Vent..."sedation"

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Specializes in Neuro, Critical Care.

Need to vent. Had a terminal, TERMINAL brain CA pt. Family states, "she doesnt want any more surgery, she just wants to go home and die". We don't do chemo/radiation on our floor. Gave her 2mg mgso4 at MN and 100mg iv DPH at 0130.

She is old, tired, dying and slow. Slow to follow commands. Call the resident at 0400, notify that she is not following commands. 5 minutes later she does. I call back, tell him not to come, but he is aware she is slow. 0600 another resident comes along and for lack of a better term freaks out and orders a stat CT. I tell him she is just slow and he needs to be more gentle and give her more time. He insists on a stat EEG. I remind him the family wants no more treatment. He gets upset that she received 2mg morphine....She had pain, i 'm not with holding pain meds from a dying cancer pt. I remind him that she had DPH at 0130 and that she never stopped following. Doesn't matter...we drag this poor woman to CT, she vomints all over herself on the CT table...we bring her back, hook her up to a stat EEG...all very traumatic for her and her family.

Suprise, the CT is unchanged, EEG negative. By this time the senior res and all the other residents are re rounding as a group. They stop at my room and by thsi time the pt is more awake. DPH wearing off...she is talking, following briskly.

The senior wants to know why she was lethargic and what I had given her.

Again I tell them 2mg mgso4 and DPH. Again, no one seems to hear DPH they are so caught up on the 2 mg of morphine (2mg, mind you). She didnt even get drowsy until after the DPH...an hour and half after the morphine. I was getting frustrated...so I say...she had a throbbing headache in the back of her head that she is rating an 8/10, her BP was 160 and she normally runs 94...she was in pain...the tears in her eyes made it even more obvious.

He says: that is a pressure HA and we shouldnt be "SEDATING" for a pressure HA. She is on dexamethasone and that should help.

Well it didnt help her HA. Shes dysphagic so no PO. They tell me to give her no more pain medication. I wonder if she cares if her pain is pressure related? I wasn't aware that I was sedating her, I thought I was treating her pain. She didnt have a neuro change after the morphine. She was drowsy from the DPH. NO one listens. If you dont want me to give morhpine, dont order it. The next night, same thing...she doesnt have a lot of pain, just once here and there she needs treated in 12 hrs...I chase down a resident...walking backward, begging for something for her...Order me Fentanyl which I asked for, nope...he says "i dont want the chief to get upset"...UGH!!!!!!!!!!!!!!!! Lucky it was time for her next dose of DPH and she fell asleep...UGHHHHHHHHHHHH. Tks for listening. Oh and I went to my NM.

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Specializes in ER, OR, MICU.

Sorry for my lack of knowledge, but is DPH . . .diphenhydramine as in Benadryl? I haven't experienced that acronym for it before.

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Specializes in ICU, Research, Corrections.

The senior wants to know why she was lethargic and what I had given her.

Again I tell them 2mg mgso4 and DPH. Again, no one seems to hear DPH they are so caught up on the 2 mg of morphine (2mg, mind you). She didnt even get drowsy until after the DPH...an hour and half after the morphine. I was getting frustrated...so I say...she had a throbbing headache in the back of her head that she is rating an 8/10, her BP was 160 and she normally runs 94...she was in pain...the tears in her eyes made it even more obvious.

He says: that is a pressure HA and we shouldnt be "SEDATING" for a pressure HA. She is on dexamethasone and that should help.

Well it didnt help her HA. Shes dysphagic so no PO. They tell me to give her no more pain medication. I wonder if she cares if her pain is pressure related? I wasn't aware that I was sedating her, I thought I was treating her pain. She didnt have a neuro change after the morphine. She was drowsy from the DPH. NO one listens. If you dont want me to give morhpine, dont order it. The next night, same thing...she doesnt have a lot of pain, just once here and there she needs treated in 12 hrs...I chase down a resident...walking backward, begging for something for her...Order me Fentanyl which I asked for, nope...he says "i dont want the chief to get upset"...UGH!!!!!!!!!!!!!!!! Lucky it was time for her next dose of DPH and she fell asleep...UGHHHHHHHHHHHH. Tks for listening. Oh and I went to my NM.

Can you go to the attending and demand pain meds? Was she a DNR? To me, that is inhumane to not treat for pain in a crying from pain, dying patient :trout:

I hate it when residents get stingy with pain meds. I am glad I don't work in a teaching hospital anymore. I usually get what I ask for when I call a doc in the middle of the night.

I sympathize with your vent:uhoh3:

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Specializes in ER, OR, MICU.
Can you go to the attending and demand pain meds? Was she a DNR? To me, that is inhumane to not treat for pain in a crying from pain, dying patient :trout:

I hate it when residents get stingy with pain meds. I am glad I don't work in a teaching hospital anymore. I usually get what I ask for when I call a doc in the middle of the night.

