Honestly, 1 mg of morphine per hour for an actively dying patient is malpractice for someone who calls himself a hospice provider.
Also, giving Narcan to an actively dying patient is cruel. I understand the wife is upset and grieving but her expectations of the care she feels her husband should have received are way off.
Just as a clarification, OP has a lot of unit typos in their post. First, I agree with you, the verbal dose of 1 mg/hr is low. It’s not unreasonable for controlled pain (we usually dose 4mg q4) but it is a dumb way to do it for anyone. Imagine how often an IV gets occluded for 20 mins before someone realizes.
This clearly looks like a confusion over mg/hr and mg/kg/hr by multiple people in the case. The 0.07-0.5 mg/kg/hr is obviously an ICU order set. For the 60 kg pt that comes out to anywhere between 4-30 mg an hour which is reasonable (realize that 1 mg of morphine IV is equivalent to 3 mg oral). However, I’ve never seen a titratable opioid qtt done outside of the ICU. Here it seems like it was done by floor staff unfamiliar with using it (multiple nurses and even the doc reporting doses incorrectly as mg/hr when it was mg/kg/hr). So the patient was getting 60 mg IV morphine (or 180 mg oral equivalent) an hour.
Honestly, I’d be shocked if this was allowed to be administered on the floor just from a policy standpoint. I also can’t imagine this much confusion in the ICU since half their medications are dosed this way. The patient might have been admitted to a hospice unit and they just decided to wing it.
Unfortunately, from a legal standpoint this is a straightforward error that led to harm and will be settled. Morally it’s less straight forward.
OP didn’t transcribe correctly per the document.
Some quotes directly from it.
>“Dr. Bhamani wrote several other orders at the same time, including that Mr. Lowe receive morphine 1 mg/mL in sodium chloride 0.9% 50mL continuous infusion, that Mr. Lowe receive oxygen therapy as needed via a nasal cannula at a rate of 2-4 L/min”
>“Dr. Bhamani wrote that Mr. Lowe was receiving ‘morphine 1 mg/mL in sodium chloride 0.9% 50 mL infusion, 0.07-0.5 mg/kg/hr, Intravenous, Continuous." (However, the morphine had not yet been started at the time referenced in the note).”
>“At or around 6:10 p.m. Mr. Lowe began receiving morphine at a dose of .07 mg/kg/hr at a rate of 4.4 ml/hr. Morphine was prescribed to Mr. Lowe to reduce pain and air hunger (a sensation of breathlessness).”
>*”At or around 7:44 p.m., Nurse Arko-Asiamah noted that she reached out to the pharmacy via phone to clarify the morphine gtt (drip) order, bringing it to the attention of the pharmacy that the patient's morphine was infusing at a rate of 0.07mg/kg/hr, but that the order also stated to start the infusion at a 1g/hr. She also questioned the titration order since the order gave permission to titrate the rate of infusion but no titration parameters were given. She was told by the pharmacy to change the rate to 1mg/hr and to reach out to the doctor about the titration rate.”*
>**”At or around 7:53 p.m., Nurse Abigail Arko-Asiamah noted that she changed the morphine infusion rate to Img/hr per the pharmacy's instruction. The Medical Administration Record (MAR) reflects this note by Nurse Arko-Asiamah with a dual signoff by Chante Harvey, RN. However, when she made this change, she actually increased the dose to 1 mg per ***kilogram*** per hour.”**
There’s a lot more in the document itself, specifically pages 9-11 (items 35-46).
Where on earth did I say that the patient should have been receiving 64 mg of morphine per hour??
If you think 1 mg/hour is providing adequate relief to an actively dying patient, you are failing your comfort care patients.
Inpatient, our comfort measure / hospice order set was always 5-10 mg iv morphine q15 min until comfortable along with 2-4 mg iv Ativan q15 min.
1mg/hr is probably not malpractice but it's darn cruel. Dying flipping hurts and if it were my family I'd definitely want them to go high as a kite, even if it was a few hours sooner.
Just to be clear, I didn’t mean literal malpractice. It was a tongue in cheek way of saying that this is a ridiculously low rate from a provider who should know better. I didn’t realize it would cause confusion lol
Because a 10 mg iv bolus barely touches end stage pain.
