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.

[austin heart, BSN, RN]

Maybe one might get the idea you don't believe in palliative care in the ER from this?

Originally Posted by thatoneguy

sounds to me like the patient should be intubated, dont know his ABG's but O2 sat of 75 and unresponsive to giving O2 not good signs and with that BP. after intubation you can give all the morphine you want with little worries. but still need to take vitals before giving. my thinking is the doc wants to intubate just waiting till his respirations are depressed enough to do so.

Not trying to be a jerk...I mean, the CYA thing makes sense, and the first thing I thought of, reading this thread was is the patient DNR even? There's a lot of issues to consider, no black and white.

Just had to point out that the thought of intubating this patient made my skin crawl!

It's clear that's it's a difficult scenario, and the acute nature of the ER makes it even more muddled. Good to hear everyone's thoughts, even ones that I don't agree with

:wink2:

That is the exact statement that I was thinking of. Why in the heck would you want to intubate this person? Just because the person is in the ER does not mean they are an acute and we don't intubate every one that presents with low respers.

And noc4senuf made the same point I did, what are you ganna do with all those vitals? You are certainly not going to treat them. Would you want to start some Dopamine for the low pressure? Some Atropine for the low heart rate? I would hope not.

And I have already said Hospice patients already receiving Morphine at home quickly adjust to any effect that it may have on their breathing. It is prescribed in small initial doses then gradually increased if it is needed. So rarely do breathing problems occur, they are usually not even listed as side effects. In fact morphine is a drug of choice for breathing distress in people with end-stage heart or lung disease: it makes their breathing more comfortable. Why on earth would it be any different just because the patient is in the ER?

[pugmum]

That is the exact statement that I was thinking of. Why in the heck would you want to intubate this person? Just because the person is in the ER does not mean they are an acute and we don't intubate every one that presents with low respers.

And noc4senuf made the same point I did, what are you ganna do with all those vitals? You are certainly not going to treat them. Would you want to start some Dopamine for the low pressure? Some Atropine for the low heart rate? I would hope not.

And I have already said Hospice patients already receiving Morphine at home quickly adjust to any effect that it may have on their breathing. It is prescribed in small initial doses then gradually increased if it is needed. So rarely do breathing problems occur, they are usually not even listed as side effects. In fact morphine is a drug of choice for breathing distress in people with end-stage heart or lung disease: it makes their breathing more comfortable. Why on earth would it be any different just because the patient is in the ER?

:yeahthat:

[twotrees2]

[yes you are right however in my experience - we often have hospice care in the nursing home and th final decision really ends with the family - if they change their minds - which many do as its hard to let go and just let them die - off they go to the er. not our fault blame the family - better yet - dont blame anyone be compassionate to the confused family and attempt to talk to them about the pesons condition to help them make the right decision.

QUOTE=MLOS]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

[twotrees2]

i have been in nursing long enough to see enough death and sad deaths because they are suffering that i would have given the 5 mg and left it at that. ( i would have gotten a specific parameter like every hour or whatever not jut till pain i sgone) however i know what you feel - i felt it for many yrs as a new nurse - i just cuoldnt see it - we werew to help them live not die. however after yrs i realize we may not be there to help them live but to help them die comfortably. cause we sure cant save em and help em live. further more- once yo go him to the floor with a pca pump - the guy was out of it who do you think needed to push the button? pain is not always subjective- you can see when a person who is dying is in distres -difficulty breathing moaning tears coming from thier eyes full of secretions such things like that show they are uncomfortable and neeed some help to be comfortable. i dont look at death as dying but starting a whoile new better life. hugs to you. and i honestly do not think i am killing someone by giving them morphine - it may decrease thier respirations but it also calms their respirations decreases secretions so they arent drowning in thie rown fluids and decreases the pain they are in. either way they will go - why would i let them suffer needlessly when i can help them die comfortably. it isnt the morphine killing them its whatever the disease rocess i sthat is killing them.

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.

[twotrees2]

oh yeah that is peeve of minetoo - who the heck cares about theaddicion especially when they are not going to live long enough to care. sigh - that is a frequent question of family members - ok grandma is 93 and half in the grave do you think she will live long enough for it to matter if she is addicted. sheesh.

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.

[twotrees2]

there were other things that shoudl have been tried first - there is sl morphine, theree are morphine suppositories - we have even given tablets rectally with special rectal tablet holders - it sounds like maybe the hospice nurse dropped the ball or the family was impatient and wanted the transfer.

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.

[twotrees2]

further more there is no reason she should have had to wait till morning for a pump - depending on where their supplier is an hour tops id say it whould take - but i know that our hopsice places around here keep that kind of stuff on hand in thier offices and get it as needed - perhaps she did not want to run to her office and do her job.