I sympathize with your vent:uhoh3:

I agree. . .I haven't worked on an oncology or neuro floor before, but I do understand what "terminal" means. . .thus, pain control is the best thing you can do for the patient. Is the family aware of hospice services in your area? I am sure they would much prefer that care over the one they are receiving at the hospital.

Hope you feel better.

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Specializes in Neuro, Critical Care.

DPH is dilantin, or phenytoin. I went to my nurse manager. He told me that I did a good job, stood my ground in demending pain meds...he says nursing management is working on the situation with the attendings and that I should document. everything. He tells me this has been happening lately and its just not right. I feel good my management backs me no matter what.

The pt. was not a DNR as her family was d/cing her back to her country, hopefully THE NEXT DAY...as soon as they had the financials worked out. So I only had her for those two days. Her family ended up getting her a charter plane and taking her home to Mexico.

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Specializes in Neuro, Critical Care.

Plus its August. We have new residents..first years...and this particular one is super new..so I sympathize, I understand what it feels like to be inexperienced in a specilized field...so I can almost understand the CT and EEG....however..if they would just listen...i spend 12 hours with her..they spend 5 minutes. I miss our old residents, they would never have done this..:( Other RNs on my floor having the same exp. we are working on a solution.

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Specializes in ER, OR, MICU.
DPH is dilantin, or phenytoin.

Just goes to show you why doctor's orders should be spelled out:uhoh3:

I feel your pain, we have new residens also and they are very difficult to work with at times because they can't understand that what's in the books is not a true picture of the issues at hand sometimes.

Thank God you have a supportive admin!!!!

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Specializes in ICU, SDU, OR, RR, Ortho, Hospice RN.

Get the pt to a Hospice in pt facility where she will get the care she so needs and deserves. Or as the family stated she wants to go home. I would forward plan discharge with the family and get her home with good hospice care.

This is an abhorrant way to look after anyone, especially some one with brain mets.

My heart goes out to you and this dear lady.

Thank you for being there for this lady and being her advocate.

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Specializes in icu, er, transplant, case management, ps.
Plus its August. We have new residents..first years...and this particular one is super new..so I sympathize, I understand what it feels like to be inexperienced in a specilized field...so I can almost understand the CT and EEG....however..if they would just listen...i spend 12 hours with her..they spend 5 minutes. I miss our old residents, they would never have done this..:( Other RNs on my floor having the same exp. we are working on a solution.

When I worked in a teaching hospital, the Chief Resident got all his residents together and told them to listen to us, about activity, about medications and about pain medications, since we have a lot more experience treating patient's pain. Most first years only have the hour of education that got in medical school. I use to pray that none of my patients would CODE the first month. The first years were not worth the powder to blow them to kingdom come. And they always seemed to be the first one there.:madface:

Woody:balloons:

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This is a good example of why I truly dislike teaching hospitals.

If the patient isn't going to be treated, what exactly did Einstein plan on doing with the results of the CT and EEG if they had showed a change?

He says: that is a pressure HA and we shouldnt be "SEDATING" for a pressure HA.
Idiot. :angryfire
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Hmm.....in my experience DPH was Demerol, Phenergan, and Haldol cocktail.

No matter what DPH is, no matter if it sedated her or not, TREAT THE *(&%^%#!! PAIN!!!!! Geez, what IS it with the baby docs?!?!?!?

I think my next action would have been to get the attending on the phone, either call yourself or have the house supe do it. The attending is, 24/7, ultimately responsible for the pt.

About the morphine: I had a LOL who had accidentally overdosed on her pain meds at home and came in obtunded. She got narcan in the field and I gave her 4 more. The private doc came in and ordered 2. I asked him "On top of the 2 she got in the field and the 4 I gave her?"

He panicked and started yelling that I'd overdosed her on narcan. I was a new nurse, I was so shaken up that I might have indeed harmed her that I went out to the nurses' station in tears. The ER doc who had ordered the 4 asked me what was wrong, and when I told him he stomped off and gave the private doc a lesson in emergency medicine dosages.

These guys get so wrapped up in textbooks that they refuse to look at reality.

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It isn't just teaching hospitals.

I had someone come back to my last facility specifically having refused surgery for a brain bleed and knowing that he was going to die. He was in horrible pain. I called the doc at night and she gave me fentanyl and 5 mg morphine (roxanol) Q1H PRN.

I gave it ALL. He was moaning and grasping his head - can we say, pressure?

The DON and my assclown supervising nurse had me in that Monday for a meeting in which I was told that I was perceived as "pushing pain meds." They had me rewrite my nurse's note with more detail because "moaning and grasping his head" wasn't descriptive enough.

BTW, he died the next shift after mine. And the idiot ADON's idiot DIL, who doesn't "like" pain meds or PRN's, gave him ONE dose of roxanol in 6 hours. The poor guy.

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