Thursday, December 12, 2013

Silly Rules Made In Ivory Towers

Why must everything be so difficult?

Soni pushed her mother quickly into the building from the parking lot, she wore a strained look on her face.  The wheel chair appeared preposterously large for the aged figure cowering under the haggle of blankets.  They were enjoying the brisk air, taking a walk around the facility, when the elderly woman called out.  Her lips curled and she moaned deeply.

Now Soni's mother had stopped talking months ago, but the devoted daughter had become adept and interpreting the grunts and groans.  The sound her mother was presently making, however, was different, alarming.  Her one arm was dead, lifeless from the stroke, but her other hand clenched her abdomen.  She winced in pain.

Soni had a bad feeling.  Something horrible was happening.  She beckoned to a CNA who helped her mother into bed.  I walked in moments later, completing my rounds at the nursing home.  I bent over the bedside and examined my patient.  Her abdomen was rock hard.  Her brow was furrowed.  Her breath left her mouth guardedly and fluttered before escaping.  She was suffering.

I explained that indeed, something catastrophic had happened: a bad appendix, a perforated bowl, a ruptured aneurysm.  Soni nodded at me as she held her mother's hand.  There would be no hospital.  There would be no emergency room huddle.  Soni wanted her mom to die quietly in her nursing home bed.  The years post stroke had been difficult and fraught with misery and dementia.  Nature was asserting itself, taking back what had been forfeited prematurely.

And this was something that I was trained to do.  I ordered a sublingual form of morphine, called roxanol.   But of course the nurse and I both knew that it was not that simple.  The miracle drug meant to keep people like Soni's mom comfortable, can no longer be given just by doctor's order.  Even though the vial was sitting in the lock box at the nursing station, the dying woman writhing in pain had to wait.  First a prescription had to be written and signed by hand, faxed to the pharmacy, the pharmacist than had to release the medication and issue an authorization number.  It took ten minutes in all.  Ten wasted minutes while someone suffered.

When confused, agitated, and in pain, the poor woman started to clench her teeth.  I knew that my only choice was to go to an Intravenous formulation.  An IV was already in place.  But again a new prescription needed to be written, faxed, processed by the pharmacist, and a new authorization given.  This time, unfortunately, I delineated the number of milligrams instead of milliliters of solution.  The pharmacist made me rewrite the prescription and start the process all over again.  Another half an hour was lost.

Agonizing over the unnecessary pain my patient was suffering, I begged the pharmacist to hurry up.  He responded the way they always respond now a days...sorry, federal regulation!

Soni's mother died quietly in bed a few hours later.  Once the medicine was released, I was able to bring her the comfort she so desperately needed at the end of her life.   I wish I could have been even faster.

There is a troubling trend in the regulatory atmosphere of healthcare.  Nonsensical rules are binding the hands of caregivers.  We are facing ever steeper barriers to basic common sense care.  Regulations meant to protect the populace are becoming an agent of harm.

Unintended consequences of silly rules, made by naive administrators, living in ivory towers.  


Duncan Cross said...

I agree that this experience was a a travesty for the patient, but the piece makes it sound like academics are thinking up these rules for no good reason. In this particular case, it's a lot more concrete: the DEA and other drug regulators put these rules in place to prevent drug abuse. My sense is they would rather let sick people suffer for ten minutes, an hour, all day, than risk having anyone spend a moment high on prescription narcotics.

Rbthe fourthtwo said...

I agree with Mr. Cross, however, this couldn't have been done without the support of the "ivory tower".

Doug Shefsky said...

Great post Justin! I couldn't agree more with you.

I think Duncan's comments are right, but it is wrong to prioritize the reckless/deviant over the weak and suffering!

As one who has been hospitalized many times and in severe pain, I can tell you that getting relief is paramount to well being, recovery and sanity.

I specialize in process improvement and I can tell you that these rules/processes/systems are created as a solution without truly understanding the root causes of the problems. When the true causes aren't understood the solutions become just more obstacles in the way of good flow of information and services.

Anonymous said...

It is a sad state of affairs how patients who are in real pain, many of them end of life pain, are held hostage by the drug addicts. How proud they must be of themselves to know how they, and not the medical professionals, control the type of care (or lack of) given to people in REAL pain. This needs to stop.

Melissa B said...

As a nurse for more than 40 years, I couldn't agree more with you - and the concerns you express.
I absolutely agree that these drugs need to be closely monitored - and accounted for.
But - there has to be a way to count the drugs - AND get the patient the meds she/he needs in a much more timely fashion. For patients in pain, there is just no acceptable excuse for making the patient wait.