frank100
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SEVEN DAYS AFTER SUSTAINING PARTIAL AND FULL THICKNESS BURNS IN A HOUSE FIRE, A 7 Y/O BOY HAS BRAIN ASPHIXIA, ARDS, MULTI ORGAN SYSTEM FAILURE AND SEPSIS. HE IS BEING MECHANICALLY VENTILATED. AFTER CONSULTATION WITH HIS PARENTS, A DO NOT RESUCITATE ORDER IS WRITTEN. AND THE BOY IS REMOVED FROM THE VENTILATOR 20 MINS LATER. BP: 86/42, PULSE: 130, RESP: 8 MIN. HE PERIODICALLY MOANS IN PAIN. HIS CURRENT PAIN MEDICATION IS MORPHINE IV (20MG/HR). WHICH OF THE FOLLOWING IS THE MOST APPROPRIATE NEXT STEP IN MANAGEMENT?
A) DECREASE IN MORPHINE UNTIL THE PATIENT´S RESPIRATIONS ARE GREATER THAN 12
B) INCREASE IN MORPHINE
C) ADMINISTER MIDAZOLAN
D) ADMINISTER NALOXONE
E) ADMINISTER PANCURONIUM
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| mazinger
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a
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| frank100
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can you explain that one to me please?
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| drk1980
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frank100 wrote:
BOY HAS BRAIN ASPHIXIA, ARDS, MULTI ORGAN SYSTEM FAILURE AND SEPSIS. HE IS BEING MECHANICALLY VENTILATED. A DO NOT RESUCITATE ORDER IS WRITTEN. HE PERIODICALLY MOANS IN PAIN.
now he needs something to only ease the pain and make him more comfortable.
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| vinidoc
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give him more morphine to ease his pain.
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| mazinger
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The way I see it is the following:
Morphine is a pain killer that causes respiratory depression..
MORPHINE CANNOT CAUSE RESPIRATORY DEPRESSION IS A PERSON WHO IS UNDER PHYSICAL PAIN. So if the RR is at 8 per min it means that you are giving more drug than needed.
Dear Drs we dont want to kill patients nor speed their deaths, we just want to help a person achieve their unavoidable deaths (like in this case) with honor and without pain. So we decrease the dose of morphine until the patient has an acceptable resp rate for his metabolic activity and wait for his death (this last part sounded awful, but Im trying to make a point here)... I think that increasing the morphine will depress his respiration further, which is 8!
So Frank what do you think?
Edited by mazinger on 07/24/06 - 11:07 AM
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| frank100
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i´m agree with you a 100%, actially (a) and (b) both seem to be the only options.
the question itself is trying to push you to choose B (by saying the patient is on pain), but all of us know that more morphine will cause respiratiry depression and it´ll cause a iatrogenic death (and you do not want to do that).
great mazinger, if you have any question let me know.
you seem to be on the right way.
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| frank100
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For me the answer is (a)
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| radonc
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My answer is B.
Because the prognosis is terrible (brain asphyxia, multi-organ failure, sepsis), you need to attend to immediate problems like pain. This is regardless of his respiratory rate. This is relief of symptoms, not euthanasia.
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| frank100
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the pediatric dose of Morphine is (1-2mg increments IV) maximun dose 10mg.
the respiratory rate can be caused either by morphine or the precarious state of the patient. this child is receiving 20mg/hr. that´s a very high dose fo a child...
my point is: of course, only a miracle can save him from this situation, but it doesn´t give you licence to help him die.
*so, if you have a terminal cancer in wich analgesia isn´t working anymore: would you give an overdose of analgesics? even though, you know that overdose can kill this person.
randoc, AS A COLEAGUE I RESPECT YOUR DESICION, perhaps you´re right. but I still won´t choose B.
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| mazinger
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Well frank the dosing thing was a sophisticated way to support your choice.. good answer!
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| AAAAA
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radonc wrote:
My answer is B.
Because the prognosis is terrible (brain asphyxia, multi-organ failure, sepsis), you need to attend to immediate problems like pain. This is regardless of his respiratory rate. This is relief of symptoms, not euthanasia.
Anyone who chooses B is going to prison and rot like HELL !
As a doctor, the intentional or unintentional death caused by opoid drugs are very alarming. Accidental death caused by morphine or other opoid substances are soooo serious, everyone should take notes here. Never give strong narcotic patches or morphine to pediatrics patients or elderly, you are giving them a death sentence---"to relieve the pain". No, you are playing God and should never do that.
