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the cause of the pain was not clear, the agitation and moaning that was treated with increasing doses of fentanyl might have been due to delirium from fentanyl, in which case the treatment should have been to decrease the fentanyl dose, not increase it. The Committee was concerned with the recognition and management of narcotic side-effects in this case. Narcotic side-effects were apparently not recognized, and therefore not managed proactively. Constipation – a universal sideeffect of narcotics, especially in an immobile elderly patient – was an ongoing problem with this patient. In addition, she was on a number of other constipating medications, including iron, neuroleptic medications, and trazodone. The only medication prescribed regularly was sennosides, once daily. Three weeks after her admission, bisacodyl 5 mg twice daily as needed, was added. The patient remained on these two medications for the duration of her stay. At times, the patient went seven to 10 days between bowel movements. Records indicated, at one point, that it had been almost two weeks since the patient’ s last bowel movement. The Committee stated that it was bewildered why the patient went for two weeks without a bowel movement and why this was not recognized by physicians reviewing the nursing charts that documented bowel movements. It could not be determined if the hospital had a routine for bowel management in patients on narcotics.
When the patient was obtunded and“ twitching”, the only vital signs
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“ The prescription of increasing doses of a transdermal narcotic as the first step after plain acetaminophen was problematic”
done were routine, based on shift change. Neither the nurses nor physicians noted respiratory rate later in the day. Lorazepam( as needed) was ordered. The Committee’ s report stated that the twitching was probably due to narcotic toxicity and the dosage of narcotics should have been reduced. The patient also suffered a new onset of urinary retention. This should prompt an evaluation as to the cause of the retention. In
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this case, it was probably due to unrecognized narcotic toxicity and untreated constipation.“ The patient’ s treatment seemed to be reactive, with symptoms treated in isolation of one another without an attempt to pull the whole picture together. There was no record of the health-care team meeting to share information and problem solve, which may have helped in this complex case,” stated the report. There was no written problem list or care plan by the health-care team after the woman’ s admission, other than“ awaiting placement.” The Committee stated that, with a persistent and unrecognized delirium, increasing sedation from narcotics, and long periods of restraint, the patient lost her ability to walk, and became functionally dependent. The Committee felt that this situation was preventable. MD |
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Issue 2, 2016 Dialogue 41 |