vent, put an oxygen mask on him, and kept him medicated with Ativan and occasional morphine. We watched him struggle so hard to breathe for about five hours that every breath made him arch up off the bed and the hospital bed would shake. Finally it was over. I knew what morphine does and wished I could have asked for more of it for him. Maybe they DIDN'T give it to him for fear of being sued for killing him. Maybe they couldn't give it to him - I don't knoe enough to know. I wish they could have asked, because believe me, there was nothing DEPRESSED about the ventilations I saw. It looked torturous.

I certainly don't believe in KILLING people, but after seeing Daddy struggle, I have no problems with high doses of morphine.

God bless the nurses who have carried out these orders and made these decisions. I agree - THE ILLNESS IS WHAT KILLS in this situation, NOT YOU.

[Happy-ER-RN, RN]

Thanks to all of you for your replies. If I were dying I would want to be given morphone non-stop until I died. Maybe if the family hadn't been so hostile I would have felt more comfortable with the idea of giving this man more morphine, but honestly I was concerned about legal (and moral) ramifications of my actions directly causing the death of this man. Perhaps there needs to be clearer policies in our hopitals or nursing practice regarding these issues. Hospice is a wonderful institution when it comes to these issues however. This case was just a bad situation--the man had been using a fentanyl patch but it wasn't controlling his pain so the hospice Dr. ordered a morphine PCA pump--the hospice nurse said she was unable to get the PCA pump until the next morning so she sent the pt. to the ER--she called and told us that he needed a PCA pump and a Kayexalate enema. Well, we don't do PCA pumps in the ER so he ended up being admitted to the hospital. The man was near his death and was not being allowed to stay at home as he had wished due to a technicality. I just think there had to have been a way to keep him at home and still take care of his pain--one of the primary goals of hospice care is pain control right? So why was he sent to the ER for pain control of all things, this should be something the hospice should have worked out, that's why I have an attitude about this situation.

I think people should be allowed to choose how they want to die, for example, if I had a traumatic brain injury and little chance of regaining my previous function, I would want someone to assist me in passing along peacefully. It is so terrible that people have to suffer because of a few sue happy people that have ruined it for the rest of us.

[caroladybelle, BSN, RN]

Several problems with the scenario.

Is the patient a DNR? And if so, is he a full active treatment or a comfort measures only? Just because a patient is on hospice does not mean they are DNR (it is illegal in several states to require hospice patients to be DNR, silly and irrational but true). And just because the patient is a DNR does not mean that they are comfort care only.

DNR does not mean do not treat...in and of itself.

Problem two, patients on Hospice/DNR - comfort measures only should not have to come into the hospital for a PCA or a Kayelexalate enema. Both of these are easily set up at home or in an office. Putting such a patient in the local ER is an inappropriate use of the ER and unduly stressful to the patient. It also (as noted in this case) may expose the patient to excessive treatment or regulations on the pain med that are not appropriate for a patient on comfort measures only.

Problem three, why is a hallucinating incoherent patient being on PATIENT CONTROLLED ANALGESIA? A drip, or the patch, etc. would be more appropriate.

Problem four, why would they put this patient through the discomfort of an enema, if he were comfort measures only? Renal failure is part of dying, the electrolytes will be out of whack. Unless it is painful, there is little reason to correct it. For that matter, why are they even drawing labs on a patient if they are merely on comfort measures.

There is a rule from "The House of G-d", that goes, "Don't take a temperature unless you want to treat a fever". Why take vital signs if you are not going correct any problem that they show?

The ER is a place for correcting acute resolvable disorders and have many rules that apply to this. The patient is dying, presumable on comfort measures, does not have a resolvable disorder (other than ending in death)and many of the standard rules do not apply.

I would not take followup vital signs if the patient is comfort measures only/DNR. Because they do not matter. You ask the patient if he is in pain, and if so, you give the appropriate and ordered med to relieve it. If the patient continues to have pain and clearly indicates this, you give meds as ordered or contact the MD as appropriate. If you are uncomfortable, you refer the situation to the Charge Nurse, and/or MD. He is dying of a disease and you are treating the only thing that can be treated, the discomfort.

But quite honestly, this should not have occurred in the ER because the aforementioned reasons.