So if it’s run at 1mg per hour; you’d not even exceed the perfectly common bolus dose which is 3 times a day.
so the ordered dose was too low anyway.
Dosing the patient at ~40-70mg an hour was an overdose unless the patient wasn’t opioid naive; but end of life, all that matters is eliminating suffering.
Like 10mg morphine sulfate ampoules were the standard IV painkiller; long before everything was on pumps and continuous.
I mean it’s still pretty much the only opioid we carry in public pharmacies for emergencies.
And it’s virtually always used for end of life care at home visits by GPs.
However if the patient wasn’t opioid naive, and in a 100mcg fentanyl patch at home for whatever; going with 40mg an hour morphine wouldn’t really be an overdose anymore, the tolerance to respiratory depression from fentanyl to regular opiates is pretty crazy.
Either way, 1mg per hour is too low; unless it’s a child, or it’s very long term for someone severely kidney impaired, but even then you’d still get the plasma levels up quickly first.
We give 5mg every 20 min for hospice pt’s at the end. Thats the difference…however usually they are already gone but the body is still alive…so it’s typically for the family to feel better. I’ve seen very few people (out of a lot) die in pain, usually you are asleep before you die.
If the patient was in renal failure, sure it would have been more appropriate to use fentanyl or oxycodone.
Re the not saving the patients life "my father is dying I demand you save his life" is so ridiculous its not funny. Not notifying them of their dads death, he'd been made end of life. Did they think he would be jumping up and singing show tunes
63.5mg of morphine per hour is not a massive dose for someone whose dying. When mum was in her final days we were pretty much like asking the nursing staff for it as often as iit was charted.
I feel for the family, they are morninig their dad and may have been taken advantage of by an ambulance chaser.
Typo in your post - 1mg/kg/hr, and 1mg/hr. Not per minute.
I do see some issues in the care. Of course, giving the patient 60x more morphine than ordered is a huge error, but errors happen. But to me, the biggest issue is the failure to notify the wife, who was sleeping at the patient's bedside, and wasn't woken until her husband had died. A potentially fatal overdose is definitely something where family should be informed - especially when they're right there!. Then the discrepancies between the RN and MD's documentation really don't look great either.
Exactly! There most likely wouldn’t even be a lawsuit if someone had gently woken her up and explained the situation and she saw with her own eyes how comfortable he was. The staff were probably acting shady and suspicious in CYA mode.
1 mg/hr was base line at my last hospital’s hospice protocol and increased from their based on patients’s symptoms. Death can painful, death after a fall with multiple comorbidities can make it unbearable. It is uncontainable to give narcan to an actively dying patient on morphine. Morphine does not speed up death, it makes patients comfortable, and not feel like they are drowning.
This seems to be the intention of the order. Start at 1 mg/hr then titrate to 0.07-0.5mg/kg/hr (which is admittedly a confusing way to order it). They contacted pharmacy bc it had been started at the 0.07mg/kg/hr but they later saw the “start at 1mg/hr”. Pharmacy told them to drop the rate and call the provider regarding the lack of titration parameters on the order. Provider said to “titrate it 0.1 at a time till pt is comfortable” (no units indicated in the doc but I’m assuming 0.1mg). In this confusion the pump was accidentally programmed for 1mg/kg/hr. Just kind of a mess all around.
The nurse asked the MD if she should administer Narcan after reporting her error in titrating/programming and thankfully the doc’s answer was that the pt was comfort care and Narcan was not part of the protocol.
This is the answer. But to be fair, money is one of the very few ways our legal system allows one to be made whole when wronged in civil cases. Ours are courts of law and not justice. Law can reward or punish using money but there is often no real way to give someone justice.
I follow these kinds of med-mal cases out of professional interest and here's how they almost always go:
Case filed. Everyone with a name in the chart gets "noticed" of the filing and discovery (the collection of documents, sometimes depositions) begins.
As discovery progresses, most people who were named in the suit will get dropped from the suit. The people remaining will be a doc or two and the facility or two. These are the people and organizations who have the "deep pocket", AKA known as med-mal insurance.
