I think I succeeded in pissing off almost the entire local medical community today. Why? I was simply trying to get one of my patient’s needs met – – that’s all. I’m a bit unforgiving when it comes to doctor’s who don’t seem to listen.
I had a patient for the past month. She died today. She died miserably, in pain and suffering – – and she really didn’t need to. We did everything we could – – that is to say, everything within the confines of our limitations.
She was an elderly lady with breast cancer that had metastized to the bone. Bony mets are no fun. Not that any mets are fun, mind you. However, bony mets tend to be rather harsh and excruciatingly painful.
She lived in a local Assisted Living facility here in town. A very nice, quaint little facility. The thing with Assisted Living is that they are limited in the services they can provide for their residents. They certainly don’t provide 24-hour nursing coverage for them…nor are they able to provide 1:1 supervision – – which is what this lady required after yesterday.
Beginning yesterday, she began to complain of increasing pain and showing signs of unrelenting anxiety and restlessness. She stopped taking her oral medications because she had several cancerous lesions in her mouth and on her tongue – – which made it very uncomfortable to take anything by mouth.
Her regular doctor is on her honeymoon and isn’t available – – which leaves me with an on-call doc who doesn’t really want to have to deal with the crisis of another physician’s patient. They are ok with taking call – – as long as no crisis crops up.
I managed to get orders for this patient so that I could aggressively treat her pain with high doses of Morphine and Duragesic and treat her anxiety with Ativan. After about 4-5 hours of sitting with her, trying to get her pain under control – – I was successful and I left her sleeping soundly.
Unfortunately, Medicare does not pay for 24-hour Hospice care – – so our agency could only provide her with 8-12 hours per day of 1:1 nursing care. She became anxious and restless overnight and began trying to get herself out of bed, independently – – and the facility is not adequately staffed for this kind of 1:1 attention that this lady was requiring.
I had tried to get the on-call doctor to directly admit this woman to the hospital for acute pain management and until we could find an available bed at a skilled nursing facility where she would be safer with adequate nursing staff available for the supervision that she required.
The on-call wasn’t willing to give me the order to admit. He told me to manage her pain with the Morphine and update her regular doctor in the morning.
So, I did. Her pain was somewhat managed overnight – – not great, but better than earlier in the day.
In the morning, I called her regular doctor’s office and was informed that she would be out of the office until three. I informed them that this woman could not wait until 3pm and wanted to speak with the on-call for the day.
I was directed to a different physician (different than the on-call yesterday). I explained the situation to him. Explained that she was worse today than she was yesterday. Explained that we had a nurse sitting with her until 1pm today – – but no one scheduled after that until 9pm and explained that I felt strongly that she was unsafe being alone, that her pain was not under control, her anxiety was through the roof and I wanted her admitted, directly to the hospital for acute pain management. I explained that our Hospice agency does this all the time – – particularly if we have a patient whose pain does not respond to our usual methods of pain control.
He wanted to put her on a Morphine drip. I agreed wholeheartedly! However, the regulations in the state of Wisconsin will not allow for a patient in an Assisted Living facility to be on a Morphine drip because they do not have 24-hour skilled nursing on staff. He argued that we do Morphine drips in a home setting by teaching the family how to manage it. Which is true. However, the regulations are different and Assisted Living facilities are not allowed to run those kinds of technical medical services without 24-hour RN coverage on-site.
He informed me that he was unwilling to admit her to the hospital to put her on a drip. He said that her doctor would be available after 3pm in the office and he increased the dosage of oral Morphine I could give her. I explained that she was refusing her oral medications because of the pain in her mouth caused by the cancer. I’d really feel more comfortable and feel we were meeting her needs better by admitting her and getting her on an IV Morphine drip and getting her pain under control while we sought out an available skilled nursing bed in the county.
He told me that he was unwilling to make that kind of decision on another doctor’s patient.
At 1pm – I finally get a hold of this lady’s actual doctor. Once again – I relay all the information to her doctor. This is the third doctor I’ve explained all this to in the past 24-hours and thought for sure that I would get through to this one.
Optimistic lil ol’ me.
Her doctor’s response? “I understand where you are coming from — but I don’t think it would be humane to admit her to the hospital, restrain her and stick an IV in her at this point. She’s dying. She should just stay where she is and try to control her pain with the medications we have available (i.e. oral Morphine)”
I explained that she didn’t require restraints. Who said anything about restraints? Her doctor responded “Well, you said she is very very restless and agitated — it sounds to me like she would only pull the IV out if we put on in unless we restrained her.”
I explained that she is agitated and restless because SHE IS IN PAIN! If we got her pain under control – – I bet’cha she’d stop being so agitated.
Still, no go. I had a few more choice words exchanged with the fine doctor – – then gave up. I put a call into our Medical Director and reported this situation – – and he would not give me the order to admit this lady…. apparently not wanting to ‘overstep’ the attending physician’s decision. The attending physician, by the way, who hadn’t physically laid eyes on this lady for at least 3-4 months.
So, we continued to dose her with the oral morphine – – fighting with her every step of the way to get the pills in her mouth because she didn’t really want to take them at all. She cried, moaned, groaned and screamed out “help me . . . . OH GOD please help me!” We dosed her with 30 mg Morphine every hour, 2 mg of Ativan every 4 hours as well as the 100mcg Duragesic patch she already was wearing.
We sang to her. Played music. Read to her. Massaged her shoulders. She slept a little bit when she got truly exhausted….but only for 15-20 minutes at a time before the pain would wake her up again and we would start all over again.
This went on for about 5 hours.
Then she died. She finally found peace after taking her final breath. But she didn’t have to go that way….if it weren’t for the brick wall that I have been hitting my head against for the past 36 hours. No one should die in pain if it can be helped. I’m not even doing this story justice – – there is so much more to it, but I’m too upset about it to write it all down at the moment.
Sad thing is, it will be forgotten. No one will question it. No one will say anything about it. Everyone will say that it’s a blessing that she is no longer suffering and in pain any longer. Everyone will say that she is in a ‘better place’ now and her pain is gone.
That could all be true. And that is all well and good. Except I know – – I know in my heart that it did not have to be that way for her.
It’s this kinda shit that keeps me up at night.