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.

[twotrees2]

a doc order is doc order - we are not allowed to order or dose on our own- then the order should have reaad 1 - 5 mg as needed ( if you can do that - we can not in the nursing home - we need specific parameters) i agree with the others - if you wer euncomfortable you should not have done it at all and left it on the supervisopr or doc to deal with. i too have refused idiotic orders - it is ourresponsibility to question any order we feel is wrong or its our butt - however we must question it not make up our own rules. .

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.

[twotrees2]

im sure you are not alone- i know it ahs bothered me attimes too., however if it really bothers you there is always the posibility to say i cant do it please someone who can take this patient. noone is heartless to your dilema. if you arent comfortable - ask for help. as for "the dirty deed" we arent there to be dr kavorkian - i would never give a dose JUST to end their life- i have to know and feel they are in pain and uncomfortable - and generally i have to say i have never NOT known when they need more. even if its just that they break out in a sweat as a comatose resident did once- i knew they were in distress. you just can feel when to do it. but there is no "dirty deed" - leave that to dr kavorkian.

I agree with what you are saying but it still bothers me knowing I am the one that did the dirty deed.

I've had patient families approach me and request I do the dirty deed. Just give him enough to end it!!!!! In my mind I'm thinking YOU give him enough to end it! Why is this my job? Not to get the patient out of pain but to actually kill them?? That isn't what I went into nursing for.

It's not a religious thing with me, it really isn't. Heck, I'm an atheist for goodness sakes. So my religion is not getting in the way of the decisions of a patient but it still haunts me knowing I'm the cause for that death at that moment. It isn't a belief issue with me in any possible way, I firmly believe it is the patient's choice. I still hate being the one to do it. It doesn't stop me from doing it, instead it just haunts me for days.

I'd be a compassionate and effective hospice nurse but OTOH, I'd be an emotional wreck. After all these years that one job just bothers me a great deal. Regardless if the patient is clear they want WHATEVER it takes to get out of pain, it still bothers me a great deal. There is a part of me that is screaming that I just don't have this right. The other part is screaming I don't have a right not to do it.

I suppose we all have our issues within nursing, something that is a challenge and that is mine. I don't want to make it sound like I keep the patient in pain while I decide, it isn't like that. I do what I have to do, it just simply bothers me later.

[MrsWampthang, BSN, RN]

I wouldn't have altered the doctor's order to my comfort level. If the doc wrote down the order for 5 mgs 'till pain gone, if you didn't give what the doc ordered, then it is a med error. That said, the nurse that sent him to ER for the PCA and Kayexallate, should have called to the attending doc and got orders to direct admit him to the floor. There was no reason for him to have to be billed for an ER visit that wasn't necessary. If you weren't comfortable following the doc's orders then you should have requested to have someone else take this patient. If that patient's ER record is audited or someone down the line notices that the doctor's order in the ER wasn't followed, you might be in for some heat from this incident, so be prepared. Next time, follow the doc's order or ask your charge nurse to advise you if you have questions about the order. I personally wouldn't confront the doc, that seems to be a privelege reserved for nurses that have paid their dues and proved themselves to the docs, and that takes years of having a working relationship with them. Yes, it is your licence on the line if a doc's order's aren't correct, but it is your job and your licence that is on the line if you don't follow the doc's orders as written.

[sphinx, BSN, RN]

Re giving the 2mg instead of the 5mg........now, do we agree that the morphine is pushed slowly? That you just don't slam the 5mg in all at once? If it were *me*, I'd push the 1st mg slowly, checking the vitals, if ok I'd give the 2nd....if the vitals were depressed after the second I would not give the rest simply because the doctor "said so". Whatever happened to nursing judgement? I am not a mindless automaton who follows orders blindly even if I know they will cause harm. If things were dicey after the second mg, I would stop, locate the Dr. Notify him what happened and get further orders and ask him to please write an order clarifying and reflecting what actually was given.

Of course that is hypothetical. If the patient was a DNR, knowing he is dying and on hospice, I'd still give the drug slowly but not monitor the vitals, which was the original question asked. That too, however, I would want the doctor to clarify in a written order. And I would want to make sure the partient had a valid hospital DNR.

Again, tough call with a lot of grey areas, I believe.

[botch92]

I work in a nursing home where doctors order 2.5 to 5 mg sometimes up to 10mg of morphine but we do SL not iV form - As some people thought what would you do with the vitals anyways? the poor person is dying.. make comfortable --- Hats off to all the Hospital nurses couldnt do it !!!!!