I have been there many, many, many times to discontinue life support system and I never ever give morphine. Let the patient dies peacefully without use of morphine to accelerate his death !
Learn the real medicine. Next time, you will be facing the Hospital Administrator and Medical Board and six months later, you will lose your medical license. Don't choose B
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| AAAAA
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Opioid-based prescription painkillers have surpassed cocaine and heroin as the cause of accidental drug overdose deaths in the United States, according to a team of CDC researchers.
However, it is unclear how many of the deaths were among individuals with legitimate prescriptions and pain-relief needs compared with recreational drug users or addicts who obtained the painkillers illegally, said Leonard J. Paulozzi, M.D., M.P.H., of the CDC's National Center for Injury Prevention and Control here.
Opioid painkillers were listed as the sole cause of overdose for 4,451 deaths in 2002, more deaths than from cocaine (2,569) and heroin (1,061) combined, Dr. Paulozzi and colleagues reported online today in the journal Pharmacoepidemiology and Drug Safety.
Opioid painkillers in the study included semi-synthetic derivatives of opium, such as oxycodone and hydrocodone, as well as fully synthetic opioid agonists such as fentanyl and methadone. All of these drugs are sold under a wide variety of brand names.
The study compared National Center for Health Statistics data on drug overdoses before opioid painkillers became commonly prescribed (from 1979 to 1990) and afterward (from 1990 to 2002). Key findings include:
Deaths from all types of unintentional drug overdoses increased 5.3% per year on average from 1979 to 1990 and by 18.1% per year from 1990 to 2002.
Between 1999 and 2002, the number of opioid analgesic overdoses on death certificates increased 91.2%, while overdose deaths attributed to heroin increased by 12.4% and those attributed to cocaine rose by 22.8%.
Among opioid analgesic overdoses in 2002, 54% were from semi-synthetic opioids such as oxycodone and hydrocodone, 32% were from methadone, and 13% were from other synthetic opioids such as fentanyl.
"The increase in drug poisoning since 1990 coincides with a dramatic increase in the prescription of major types of opioid analgesics, as physicians were encouraged to prescribe stronger analgesics (i.e., opioids) for pain management," the CDC investigators said.
"Worldwide consumption of morphine, hydrocodone, oxycodone, fentanyl, and methadone, most of which is accounted for by the United States, increased at least fourfold from 1990 to 2002," they said.
However, "evidence also suggests that at least some of these deaths are related to intentional abuse of drugs-not to therapeutic dosing errors among those suffering chronic pain," they added.
For example, medical examiners in states with epidemics of opioid overdoses have found that most victims had a history of substance abuse and did not have a prescription for the medication, they said.
Although the study highlighted an association, it did not establish a causal connection between the increase in prescriptions for and the increase in overdose deaths from opioid painkillers, said David E. Joransen, M.S.S.W., and Aaron M. Gilson, Ph.D., of the University of Wisconsin-Madison, in a commentary.
Further evidence that the increase in overdose deaths may be related to illegal use of opioid painkillers is that up to 6 million doses of these drugs were stolen from U.S. pharmacies in 2003 alone, according to data from the Drug Enforcement Agency, the commentators said.
"Unwittingly, publicity about simple associations can exacerbate fears of appropriate medical use of prescription drugs among pain patients and the public, trigger more drug control, and increase fears of regulatory scrutiny among legitimate prescribers and dispensers. All of these can lead to further under-treatment of pain," they warned.
The authors concluded that "the overall goal should be to identify ways to reduce deaths from opioid analgesics without diminishing the quality of care for patients with a legitimate need for pain management."
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| AAAAA
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synthetic opioid agonists such as fentanyl patches (another opoid) causes death in U.S. in an alarming rate. So morphine pump should be decreased and let the patient dies peacefully.
DO NOT INCREASE MORPHINE PUMP RATE !
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| AAAAA
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the overall goal should be to identify ways to reduce deaths from opioid analgesics without diminishing the quality of care for patients with a legitimate need for pain management."
IS INCREASING MORPHINE A LEGITIMATE NEED FOR PAIN MANAGEMENT IN THIS CASE??
NO
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| mazinger
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Dear AAAAA U always make things more clear and I appreciate that lad, but go easy on the people of the forum.. We are participating on discussions and we want everyone to participate and not to feel embarrased and hide eventhough I liked the part "of people rotting in hell"... hahahaha you made laugh..
Well thanks for the explanation!
