How Doctors Decide Whether a Patient is Sedated From Opiate Overmedication or Just Plain Dying

He's dead now but when he was alive he spent a lot of money on cigarettes and alcohol, much like many people that you know. He had seen the light years ago though, in no small part due to the love and guidance of his wonderful and supportive wife.

No longer a boozehound with a hacking cough, he had been living a life full of family, friends, and fortune when he was stricken down by non-small-cell lung cancer which quickly metastisized to bone and brain.

He was hospitalized for pneumonia but deteriorated over a week's time. His ability to swallow was impaired so one Monday it decided to place a gastrojejeunal feeding tube. He was fatigued to the point where he would no longer speak because he barely had enough energy to maintain other functions, such as breathing.

I checked on the patient and his wife hourly, did turning and positioning, mouth care, suctioning as needed, and provided morphine for pain as prescribed.

Then I got a call to speak with doctors at the nurse's station.

It needs to be called something else, like the "everybody in the hospital except the fucking nurses station." When it's not crowded with residents, attendings, consulting doctors, therapists entering notes into the computer, and other hospital groupies, it's vacant because us nurses are somewhere closer to the patients themselves.

"We need to hold his pain medication because he's too sedated," said the attending.

"Fucking hell he is," I replied. At least that's what was in the invisible cartoon word-bubble over my head.

"He got seven and a half of oral morphine this morning, three migs IV before we sunk the NG tube for the PEG placement, and I gave him ten through the tube when he got back," and the two residents looked at me as if my hair had just caught fire, which of course it had. That was about equivalent to what he was getting when he was on a pump, which they had stopped the day before.

I may as well have been speaking French to ducks.

Ducks. Not geese. Many geese are native French-speakers but in that horrible Quebecois dialect so despised by Parisians, who are the true guardians of that precise and beautiful language. Rare is the French-speaking duck because most come from Long Island.

Please continue reading because I am saving a punchline for the end.

"Well if he's not oversedated then why isn't he responsive?" the attending asked.

"He's dying," I matter-of-factly replied.

They said that he wasn't like that yesterday, and I said well, that was yesterday. Bozos. They again told me that all pain medications should be held until he wakes up, and I directed them to the recent orders written by the palliative care doc and the pain-management nurse. I also said "No."

The patient wasn't going to wake up to chat about some bullshit with some asshole doctor. That was not a realistic expectation.

Whenever I hear something like "well, he wasn't like that yesterday," it usually comes from a family member who is processing grief and going through denial and bargaining. But in this case it was the attending doctor and a couple residents. They were bargaining with me about pain medications. And in denial. And angry at me for disagreeing with their bullshit.

I added that I was going to do all I could to keep this patient comfortable and that I was just advocating for the patient. The attending said "that meant I was saying they were *not* advocating for the patient," and I pointed out to them that my advocacy did not logically negate theirs. Dickheads.

Then they asked me how I knew he was dying and I said "Well, just look at him. And you could also read the palliative care notes," which said that the patient was clearly in the active process of dying.

One of the residents said she'd been seeing the patient since his admission and that she knew him better than I did. I spend more time with patients in one shift than they do in a week but to understand that they'd have to do math. Like addition and stuff.

They wanted me to call the pain nurse to get the morphine orders changed. Fuck no. I said that her number's in the chart and they could call her themselves. I wasn't going to get into that, again reminding the team that she'd already given increased morphine orders.

The next day one of the residents slipped by without speaking to me and wrote an order to stop the scheduled morphine. I didn't care because the PRN order allowed me to give them ten migs hourly. And besides, moments later the pain nurse called to reinstate the scheduled doses.

After visiting the patient, the palliative care doctor told me he'd called the attending, "but he doesn't get it." I liked that guy, as well as his nurse. They were right with me.

He said one of two things could happen: meds could be held and the patient would get restless and very uncomfortable, or we could medicate him. Either way he was going to die soon. When he and his nurse left they said "thank you for using your brain" and I thanked them for their support.

The oncologist came in while the wife was out hospice-shopping. He called her and asked her to come in because the patient wasn't going to last long enough to be transferred.

Other family members came also. There was a real crowd in the room. Quiet teardrops.

I kept the monitor on so that when his rhythm decayed I'd know.



I medicated him with a few more migs of morphine at 4 p.m. (right after I had my lunch-break,) having promised the wife that I was not going to let him be uncomfortable. Fifteen minutes later his heartrate dropped by half. "Here we go," I said to other nurses as I walked from the monitors to the patient's room. His wife was bent over him, hugging him and crying. A dozen family members stood vigil. I told her, in a quiet voice, that his heart was going and that he would pass soon.

He was gone in ten minutes. About twenty-four hours since I had told the resident team that the patient was dying, not napping.

He died in his wife's arms, surrounded by family members.

I tried paging both residents but they were post-call. The house resident was surprised by the death, even though the patient was DNR and this was expected. He had not been fully informed.

When he came to pronounce the patient he showed me the message they'd left as a report on this patient: "If nurses request increased pain meds do not change orders." Nothing about dying.

Now that's just plain creepy.

So anyways, here's how some attending doctors and their resident teams can tell when a patient is dying, as opposed to being sedated from too much medication: Just fucking listen to the fucking nurse.