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  1. #1
    kingella kingae is offline Newbie 510 points
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    Question on pain med

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    So let's say there's a terminal patient who's being taken care of in the hospital and he's on soooo much pain med that it leads to resp arrest. when he is revived, he tells the doc that he just doesn't want to live with the pain anymore. so what should the doc do?

    continue to give the same dose of pain med?
    or
    decrease the pain med just enough so that the patient doesn't go into resp arrest?

  2. #2
    Water's Avatar
    Water is offline Member 519 points
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    Definitely cutting back on pain med because apparently it passes its therapeutic level. ABC priority. There is also gap between therapeutic level and respiratory arrest. At the least, there is the lethargy level. So, pain management does not have to be either therapeutic or respiratory arrest. chronic patients need to be educated on the fact that pain will be reduced with medications; however, they do not always eliminate the medications. Consider teaching guided imagery and other modalities in conjunction.

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    AUCMD2006's Avatar
    AUCMD2006 is offline Ultimate Member 6129 points
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    ever had a terminal patient?

    Quote Originally Posted by Water View Post
    Definitely cutting back on pain med because apparently it passes its therapeutic level. ABC priority. There is also gap between therapeutic level and respiratory arrest. At the least, there is the lethargy level. So, pain management does not have to be either therapeutic or respiratory arrest. chronic patients need to be educated on the fact that pain will be reduced with medications; however, they do not always eliminate the medications. Consider teaching guided imagery and other modalities in conjunction.

    ever had a terminal patient? probably not, you offer pain meds that they need for comfort care. the "therapaudic level" is determinded by the patients level of comfort not your pocket drug guide or PDA.

    every physician knows that past a certain dosage a side effect of pain medication are respiratory complications. you explain to your patient that the dosage required to control his/her pain may interfere with his/her breathing, if they agree you continue with adequate pain mgmt

    making someones last few days on earth as confortable as posible should be one of your guiding principles. in all honesty, cutting a termial patients pain meds down is not only horrific to watch but you are only giving them a few extra days of misery, no sleep, no hope etc. tell you what, take a ABG needle and take it at a 30 degree angle 1/2inch medially to your radial artery and hit the bone with the tip, now tape it in that area and see how long you last, try and relax, do "image guided" therapy, hang crystals around your head, magnet therapy, yoga, whatever you want and see if it helps, then try and sleep...now imagine that same level of pain in every bone in your body, multiply that for 2 years then decide if cutting back a pts pain meds are an ethical choice.
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    Water's Avatar
    Water is offline Member 519 points
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    Yes, I have been trained and worked in hospice for half a year. I also have worked on neurosurgery units where patients who suffer chronic pain and decide to have neurosurgery. I also have an extensive experience in rehab as well. I am quite familiar with pain management.
    Your patient is a full code patient, not a hospice patient. Your explaination is applicable for a hospice patient. For a no code patient, you consider pain consult or epidural, pain pump, etc.
    Last edited by Water; 09-09-2007 at 07:06 PM.

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    AUCMD2006's Avatar
    AUCMD2006 is offline Ultimate Member 6129 points
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    Quote Originally Posted by Water View Post
    Yes, I have been trained and worked in hospice for half a year. I also have worked on neurosurgery units where patients who suffer chronic pain and decide to have neurosurgery. I also have an extensive experience in rehab as well. I am quite familiar with pain management.
    Your patient is a full code patient, not a hospice patient. Your explaination is applicable for a hospice patient. For a no code patient, you consider pain consult or epidural, pain pump, etc.
    question doesn't say it is a full code, it said that he no longer wished to live in pain, at which point you get a dnr order and see the living will, directive etc

    working with these patients is good experince but actually having the reponsibility for making the decision takes you to another level
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    Water's Avatar
    Water is offline Member 519 points
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    Unless otherwise stated, every patient is a full code.
    Writing an order does not make you the decision maker. If you were on my team of clinicians and write such an order, I would personally talk to your attending. And yes, I have done that before to others because of patients' safety. I will not counter any further argument from you. I am here to learn and exchange knowledge, not to argue with you. I hope the poster received his/her answer.
    Last edited by Water; 09-10-2007 at 05:35 PM.

  7. #7
    AUCMD2006's Avatar
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    read the post

    Quote Originally Posted by Water View Post
    Unless otherwise stated, every patient is a full code.
    Writing an order does not make you the decision maker. If you were on my team of clinicians and write such an order, I would personally talk to your attending. And yes, I have done that before to others because of patients' safety. I will not counter any further argument from you. I am here to learn and exchange knowledge, not to argue with you. I hope the poster received his/her answer.

    read the post again, make it in order for you

    -pt complains of intolerable pain
    -pt states he no longer wishes to live (i.e. possibly no more medical interventions)
    -physician then interviews pt wether it is depression or if the pt wants to be dnr. i didn't mean that i write a dnr order without consulting the pt that was obvious i thought. and physicians can write dnr orders without pt consent in cases when doing cpr is futile and each hospital has policies for doing so. in most cases though the CYA mentality prevails and you just refuse to provide cpr and turf the pt to someone who will
    -if pt is dnr then adequate pain meds

    my original reply assumed that a physician will do the above since that is what we all do and is a given, i didn;t think i even had to mention it but as a lay person maybe it is new to some.

    i agree with you, if not dnr then you cut pain meds back to prevent resp failure but again i presumed the pt had been worked up for dnr. my mistake the question is vague on this you are right

    i have also seen nurses and other allied health profs question the orders writen be it out of real concern for the pt or out of MD envy. either way i have only dealt with it in oncology and not hospice so maybve i only see a limited number of cases
    Last edited by AUCMD2006; 09-10-2007 at 11:47 PM.
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  8. #8
    kingella kingae is offline Newbie 510 points
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    ok guys... um, maybe my wording in the original post is making all this argument. so how about u guys settle it by answering the following question? and please explain. thanks.

    A mentally competent 76-year-old man is in the
    terminal stage of
    multiple myeloma. He is unable to move and requires
    24-hour nursing
    care. Increasing doses of narcotics are needed to
    control severe pain.
    As a result, when he is pain-free, respiratory
    function is impaired and
    consciousness is clouded. The patient says he cannot
    live with this
    degree of pain and asks to be given a lethal injection
    of pain
    medication. Which of the following is the most
    appropriate step regarding the
    pain medication?

    A
    ) Reduce the dosage so as not to impair respiration

    B
    ) Administer the dosage necessary to control pain
    despite
    respiratory impairment

    C
    ) Administer the dosage necessary to control pain
    and add a
    centrally acting stimulant

    D
    ) Appeal to the family to convince the patient to
    tolerate a bit
    more pain

  9. #9
    AUCMD2006's Avatar
    AUCMD2006 is offline Ultimate Member 6129 points
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    none of the above. you can't give a patient a "lethal dose" of any medication regardless of how they ask for it. just ask kavorkian. what you can do is give appropriate pain relief.

    as far as i know you can not take a dnr request from a person heavily sedated.
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  10. #10
    md.ammar is offline Newbie 510 points
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    thanx man
    great

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