After browsing the site for awhile, I feel I've calmed down enough to post about this rationally!
I was asked to see a patient tonight who has terminal Ca. It was a first visit for me...though this lady had been on service for awhile, I'd never seen her before. I was to go in and give her Decadron and 2.5 mg. of Haldol.
When I arrived, she was sleeping very peacefully, vitals stable, but resp. rate was only 8. When she awoke while I checked her vitals, she was not able to talk. I went back downstairs, and talked to the family about her history. Apparently, that morning, she had been walking and talking, though in a lot of pain. She'd even gotten up and showered, with assistance. Then, when the palliative care doctor came in, he gave her Haldol and applied a 50 ug Duragesic patch. This was at 2:30 in the afternoon, and she'd been sleeping steadily ever since. She had not even been up to go to the bathroom.
I told them I was concerned that maybe she was a little over sedated, and I was NOT comfortable giving the Haldol without checking with the doctor.
The attending calls me back (after a long wait) and tells me to hold the Haldol, and remove the Duragesic patch. He said to use Dilaudid P.O. for pain, but if that didn't work, to re-apply the Duragesic, but use a 25 ug patch instead of 50.
I carried out his orders. No sooner had I done so than the primary care doc. calls, flaming mad. He told me that what I'd done was totally, totally inappropriate. I should have reassured the family that it was perfectly okay at this point for her to have such a low resp. rate, and not be able to talk or respond to them. I tried to tell him, that YES, I agreed that would be so, if the patient were actively dying. But someone who was walking and talking earlier today, has good colour and perfectly stable VS isn't exactly end stage. He would have none of it, and continued to rake me over the coals. "You should have been reassuring the family, instead of getting them upset about this!" he ranted. "I don't know what kind of training they're giving the nurses, but it's not good! You should know better! Tell them to talk to her softly...it doesn't matter if she can't talk back...."
He then spoke to the family at length, then called me back, and told me to reapply the Duragesic patch, but only half a patch (put Opsite under the other half). As he was about to hang up, I reminded him about the Haldol: should I hold it or give it? "Hold it," he told me. "I gave her some this afternoon, so she'll be okay."
So, palliative and hospice nurses, what would YOU have done? I frankly think he forgot about the Haldol dose. If it hadn't been for that, I probably would have left well enough alone, in spite of the respiratory rate being so low. Right now, I am FUMING over this doctor's arrogance, and the way he treated me. His whole conversation with me took place on the phone, RIGHT BESIDE the patient's bed, with the whole family listening. The family was very understanding, and told me "You did what you though was right, don't worry about it," which makes me feel a little better. Still, it ruined my evening. I had hoped to finish early, and get in a workout at the gym before coming home. Instead, I got home after the gym closed, too angry and too uptight to even think of going to bed.
Arrggh. Gonna go for a nice, long walk with the dog, and try to get over this!
I've had that same experience as the speaker in your palliative care course. Recently had a GP tell me he wouldn't increase his patient's MSO4 from 2 mg to 5 mg because it might decrease her respirations, so let's put a Duragesic patch on her. Duh. Not only is short acting morphine a better choice for many reasons, but this idiot completely forgot that he had put her on Duragesic a month before (twice before actually) and each time she had severe vomiting, unrelieved by anything. A lot of docs perceive Duragesic patches as some kind of benign medication. It's certainly left to nurses to know these medications and speak up when we think there is a problem.
I haven't seen her since Thursday night, but I asked the nurse who saw her last night to give me report. Her pulse and BP are still stable, but the respiratory rate remains low (11 over 4 minutes...uh...I'm assuming that was an AVERAGE, not the acutal rate!). They now have her on 1/2 of a 25 ug patch, and they held the Haldol again last night. They've also reduced the dose of Haldol to .5 in the a.m. and 1.5 in the p.m.
This time, no one threw a fit when the nurse called about the Haldol... lucky me, to be the first one in there after it was prescribed, and catch all the ****!
Why he doesn't just make it PRN is beyond me! Maybe he doesn't trust the nurses?
I think he's using Haldol because she has lymphoma with brain mets. I didn't see her when she was in pain, but the family said she was 'climbing the walls' with the pain. So, I'm guessing there was agitation along with it. No one has mentioned confusion, though.
I was asked to see a patient tonight who has terminal Ca. It was a first visit for me...though this lady had been on service for awhile, I'd never seen her before. I was to go in and give her Decadron and 2.5 mg. of Haldol.
I am in nursing school...from day 1, our instructors have drilled it in our heads that if the dosage seems too much, too little, or just something about it doesn't "sit right"...clarify it before you give it...it's your conscience and your license. I am glad to see an example of critical thinking!
Good for you, Pvcc! It's not an easy lesson to learn. I used to teach school, and OH! so rarely did I see a student doing anything but parroting back what they'd learned from the book or class notes!
If your REALLY want to fine tune your critical thinking skills, you might want to try community nursing. Nothing like being out there alone to sharpen your wits, and make you think 'outside the box'! That's one reason I enjoy it so much.
Just to clarify, I have had patients with resp. rates as low as 6, and done nothing about it, because they were obviously going to die within hours. That's where critical thinking comes into play. This lady was up and showered the day I saw her! I mean...HELLOOO?? And now she can't even sit up in bed without someone supporting her from behind? People usually don't go downhill THAT fast, with no warning. Even if that were what was happening, I'm sure her other vitals would have reflected the sudden slide.
