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.
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.
Hospice would have been the best place for her but apparently they don't have hospice in Mexico? She was just going to be with us until her family arranged a charter plane to get her back to Mex.
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!!!!
yep, we tell them over and over again not to use it...the pharm wont accept it, so its a huge pain for me bc depending who is on call, I have to call and tell them and get it changed and re fax everything all over again..so it would be sooo much easier for me if they just wrote it out. llol:)
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.
Reading that made me ill. I wonder how "descriptive" her charting was to validate her lack of medication.
Your doc should have ordered the pain meds q1hr, or an infusion. No PRN. One of my docs calls PRN doses "per RN." He says too often patients are at the mercy of nurses who don't "like" pain meds or don't think they need them.
BTW, I love teaching hospitals. When one encounters an ill-informed doc, one simply goes over his/her head! (after an appropriate Q and A session with them. After all, they are here to learn from us too).
Specializes in ICU;CCU;Telemetry;L&D;Hospice;ER/Trauma;.
Okay...so the junior resident ordered yet ANOTHER CT scan on a dying cancer ridden patient because????? what was the PLAN?? Take her to surgery and REMOVE HER ENTIRE CANCER RIDDEN BRAIN??? Put in a few BURR HOLES perhaps???
Med schools NEED TO TEACH DOCTORS>>>NEW ONES>>>> THE IDEA OF COMFORT>>>>IE>>>>DNR>>>>HOSPICE>>>>
if the family and patient wish this for themselves....THEN FOR GOD SAKES GIVE IT TO THEM!!
I recently had an idiot session with a cardiologist who believed that his patient was going to get well...despite the fact that he, his wife, his family, and all the other doctors involved clearly decided on a comfort measures only pathway for this patient....he wanted him to be extubated, NO MORPHINE....just let him rasp and grasp for breath until he's breathing 50 times a min....uh huh....the man had completely rotted lungs....zippo....nada....and the idiot cardiologist believed he would get well...83 years old....overweight....smoked until he ended up on a vent....what a moron! The man died 12 hours later....but he didn't have a peaceful going....because the cardiologist didn't want him to have comfort....dumb a$$! I am sure in his pea brain, a lung transplant might be a possibility! sigh.
Okay...so the junior resident ordered yet ANOTHER CT scan on a dying cancer ridden patient because????? what was the PLAN?? Take her to surgery and REMOVE HER ENTIRE CANCER RIDDEN BRAIN??? Put in a few BURR HOLES perhaps???
Med schools NEED TO TEACH DOCTORS>>>NEW ONES>>>> THE IDEA OF COMFORT>>>>IE>>>>DNR>>>>HOSPICE>>>>
if the family and patient wish this for themselves....THEN FOR GOD SAKES GIVE IT TO THEM!!
I recently had an idiot session with a cardiologist who believed that his patient was going to get well...despite the fact that he, his wife, his family, and all the other doctors involved clearly decided on a comfort measures only pathway for this patient....he wanted him to be extubated, NO MORPHINE....just let him rasp and grasp for breath until he's breathing 50 times a min....uh huh....the man had completely rotted lungs....zippo....nada....and the idiot cardiologist believed he would get well...83 years old....overweight....smoked until he ended up on a vent....what a moron! The man died 12 hours later....but he didn't have a peaceful going....because the cardiologist didn't want him to have comfort....dumb a$$! I am sure in his pea brain, a lung transplant might be a possibility! sigh.
no one could go to the chief of staff??
no other doctors would intervene on behalf of this pt??
Okay...so the junior resident ordered yet ANOTHER CT scan on a dying cancer ridden patient because????? what was the PLAN?? Take her to surgery and REMOVE HER ENTIRE CANCER RIDDEN BRAIN??? Put in a few BURR HOLES perhaps???
Med schools NEED TO TEACH DOCTORS>>>NEW ONES>>>> THE IDEA OF COMFORT>>>>IE>>>>DNR>>>>HOSPICE>>>>
if the family and patient wish this for themselves....THEN FOR GOD SAKES GIVE IT TO THEM!!
.
Amen. This is what I am screaming. Let alone, it was 0630 and I was intubating my other pt next door...so my patience for him was wearing thin....I argued with him for awhile, but in the end he wins. My NM said the same thing-sometimes docs, esp. the new ones just don't know when enough is enough.