Edited by mazinger on 07/25/06 - 10:45 AM
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| drhyd
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I have read in crush the boards, that u can give pain medication or anything that relieves pain ,( here intubation is removed as it is futile) even if it enhances the progression of death. So i chose option B.
drhyd
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| yasmeen
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my answer is also b the best thing we can do is to relieve his pain and don,t forget his parents consent for dnr he even is,nt on ventilator anymore so why make his death painful.
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| AAAAA
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I tried to give you a real case.
The lady in Florida who has been on feeding tube for 16 years and was discontinued.
The lady was on DNR.
Did her doctor give her morphine before her death ?
No. It took her 14 days to die ? I forgot number of days and everyone watched this case very carefully. No one, no doctor will give morphine at all. No.
I knew the book said to give morphine to ease the pain but in reality, you discussed the case with the parents and waited for 2-3 days and may be get an EEG and confirm brain death. I will discuss this case in detail in next post.
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| AAAAA
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"A DO NOT RESUCITATE ORDER IS WRITTEN. AND THE BOY IS REMOVED FROM THE VENTILATOR 20 MINS LATER. BP: 86/42, PULSE: 130, RESP: 8 MIN. HE PERIODICALLY MOANS IN PAIN"
DNR does not mean removal of the ventilator. They are two separate things.
Do not resusitate means do not resusitate.
Removal of ventilator means patient has absolutely no hope of recovery, and in most instances, brain death, ARDS, sepsis, multiple organ failure.
They are two separate things. So the patient is dying slowly with slow respiratory rate.
WHY INTERVENED ?
Let the boy died peacefully, by giving morphine, you hastened the death !
This is the case in medical ethics and I was asked whether I should give morphine.
The answer is NO !
Why? Why do doctors have to play GOD ?
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| AAAAA
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By LARA SETRAKIAN and ABC News' Law & Justice Unit
May 26, 2006 — Today, on his 78th birthday, Jack Kevorkian, the man known as "Dr. Death," is slowly dying in prison.
And, according to his lawyer, Kevorkian seems to have second thoughts about helping people die.
For years, Kevorkian was the center of a national debate around the highly controversial questions surrounding physician-assisted suicide or "mercy killing:" Do the terminally ill have the right to choose when and how they die? Do doctors have the ability, even an obligation, to help them die as they choose?
Now, as he sits in jail, Kevorkian may have had a change of heart — not about his dedication to the "death with dignity" movement, but on how he went about promoting it.
Specifically, his lawyer suggests, he questions the more than 100 suicides he said he assisted throughout the 1990s. One assisted suicide — the death of Lou Gehrig's disease patient Thomas Youk, which was taped and broadcast on "60 Minutes" in 1998 — earned him a prison sentence of 15 years to 20 years for second degree murder.
"He did what he did, and it brought it to public awareness [of physician-assisted suicide]," said Kevorkian's attorney, Mayer Morganroth. "He now realizes that having performed it when it was against the law, wasn't the, probably, appropriate way to go about it. … What he should have done was work towards its legalization verbally. … Pursuing that cause, and not performing it because it still was against the law."
'He Gets Depressed at Times'
These days, Kevorkian resides in Michigan's Lakeland Correctional Facility. Less than a week ago, Morganroth publicly stated that doctors had told Kevorkian he had less than a year to live.
Kevorkian suffers from Hepatitis C, which he contracted during service in Vietnam. Morganroth said Kevorkian's liver enzyme levels were three to four times above normal — a clear signal his liver was failing.
In light of his failing health, Kevorkian has requested a commutation of his sentence, a pardon that would get him released from prison. Under the conditions of his current sentence, he is not eligible for parole until June 1, 2007, but he can apply for a commutation on medical grounds before then.
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| s2ckdeficient
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The boards gives you questions like this to make us feel uncomfortable. The answer is increase the morphine. Decreasing the morphine is going to make the patient suffer a terrible death, giving pancuronium is going to paralyze him, naloxone is going to make him terribly painful.
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| s2ckdeficient
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Any answer that results in the patients death is likely to be the answer on the exam.
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| ed222
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DNR means do not resuscitate but it is our duty to provide care under the standarda of the medical profession. To intoxicate with more pain killers is not standard, but rather to alleviate the pain is. We want to help but we don't want to complices if they want to die. I think A is the correct answer
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| jvo_md
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I think a could be the answer. If the boy would have been Brain death, he would have not felt any pain. So, i think decreasing morphine could be the best answer.
If the Boy would have had a terminal condition that culd cause pain and there would have not been anything else to do to save him, i would have choosen B.
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