[Marylou1102]

Reading these posts I have two comments to make. 1) When Happy-ER-RN gave only two mg. of the Morphine, did you have a doctors order to do it that way? If not you could be sued for not following doctors orders. It is not our place to change the orders of the physicians, no matter how terrible you think they might be. If you feel uncomfortable with an order, you can talk to the physician about it or you can go to your supervisor and let him/her know that you do not feel comfortable giving it. You can refuse to do something you don't feel comfortable doing, I have.

2.) The other comment I want to make concerns something another poster said. She mentioned that a patient that has been on pain medication for a long time grows used to it and requires periodic increases to maintain effectiveness. I once had an A&O CA patient who was receiving 262mg MS/hr. My pharmacist told me he had one receiving over 300mg/hr.

[leslie :-D]

definitely! i've given mso4 150mg/hr....there is no ceiling when it comes to managing one's pain.

i am currently managing a 6 yo girl (at home) who was initially on a mso4 drip. i consulted w/the md who agreed there was no reason for her to receive it iv and we switched to roxanol sl. her parents, in a sudden panic, brought their dd to the onc today for rad txs to her brain tumor. thankfully, the onc discouraged and persuaded the parents not to debulk the tumor as her remaining time would be compromised w/undue discomfort.

i still don't understand the rationale of getting a drip or even infusion pump when it can be administered po/sl- the least invasive way. with vigilant and ongoing assessment, a pt's pain can be well-managed w/o having a needle in your vein.

i don't know what this hospice agcy was thinking....

leslie

[caroladybelle, BSN, RN]

2.) The other comment I want to make concerns something another poster said. She mentioned that a patient that has been on pain medication for a long time grows used to it and requires periodic increases to maintain effectiveness. I once had an A&O CA patient who was receiving 262mg MS/hr. My pharmacist told me he had one receiving over 300mg/hr.

I have them alert and oriented, walking around on Morphine 700mg/hr IV via PICC and a purse/bag pump. The concentration was 50mg/cc. They could administer 50mg as a bolus, every 15 minutes but rarely used it.

The highest dose, I have heard of was 1.25 grams (1250mg)/hr. The patient was awake and oriented but bedridden.

[Indy, LPN, LVN]

Reading these posts I have two comments to make. 1) When Happy-ER-RN gave only two mg. of the Morphine, did you have a doctors order to do it that way? If not you could be sued for not following doctors orders. It is not our place to change the orders of the physicians, no matter how terrible you think they might be. If you feel uncomfortable with an order, you can talk to the physician about it or you can go to your supervisor and let him/her know that you do not feel comfortable giving it. You can refuse to do something you don't feel comfortable doing, I have.

2.) The other comment I want to make concerns something another poster said. She mentioned that a patient that has been on pain medication for a long time grows used to it and requires periodic increases to maintain effectiveness. I once had an A&O CA patient who was receiving 262mg MS/hr. My pharmacist told me he had one receiving over 300mg/hr.

I'd agree on other meds but not morphine. I was taught to give it 1mg/minute and pause in between each 1mg to look at the effect and if patient is responsive, ask about pain relief. So if they become unresponsive during my giving it, I stop. So usually my orders are 2-10 mg... if a patient fell asleep at 1mg I'd stop even if it's 2mg minimum. I'd chart 1mg given, 1mg held due to sedation. It's not that the nurse doesn't try to follow doctor's orders, I would think for that drug there's automatic leeway to stop when it's time to stop.

[Bipley]

...but honestly I was concerned about legal (and moral) ramifications of my actions directly causing the death of this man. ...

I think people should be allowed to choose how they want to die, for example, if I had a traumatic brain injury and little chance of regaining my previous function, I would want someone to assist me in passing along peacefully. ...

?????

Maybe Dr. Kevorkian (sp?) had the right idea. Let the patients make their own decisions regarding their own body instead of us deciding that we know better. :stone

[Xbox Live Addict]

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!!!!

Right you are.

I am a charge LPN at a nursing home, and I see plenty of dying people. I have actually had MDs write actually write orders NOT to take vitals on certain patients. It makes no sense not to take vitals, if for no other reason than covering yourself and being able to show that you were taking care of them. On other patients who are dying and have no orders to stop vital signs, we take vitals on them at regular intervals. Taking vital signs is a basic nursing assessment and a nursing judgement, is it not?

[Bipley]

according to an abstract published by the national library of medicine's pubmed.gov, there is a protocol out there that could allow this patient to be pain free in 3 days. (see link).

a quote from the abstract:

"a consistent finding in these patients was the disappearance of pain within the initial 3 days of cs-treatment."

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=6522427&dopt=abstract

oh lord, here we go again.