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COLORS: RED - PAIN ORANGE - AGITATION GREEN - TERMINAL
Brief History and Hospital Course
This 93 year old widowed white female had previously become severely agitated and depressed, and could not speak intelligibly. She had suffered a profound stroke in August, four months PTA, and exhibited what appeared to be severe multi-infarct dementia with multiple previous CVA’s seen on CT scan. Holladay Health Care Center could no longer contain her agitation, yelling, and continual falls with head lacerations. She had previous medical history significant for angina and ischemic heart disease. Medications on admit included Isordil, Synthroid, Zantac, and routine Xanax, Zoloft, and trazodone. (Photo)>>
Her Xanax was stopped and the patient begun on a slow benzodiazepine taper, using Klonopin. Zoloft was discontinued in favor of Serzone. Risperdal was started, and slowly increased, while trazodone was continued. On the fifth hospital day 12/11 she appeared seriously ill, with poor fluid intake, but an IV was proscribed by her Medical Treatment Plan. Her son at this point said he wanted to "let her go."
On the seventh hospital day 12/13 she appeared to be in distress or pain, and morphine prn was ordered, but never used, and this prn was discontinued on 12/19. Instead she improved markedly, and though she remained profoundly demented, her energy, mood and self-care improved steadily until about the 24th, her eighteenth hospital day, but from that point she deteriorated, with less agitation but progressively increasing dysfunction, including poor oral intake. On Christmas Day small 2 mg. doses of morphine were tried due to the patient appearing to be in pain; this did seem to help her but she did poorly again when it wore off.
On the 26th the patient had an apparent seizure and the internist started an IV and Dilantin loading, despite the prohibition in her Medical Treatment Plan against IV’s. This IV was discontinued by the psychiatrist. The head nurse noted pain and discomfort, and a now order of morphine 2 mg. IM helped; later that day she fed herself. On 12/30, her 24th hospital day, she had "coffee grounds emesis" – copious hematochezia, and her HCT dropped from 40 to 30 immediately. On the next day she had melena, was hypotensive, and was unresponsive.
The family was informed of the poor prognosis with no IV, and on 12/30 decided she would be best served by not intervening. All previous medications were discontinued. Morphine was gradually increased from 5 mg. q4hrs to q3hrs, and then 10 mg. q3hrs (Go to Merck Manual>>), with additional now and prn orders for acute breakthrough discomfort and pain. Unfortunately, during the night of the 2nd through the 3rd, a nurse completely held all scheduled doses of analgesic secondary to her fear of patient respiratory depression, and when the physician arrived in the morning the patient was groaning in pain, twitching, and repeatedly "moaning loudly" still at 6:00 PM that evening. Because of the nurse allowing the pain to go completely untreated it was very difficult to regain control, and the physician was in touch with the unit throughout the day by telephone, ordering repeated higher doses of morphine in addition to her scheduled doses, all in response to nurse reports of symptoms. One 15 mg., one 25 mg., and two 30 mg. doses were needed (besides scheduled doses) to get pain and suffering curbed. The patient died at 8:10 PM, her family at her side.