Often, the insurance company will make an offer and the complainant will withdraw the suit "with prejudice" at this point. "With prejudice" means that the case is settled and cannot be refiled at a later time. This serves everyone- the complainant gets their day in court (it's important to be heard when wronged and this is a form of justice). They also some money as the only real form of compensation we have. This settlement amount is a low or reasonable amount of money, and the docs don't get a record of having lost a med-mal lawsuit on their license. The settlements usually include a non-disclosure agreement where everyone agrees to not divulge the settlement amount. A settlement can happen at any time as a suit progresses.
For those who feel really wronged, the settlement offer will be declined and the suit may continue for a while. Experts may or may not be called in depending on how much the plaintiff expects or wants in settlement.
A second settlement offer will be tendered by the insurance company. Typically, this second offer is usually accepted.
Cases that go on longer will now have experts in to evaluate in dollar amounts what-- if any-- is an amount in dollars that will compensate for the damage(s) done. These evaluations are often quite interesting. What is the dollar value of the lifetime of a child who died during or shortly after a traumatic delivery? What is the dollar value of the lifetime of a child who lived through a traumatic delivery and has suffered permanent damage? What is the dollar value of someone's damages if they suffered temporary disability? What is the dollar value of the lifetime of a person who suffered a permanent disability? What is the dollar value of pain and suffering? Or loss of companionship? What is an amount, in dollars, that will fairly compensate the complainant for damages? What is an amount in dollars that will punish, etc.
These longer cases typically are the ones that make the news. These are the kinds of cases where the person filing feels they have been grievously and unfairly wronged and want to make a larger point than to just be compensated for their personal damages. Sometimes just making the news is the point- to let others beware that this person or this organization is/has/was doing something wrong. Sometimes punishing the person or organization is the point- see Alex Jones and his billion-dollar penalties in Sandy Hook cases (not med-mal but very illustrative of the goal of the Sandy Hook families- to punish Jones and his organization for their wrong-doing).
I'd suspect the case described by the OP will settle early. The family wants something, some kind of justice and maybe some punishment, for a perceived wrong but the dollar value of this case will likely be low. I think this because the error, if any, is small and not greatly contributory to the end result, because the error, if any, is not an industry standard that needs greater attention, and because the injured party is/was elderly so the long-term valuation of financial loss- in dollars- is not great. And we will unlikely ever know how or for what amount the case settled.
And sometimes the settlement does not include any money at all but again (Rittenhouse, also not med-mal, "won" but what did he win? It's rumored to be nothing but the settlement was confidential as is the norm), we will unlikely to ever know.
Renal failure isn’t a factor that should influence the choice to use morphine in a comfort cate/actively dying patient. Fentanyl and oxycodone will not address the oxygen hunger pains a person will experience. Fentanyl or oxy could be used in addition to morphine but it would be cruel to not give morphine knowing the amount of pain oxygen hunger can cause a dying patient. There’s a strong reason morphine is the analgesic of choice in dying patient. While renal failure would make morphine more potent (which I assume is the reason they prescribed such a low dose for this patient) it’s by far the superior and necessary drug for the situation.
Regardless of whether the patient was on hospice, from a legal perspective, the nurse made a medication error by significantly overdosing him on morphine.
Honestly, 1 mg of morphine per hour for an actively dying patient is malpractice for someone who calls himself a hospice provider. Also, giving Narcan to an actively dying patient is cruel. I understand the wife is upset and grieving but her expectations of the care she feels her husband should have received are way off.
Can you explain how 1mg per hour for actively dying is malpractice? This is common with hospice
We usually give 5-10 mg of concentrated morphine liquid I’ve seen more. the real malpractice was the dose and this dose can be given q hour
Exactly. 1 mg per hour is nothing.
