Tuesday, September 8, 2009

Then again, don't we all?

Yeah, I guess sometimes I DO act like a dick...

On one occasion when I was caring for a patient whose family had decided to redirect care, the new resident asked for directions on how to order morphine to manage the patient’s pain and dyspnea.

“Order a drip of 100mg in 100ml,” I replied. “And set the dosing at 0-10mg per hour, titrated as required to control symptoms.”

That’s what I told her to do because, well, I guess that’s how we always do it. I admit that wasn't a very well thought-out line of reasoning. And while it maybe wasn’t a particularly dick-ish position, it certainly set the stage for what followed.

A colleague, D--, overheard our conversation. She had recently completed a clinical practicum in palliative care as part of her nurse practitioner program, and was well-aware of my interest.

D-- approached me and asked, “Why are you doing a morphine drip?”

That’s when my hackles went up. That’s when the dick-ishness kicked in.

I gave her my best blank stare, and though I can’t remember exactly what I said in response, I do know that my internal alarms were screaming, “Hey! I know what I’m doing! This is MY patient! Go away!"

Maybe it would have been more helpful if my internal alarms had screamed, “Hey! Don’t be a dick! She might be trying to help!”

D-- said our hospital had recently issued new guidelines for managing symptoms at end of life, but I couldn't hear her through the closed door of my mind, and the screaming. I was using my internal energy to defend an indefensible position. Dicks don't listen.

The better angel of my nature began to assert itself, at least to the point of saying, "Well, if you've got something you can refer me to, let's see it."

I made a dismissive gesture with my hand. "Now go away."

But now at least a door was open.

To her great credit, D-- didn't respond to my ridiculously bad manners and utter lack of professionalism. Instead, she returned to her laptop, looked up the relevant guidelines, and placed a printed copy on my workstation as I retreated into the patient's room to compose myself.

I picked up the guidelines and reviewed the section on morphine dosing that applied to my situation. The guideline recommended starting opioid-naive patients on an intravenous dose of 2-4mg, given as needed, as frequently as every hour.

The guidelines stated that a continuous infusion of intravenous morphine was appropriate if the patient's symptoms were not well-controlled with the as-needed dosing, and if the patient required doses every single hour.

Instead of a vague parameter like "set the infusion at 0-10mg per hour, then titrate as required to control symptoms," the guidelines also provide mechanisms for setting an appropriate initial infusion dose, based on the previously-tried as-needed dosing; and for increasing the dose when required.

The wisdom of following established guidelines and using proven tools should be obvious. But as Betty Ferrell and Margo McCaffery say in their 1997 study, Nurses' knowledge about equianalgesia and opioid dosing:
Nurses are recognized as the cornerstone of palliative care. Yet, surveys of nurses' knowledge of cancer pain management reveal serious knowledge deficits that could adversely affect the care of patients with cancer pain.

This work is difficult enough, and there's always a lot to be learned. I've learned not to complicate it further by being a dick.

Thanks, D--.

3 comments:

  1. Seems like you have one of the most essential traits of a good nurse: the ability to self-reflect. Nice blog. Glad I stumbled on it.

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  2. Thanks very much, man. I appreciate the comment as well as the observation, and I agree with you.

    Thanks also for the link. I've done the same, and will keep an eye on what you're doing, too.

    How'd you find me?

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  3. Great post! I recognized myself in this, especially in regard to medically advocating for my mother. I was always about as successful as you at negotiating through my dick-headedness, which is to say, most of the time, if the medical professionals were patient, I made it through. Sometimes I didn't. Thank the gods that, during those times, I didn't have a license to practice medicine!

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