Specializes in ICU;CCU;Telemetry;L&D;Hospice;ER/Trauma;.
We have a pseudo-ethics committee/ doctor....who mostly just goes from one unit to another searching for donuts...he's pretty useless...when the rubber meets the road, he sits down and puts up his feet...so, I am not really sure what they pay him for...
It's sad...the other doctors didn't want to "over step" with the cardiologist because he had the primary care of the patient....soooo
I guess we respect the primary doctor all over the place, but the patient's needs and such are just secondary....
When I was in Surgical ICU, even though there were residents, it was a closed unit and the residents could only round and make suggestions. We had Intensivists (sp) who took over and oversaw all their care in ICU. There were also PAs who worked only in our unit, so they too, specialized in intensive care. Our patients frequently had pain issues, and never had to deal with residents ordering unnessesary tests and not wanting to give pain meds. Sometimes there were patients that I felt were not medicated well enough for pain, and typically talking to the doc or PA would get results, if not increasing the dose or frequency, then perhaps a new pain med. When we had a patient go on comfort care only, if they don't go to hospice (typically they were so ill they might never make it to hospice, or home for homecare hospice) they would immediatly be put on a morphine drip titrated for patient comfort.
I'm glad your patient was able to be discharge home, to be with family. I hope that she is getting something for pain there, and has a more comfortable death. Sounds like her hospitalization was really unpleasant to say the least:o
This whole thread upsets me terribly. I am huge advocate of pain control/relief and it just infuriates me when doctors won't give enough to keep a patient comfortable.
One night I got so angry that I had a meltdown and threatened the resident with the Ethics Committee and a call to the local newspaper, along with wishing her as much pain as she'd caused patients to have by her withholding of medication. It wasn't a pretty tantrum at all... but I was SO upset.
I got 2mg of morphine. :angryfire
It will be this very subject that is ultimately going to drive me away from nursing.
We used to have a pain nurse. Im not sure what happened to her but shes gone. Usually we are very liberal with pain medication, however, sometimes around this year, or so I hear, some of the newer residents are like this...
I sort of understand, as it's not good to sedate a neuro pt. as it really can mask changes, BUT..how can we NOT treat pain? There are some drugs out there that can relieve pain w/o sedating...I don't understand why we just don't use those drugs...
We have intensivists but the residents or the attending handles pain meds...our intensivists can be attendings but normally they arent as we are neuro.
I went up the chain of command but she was dc'd the next day...I would have pushed the issue further but she wasn't there very long. I made my opinion clear, we are following the issue.
Eventualy I did get them to give me 25mcg of fentanyl so she got that and the dilantin and she was knocked out. She didn't complain again of pain or I would have just called them and called them until they gave me something. She wasn't in constant pain according to her. When she had pain though, it was severe and she really couldn't tell me what or where...I treated her once with the morphine and once with the fentanyl so I felt like she was ok, but the whole situation really made me mad and if I handnt finally chased another resident down the hall demanding and guilting him into giving me something they never would have...and the fact that the resident made the statement "well I dont want the chief to be mad at me" Sigh.
He says: that is a pressure HA and we shouldnt be "SEDATING" for a pressure HA.
Whoops! Missed that day in nursing school when they taught us that 2mg morphine is considered sedation!
I am huge advocate of pain control/relief and it just infuriates me when doctors won't give enough to keep a patient comfortable.
One night I got so angry that I had a meltdown and threatened the resident ... with wishing her as much pain as she'd caused patients to have by her withholding of medication. It wasn't a pretty tantrum at all... but I was SO upset.
Amen. Same thing happened to me recently when a brand new FELLOW (who should know better) told me a baby wasn't suffering and "can't cry because he has an ETT." I lost it.
I will continue to advocate for my patients as much as I need to, regardless of how many toes I have to step on along the way. It may have taken me almost 2 years to find my voice, but I'm sure as heck not going to keep quiet now!
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GrnHonu99, RN
1,459 Posts
Hospice would have been the best place for her but apparently they don't have hospice in Mexico? She was just going to be with us until her family arranged a charter plane to get her back to Mex.