They had her on half a 25mcg patch? Did they cover 1/2 the patch or did they cut it? I can't believe that there was a nurse who actually followeed that order. Of course, you'd think for what they charge for each patch(approx $37.00/patch for 75mcg) that Janssen would develop a 12.5mcg patch for opioid wimps or little old people who can't tolerate the 25mcg patches. Fentanyl can and does cause some really powerful nausea, and it's really hard to forget it when you have experienced it due to the intensity of it.
I'd say that this PMP has an attitude for sure. Did his head fit through the doorway with it being so large? How sad and awful for his clientelle that he is so egocentric and insecure. Maybe you could give Janssen an anonymous call and very diplomatically encourage them to send their detail rep for his region to this doctor's office to review the correct application and indications of the patch. He could say they were having some safety issues and that they are just making sure that everyone understands exactly how they are meant to be used.
Opioids can cause somepowerful itching and also some very powerful nausea. Most of the time it is dose related and when the dose is adjusted correctly, pts start to realize that their symptoms are getting better.
Doctors can really be uh, a bigger problem for pts than their diseases can be. Do you think they were sent to earth just to aggravate us or punish us??? Maybe THEY are our hell on earth or at least I believe some of them are!!!
Can you imagine if we told a doctor that IF he wanted the pt to have just one half of a patch applied, that HE would have to apply it himself? Wouldn't you just love to say that to him sometime? The thought of it is tempting but unreasonable and sure to get you fired!
I saw her on Sunday, and she is now awake and alert, though very weak. The pain is under control, and she is able to talk with family, who were gathered by her bedside. She can still make it to the bathroom, with the assistance of 2 people. I have ordered a commode chair for her, though, as it is obvious that soon she will not be able to walk that far.
Her respiratory rate (on 1/2 of a 25 ug. patch) is 11 to 13 at rest. I'm very happy with how things are going for her.
Thanks everyone for your input. And Pappy, I am going to look into contacting a pharmeceutical rep. re this 1/2 patch business. This palliative care doc. has everyone in the area doing it as a standard, acceptable part of their nursing practise. In theory, since the drug IS absorbed through the skin at a constant rate, the amount of drug SHOULD be roughly proportional to the surface area of the skin in contact with it. That's why the 50 ug patch is much larger than the 25. However, like they taught us in nursing school, DON'T EVER ASSUME!! Cuz it can make an 'ass' out of 'u' and 'me'!
(And no, the doctor did NOT tell me to cut the patch in half! He may have a few problems, but he's not stupid!)
I cannot address the palliative care issue, but the rudeness of the doctor I WILL address. You will learn this as you get older, but what I would have done is interrupt the MD when it became apparent that his tone was anger. As for now, I would notify my supervisor of this incident. Sorry you had to encounter this.
I contacted Janssen-Ortho today, and got the following response re. using half a patch:
An alternative to cutting membrane-controlled transdermal patches such as Duragesic has been described by Lee and Anderson. They suggest applying a piece of impermeable material, such as an adhesive bandage, on the skin to block a section of the patch. The bandage is applied to the skin, and then the patch is applied, such that a section of the patch overlaps the bandage. The surface area of the blocked portion of the patch should be proportional to the intended dose reduction. The authors state that it is necessary to secure the impermeable material and the patch to the skin by placing another adhesive bandage over the whole system.
Please note that Janssen-Ortho Inc. does not promote or endorse this intervention as Duragesic has not been studied under these conditions.
The drug monograph for Duragesic is available on their website, and they very clearly state that one of the commonest and most dangerous side effects is respiratory depression!! It has actually resulted in some deaths in patients who were 'using the patch incorrectly', (whatever THAT means!) I researched Haldol, and it does NOT cause respiratory depression, though it may cause respirations to be deeper than usual.
Hmmm.... how to get this info across to the doctor, without ruffling feathers!
Specializes in Vents, Telemetry, Home Care, Home infusion.
It has actually resulted in some deaths in patients who were 'using the patch incorrectly', (whatever THAT means!)
Don't know if you are aware but some facilities have a problem with patches being removed from client's chest, fentynal syringed out of product and injected---new"recreational" drug
Killed a nnurse in my area-----------so i suspect that's what they mean.
I would request Jansen inservice staff with Dr present, they have great material re drug conversion guides.
While in I had one patient use 6 100ug patches while in hospice-- awake and walking around home before we changed him to a pump as bone mets severly ecallated pain--also on other drugs.
Five years ago had a homecare patient PAYING HIMSELF and using 5- 100ug patches every three days; refused hospice which would have paid for drugs as he didn't want to loose Stephanie CETN and myself. Finally drug bill as $1,000 every three weeks and I made him realize family could use that money more than him.
He even drove the family to Atlantic City with BP 70/50---boy did the power of prayer prevent an accident. Finally on hospice with family administering hourly sublinqual Morphine prior to death.
hospicenurse
84 Posts
Jay-Jay -
I've had that same experience as the speaker in your palliative care course. Recently had a GP tell me he wouldn't increase his patient's MSO4 from 2 mg to 5 mg because it might decrease her respirations, so let's put a Duragesic patch on her. Duh. Not only is short acting morphine a better choice for many reasons, but this idiot completely forgot that he had put her on Duragesic a month before (twice before actually) and each time she had severe vomiting, unrelieved by anything. A lot of docs perceive Duragesic patches as some kind of benign medication. It's certainly left to nurses to know these medications and speak up when we think there is a problem.
Btw, how has your patient been since that night?
Gail