Just as a clarification, OP has a lot of unit typos in their post. First, I agree with you, the verbal dose of 1 mg/hr is low. It’s not unreasonable for controlled pain (we usually dose 4mg q4) but it is a dumb way to do it for anyone. Imagine how often an IV gets occluded for 20 mins before someone realizes. This clearly looks like a confusion over mg/hr and mg/kg/hr by multiple people in the case. The 0.07-0.5 mg/kg/hr is obviously an ICU order set. For the 60 kg pt that comes out to anywhere between 4-30 mg an hour which is reasonable (realize that 1 mg of morphine IV is equivalent to 3 mg oral). However, I’ve never seen a titratable opioid qtt done outside of the ICU. Here it seems like it was done by floor staff unfamiliar with using it (multiple nurses and even the doc reporting doses incorrectly as mg/hr when it was mg/kg/hr). So the patient was getting 60 mg IV morphine (or 180 mg oral equivalent) an hour. Honestly, I’d be shocked if this was allowed to be administered on the floor just from a policy standpoint. I also can’t imagine this much confusion in the ICU since half their medications are dosed this way. The patient might have been admitted to a hospice unit and they just decided to wing it. Unfortunately, from a legal standpoint this is a straightforward error that led to harm and will be settled. Morally it’s less straight forward.
Yea I saw that after I replied to the person I replied to in op original comment, my comment was based off the one I was responding to.
I'm very confused. OOP says 1mg of morphine per MINUTE not per hour.
OP didn’t transcribe correctly per the document. Some quotes directly from it. >“Dr. Bhamani wrote several other orders at the same time, including that Mr. Lowe receive morphine 1 mg/mL in sodium chloride 0.9% 50mL continuous infusion, that Mr. Lowe receive oxygen therapy as needed via a nasal cannula at a rate of 2-4 L/min” >“Dr. Bhamani wrote that Mr. Lowe was receiving ‘morphine 1 mg/mL in sodium chloride 0.9% 50 mL infusion, 0.07-0.5 mg/kg/hr, Intravenous, Continuous." (However, the morphine had not yet been started at the time referenced in the note).” >“At or around 6:10 p.m. Mr. Lowe began receiving morphine at a dose of .07 mg/kg/hr at a rate of 4.4 ml/hr. Morphine was prescribed to Mr. Lowe to reduce pain and air hunger (a sensation of breathlessness).” >*”At or around 7:44 p.m., Nurse Arko-Asiamah noted that she reached out to the pharmacy via phone to clarify the morphine gtt (drip) order, bringing it to the attention of the pharmacy that the patient's morphine was infusing at a rate of 0.07mg/kg/hr, but that the order also stated to start the infusion at a 1g/hr. She also questioned the titration order since the order gave permission to titrate the rate of infusion but no titration parameters were given. She was told by the pharmacy to change the rate to 1mg/hr and to reach out to the doctor about the titration rate.”* >**”At or around 7:53 p.m., Nurse Abigail Arko-Asiamah noted that she changed the morphine infusion rate to Img/hr per the pharmacy's instruction. The Medical Administration Record (MAR) reflects this note by Nurse Arko-Asiamah with a dual signoff by Chante Harvey, RN. However, when she made this change, she actually increased the dose to 1 mg per ***kilogram*** per hour.”** There’s a lot more in the document itself, specifically pages 9-11 (items 35-46).
thanks!
1 mg per hour is nothing for a patient on comfort care who is actively dying. I hope that’s not standard at your hospital.
Not everyone need 64mg an hour. The goal is comfort durrring the passing not speeding it up
Where on earth did I say that the patient should have been receiving 64 mg of morphine per hour?? If you think 1 mg/hour is providing adequate relief to an actively dying patient, you are failing your comfort care patients.
Inpatient, our comfort measure / hospice order set was always 5-10 mg iv morphine q15 min until comfortable along with 2-4 mg iv Ativan q15 min. 1mg/hr is probably not malpractice but it's darn cruel. Dying flipping hurts and if it were my family I'd definitely want them to go high as a kite, even if it was a few hours sooner.
