Scenario:What would you do?

little-nurse · Feb 10, 2012

If a patient is coming from a hospice; then it's clear that the patient is receiving palliative care. I don't know what a palliative patient coming from a hospice is doing in the ER. Hospices I know receive the medical pain and symptom management in the hospice itself. For a 5mg Morphine to be given at the hospital, I think is unnecessary discomfort and stress for the patient and the family. Transporting a palliative patient is a painful enough experience. Another thing is as far as palliative nursing goes; it's understandable that what seems to be like the end-of-life stage occurring in this scenario; the patient's vitals is going to be out of whack anyway. Continuing to do vitals on a patient who is a DNR is added discomfort to the patient during end of life; which totally contradicts palliative nursing all together. Given the fact that yes morphine decreases resp. rate; but from the look of the patient it's not going to turn out well. At this point in time the possibility of the patient's nearing end is the best time to support the family with a short conference of what could happen next at this time. Give the family the time to absorb the situation; no morphine or enema can change of what may come next. Nevertheless, since the patient's BP is low and O2 sat is 75%; giving the Morphine 5mg could be more than what this patient can handle. Giving less than 5mg is going to go against MD orders but to make sure the pt can handle a low dose will at least settle any discomfort.

Just my tidbit...I've been involved with palliative nurses before and they are a great resource with vast knowledge of the care and support that the patient and family needs. From dealing with constipation, adverse effects of pain meds, and everything else to expect in palliative care. I've had a nice opportunity to collaborate with them especially when the patient and family decides to have a planned death in the home. To have a visiting nurse, a palliative nurse and a doctor to provide all the care that would meet the patient and family's needs is I believe the 'peace of mind' that healthcare professionals can give.

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.

tokmom, BSN, RN · Feb 10, 2012

follow PnP. My nursing judgement says to keep him on the monitor. I would also titriate that MS. It doesn't sound like the family is ready to let go,so this pt wouldn't be dying on my ED stretcher!

Arshia · Jun 11, 2012

Accountability is a critical aspect of nursing care.an example of accountability is demonstrated by:

a.Selecting the medication schedule for client

b. Implementing discharge teaching plans that meet indivisual needs

c.Evaluating the clients outcomes after implementation of care.

d.Promoting participating of all staff members in unit meetings

please i need some scientific rationales to the related scenario

Arshia · Jun 11, 2012

yes u are right

jeannepaul, BSN · Jun 12, 2012

I know this is an old thread but there were some questions that were never answered. The reason we tell patients not to call 911 and not go to the hospital while on service is a billing issue. Medicare will only pay for either hospice or hospital, that is for the same diagnosis. If we had a patient on service for cardiac, and he went to hospital for chest pain, the family would get the bill if they did not revoke service to allow for medicare to step back in and pay for whatever they pay for.

Yes, they would be allowed to come back on hospice service once they were stable and came back home. You do not loose the hospice benefit. If they go to ER and they do not get admitted, they do not have to come off service.

I cannot believe a proper hospice nurse would send a patient to the ER that close to dying, knowing he could pass away enroute. Once they get that close, they should not be going anywhere. If the pt. or family did not want him dying at home, he should have been transfered before he was active.

There are certain stages terminal patients go through, and it doesn''t matter what the disease is, it is usually the same. Yes I do know not everyone goes through all of them, or sometimes they can go through every one in a few hours, or some, esp. heart and lung patients that are stable, and crash quickly, but if they go through the normal stages, the hospice nurse should be teaching the family what will be coming next, what to expect and how to handle/treat the symptoms.

Most of the time when families panic, it is because teaching has not been properly done. You have to tell them the same thing over and over again at each visit before they can process it.

As Far as the medication, I am still amazed that some nurses are so uneducated about the dying process and how the body shuts down that they freak out at giving the proper amount of medication.

I personally do not believe that Morphine "Kills" the dying patient. They are usually either having rapid resp, gasping, rapid HR and are so uncomfortable to let go. Once the patient is finally comfortable they are able to let go. I look at it this way. when you are in pain, it is very difficult to sleep, you toss and turn and you are soo tired, but you just cant sleep. Finally, you get some pain relief, you are now able to drift off to sleep, your body is not so tense and you can relax. I believe it is the same for the dying.

Most families in hospice have some sort of higher power, and if they believe that, the day and time of all our death's, are already known, then we are not hindering or hastening anything.

Is oxygen going to prolong someones life? for a while maybe, but not forever, if they are dying, the sats are going to go down regardless of what you do. Do we administer oxygen, most of the time and not always for the patient. Sometimes it is for the families, because our first reaction when the patient has apnea or rapid resp, is to do something, the patient may not be in distress, but breathing differently, but it is difficult to stand there and not do anything.

Sorry to get on my soapbox, esp. in such an old thread, but if someone can learn and understand the dying process and not be afraid to make the patients comfortable and really understand they are not killing them with Morphine, it is worth it to me.

one more thing, so many time I have heard that families and nurses think we put patients on hospice, give them morphine and kill them. Not to mention stop feeding them and starve them, but that is for another thread....

Katie82, RN · Jun 12, 2012

you are right, palliative care involves an entire different set of protocols. Patients in hospice agree to "comfort measures only", so doing vitals would have been a waste of time, since you would not have initiated treatment or coded him. Very difficult for staff that are focused on taking life-saving measures, perhaps admission to the ER might not have been the best choice. Most hospices can do this in the home....