Standard med orders for dyspnea

[hooterhorseRN]

76 y.o. male admitted to Hospice with dx of stage five lung cancer. He was alert, oriented and talking about getting a second opinion the day of his admission. Hospice nurse started him on 1mg Ativan q hour and 10mg of morphine q hr. He was not having any pain and was opiate naïve. On supplemental O2 and utilizing neb TX for dyspnea. Family said he was "snowed" from the very first dose of meds thatday. Wife would shake him to wake him up to take his hourly meds that afternoon. Wife found him dead at 3am the next morning. My question is, why on earth would he be prescribed Ativan and morphine in that manner for dyspnea?

[duskyjewel]

Being a CNA, I have no idea as to why the drug orders were what they were.

What I can say is that incidents like this upset me because they reinforce mistaken ideas about hospice and increase the fear of the public about using hospice services.

[toomuchbaloney]

The orders sound like an application of a standard order set without adjusting them to the reality of the patient assessment. If this were my hospice we would be discussing the WHYs of that in very intimate detail at the next IDT.

There is nothing in the description of the patient which would support those orders, nothing, IMHO. Those were orders which would snow most people.

Not good.

[loriangel14, RN]

We commonly use that combination on out floor for dyspnea but out orders are 1-10 mgs so you can titrate up as needed.

[meanmaryjean, DNP, RN]

Did the family not understand the 'prn' part of the order? I'm assuming it was prn- or should have been. And a person talking about 'second opinions' should not be eligible for hospice care IMHO.

[chopwood carrywater]

Perhaps the family did not understand - or was not told- that those meds are given q hourly until the symptoms have been managed. And yes, it seems like the morphine, and possibly the Ativan as well, should have been titrated up from a lower dose. Perhaps there are other aspects of the pts condition and needs that may have played a role.

[guest538567]

The doses may not have been inappropriate although I think a dose range is safer in a naive patient. I am much more concerned that the medications were given scheduled and not prn and the family was waking the patient to give the medication. This certainly should be addressed in some fashion with your agency. Perhaps take a look at your policies and standing orders and encourage some staff education.

These are the unfortunate events that lead people to have biases that "hospice kills people with morphine".

Also, FYI - the last stage of lung cancer is stage IV.

[jschut, BSN, RN]

If he was alert and oriented, he could have been started with Roxanol 20mg/ml at 5mg q4PRN and titrated up. I think the dose mentioned was a bit overboard, but then again, I don't know the circumstances...

PS: Cancer goes to Stage IV...

[TammyG]

The doses are a little high to start, but not crazy high. But, they absolutely should have been given PRN only. You don't mention what symptoms the patient had, other than some dyspnea. You should never wake a patient to give him "hourly meds". An overdose of opioids will make the patient sleepy, and thus protect him from getting more opioids (since a sleeping patient would not need a PRN medication). I would like to think that this never happened, as you describe.

[thenightnurse456]

Ativan may have been ordered for anxiety related to being short of breath.

[Carpediem1012, BSN, RN]

What was his resp rate? His sedation level? Were these being monitored?

[toomuchbaloney]

Here is the bottom line.

The orders which are reflected in the OP are inappropriate for the patient described as evidenced by his response.

It is inappropriate to initiate Q1hour prn orders for a patient who is opiate naive AND NOT in acute distress. This looks like application of cookie cutter orders without adjustment for the individual patient needs.

In my view, it is inappropriate to blame the family...they were following orders which said that they should/could give the meds that often. The presence of those orders represents the error and failure here, not the actions of a well meaning family trying to give the hospice meds the way they believe they were directed to.