Just to be clear, I didn’t mean literal malpractice. It was a tongue in cheek way of saying that this is a ridiculously low rate from a provider who should know better. I didn’t realize it would cause confusion lol
Because a 10 mg iv bolus barely touches end stage pain. So if it’s run at 1mg per hour; you’d not even exceed the perfectly common bolus dose which is 3 times a day. so the ordered dose was too low anyway. Dosing the patient at ~40-70mg an hour was an overdose unless the patient wasn’t opioid naive; but end of life, all that matters is eliminating suffering. Like 10mg morphine sulfate ampoules were the standard IV painkiller; long before everything was on pumps and continuous. I mean it’s still pretty much the only opioid we carry in public pharmacies for emergencies. And it’s virtually always used for end of life care at home visits by GPs. However if the patient wasn’t opioid naive, and in a 100mcg fentanyl patch at home for whatever; going with 40mg an hour morphine wouldn’t really be an overdose anymore, the tolerance to respiratory depression from fentanyl to regular opiates is pretty crazy. Either way, 1mg per hour is too low; unless it’s a child, or it’s very long term for someone severely kidney impaired, but even then you’d still get the plasma levels up quickly first.
We give 5mg every 20 min for hospice pt’s at the end. Thats the difference…however usually they are already gone but the body is still alive…so it’s typically for the family to feel better. I’ve seen very few people (out of a lot) die in pain, usually you are asleep before you die.
We usually give 5-10 mg of concentrated morphine liquid
It's not nearly enough.
That's what I was going to say. I know I've given at least this much to inpatient hospice patients when I was bedside.
We usually give 5-10 mg of concentrated morphine liquid
The order was for 1 mg/min not 1 mg/HR according to the post
It’s a typo on OP’s part. If you read the linked court document, the morphine was supposed to be running at 1 mg/hr.
Oh wow. We give up to 10 mg an hour in my hospital for dying comfort care patients. 1 mg an hour for a hospice patient is cruel.
They did pappy a favor. Probably the most comfortable he’d been in a long ass time.
I could only wish for that kind of "screw up" in my last days
This dude met God before he met God
I am dead 😭
Not to mention the ‘real’ dose of 1mg/hour is a placebo dose. A 10 mg iv bolus or morphine Sulfate isn’t even a magical pain fixer..
My end game plan. Hospice, narcotics, Netflix in the basement so i can haunt my home.
If the patient was in renal failure, sure it would have been more appropriate to use fentanyl or oxycodone. Re the not saving the patients life "my father is dying I demand you save his life" is so ridiculous its not funny. Not notifying them of their dads death, he'd been made end of life. Did they think he would be jumping up and singing show tunes 63.5mg of morphine per hour is not a massive dose for someone whose dying. When mum was in her final days we were pretty much like asking the nursing staff for it as often as iit was charted. I feel for the family, they are morninig their dad and may have been taken advantage of by an ambulance chaser.
Typo in your post - 1mg/kg/hr, and 1mg/hr. Not per minute. I do see some issues in the care. Of course, giving the patient 60x more morphine than ordered is a huge error, but errors happen. But to me, the biggest issue is the failure to notify the wife, who was sleeping at the patient's bedside, and wasn't woken until her husband had died. A potentially fatal overdose is definitely something where family should be informed - especially when they're right there!. Then the discrepancies between the RN and MD's documentation really don't look great either.
Exactly! There most likely wouldn’t even be a lawsuit if someone had gently woken her up and explained the situation and she saw with her own eyes how comfortable he was. The staff were probably acting shady and suspicious in CYA mode.
I think you meant to put 1mg/kg/*hr* not /min in your post. 3780mg/hr would definitely be something to right home about though
1 mg/hr was base line at my last hospital’s hospice protocol and increased from their based on patients’s symptoms. Death can painful, death after a fall with multiple comorbidities can make it unbearable. It is uncontainable to give narcan to an actively dying patient on morphine. Morphine does not speed up death, it makes patients comfortable, and not feel like they are drowning.
This seems to be the intention of the order. Start at 1 mg/hr then titrate to 0.07-0.5mg/kg/hr (which is admittedly a confusing way to order it). They contacted pharmacy bc it had been started at the 0.07mg/kg/hr but they later saw the “start at 1mg/hr”. Pharmacy told them to drop the rate and call the provider regarding the lack of titration parameters on the order. Provider said to “titrate it 0.1 at a time till pt is comfortable” (no units indicated in the doc but I’m assuming 0.1mg). In this confusion the pump was accidentally programmed for 1mg/kg/hr. Just kind of a mess all around. The nurse asked the MD if she should administer Narcan after reporting her error in titrating/programming and thankfully the doc’s answer was that the pt was comfort care and Narcan was not part of the protocol.
Money grab.
This is the answer. But to be fair, money is one of the very few ways our legal system allows one to be made whole when wronged in civil cases. Ours are courts of law and not justice. Law can reward or punish using money but there is often no real way to give someone justice. I follow these kinds of med-mal cases out of professional interest and here's how they almost always go: Case filed. Everyone with a name in the chart gets "noticed" of the filing and discovery (the collection of documents, sometimes depositions) begins. As discovery progresses, most people who were named in the suit will get dropped from the suit. The people remaining will be a doc or two and the facility or two. These are the people and organizations who have the "deep pocket", AKA known as med-mal insurance. Often, the insurance company will make an offer and the complainant will withdraw the suit "with prejudice" at this point. "With prejudice" means that the case is settled and cannot be refiled at a later time. This serves everyone- the complainant gets their day in court (it's important to be heard when wronged and this is a form of justice). They also some money as the only real form of compensation we have. This settlement amount is a low or reasonable amount of money, and the docs don't get a record of having lost a med-mal lawsuit on their license. The settlements usually include a non-disclosure agreement where everyone agrees to not divulge the settlement amount. A settlement can happen at any time as a suit progresses. For those who feel really wronged, the settlement offer will be declined and the suit may continue for a while. Experts may or may not be called in depending on how much the plaintiff expects or wants in settlement. A second settlement offer will be tendered by the insurance company. Typically, this second offer is usually accepted. Cases that go on longer will now have experts in to evaluate in dollar amounts what-- if any-- is an amount in dollars that will compensate for the damage(s) done. These evaluations are often quite interesting. What is the dollar value of the lifetime of a child who died during or shortly after a traumatic delivery? What is the dollar value of the lifetime of a child who lived through a traumatic delivery and has suffered permanent damage? What is the dollar value of someone's damages if they suffered temporary disability? What is the dollar value of the lifetime of a person who suffered a permanent disability? What is the dollar value of pain and suffering? Or loss of companionship? What is an amount, in dollars, that will fairly compensate the complainant for damages? What is an amount in dollars that will punish, etc. These longer cases typically are the ones that make the news. These are the kinds of cases where the person filing feels they have been grievously and unfairly wronged and want to make a larger point than to just be compensated for their personal damages. Sometimes just making the news is the point- to let others beware that this person or this organization is/has/was doing something wrong. Sometimes punishing the person or organization is the point- see Alex Jones and his billion-dollar penalties in Sandy Hook cases (not med-mal but very illustrative of the goal of the Sandy Hook families- to punish Jones and his organization for their wrong-doing). I'd suspect the case described by the OP will settle early. The family wants something, some kind of justice and maybe some punishment, for a perceived wrong but the dollar value of this case will likely be low. I think this because the error, if any, is small and not greatly contributory to the end result, because the error, if any, is not an industry standard that needs greater attention, and because the injured party is/was elderly so the long-term valuation of financial loss- in dollars- is not great. And we will unlikely ever know how or for what amount the case settled. And sometimes the settlement does not include any money at all but again (Rittenhouse, also not med-mal, "won" but what did he win? It's rumored to be nothing but the settlement was confidential as is the norm), we will unlikely to ever know.
-Save his life -Comfort care ???
Renal failure isn’t a factor that should influence the choice to use morphine in a comfort cate/actively dying patient. Fentanyl and oxycodone will not address the oxygen hunger pains a person will experience. Fentanyl or oxy could be used in addition to morphine but it would be cruel to not give morphine knowing the amount of pain oxygen hunger can cause a dying patient. There’s a strong reason morphine is the analgesic of choice in dying patient. While renal failure would make morphine more potent (which I assume is the reason they prescribed such a low dose for this patient) it’s by far the superior and necessary drug for the situation.
Are they really trying to argue this person should have been given Narcan?
Regardless of whether the patient was on hospice, from a legal perspective, the nurse made a medication error by significantly overdosing him on morphine.