Saturday, October 1, 2011
Contract
A 62 year old man is admitted to the hospital with shortness of breath. His health has been deteriorating over the past five years due to a variety of irreversible conditions. One of the conditions is a chronic headache. The headache can only be controlled with high doses of Demerol, a very strong pain killer. The patient is not always good about following his doctor’s treatment program, and so the doctor made a “treatment contract” with the patient whereby the doctor agrees to give the patient the 300 mg of Demerol needed to control his pain in return for the patient following the doctor’s treatment plan for the other conditions. The patient’s doctor is vacationing in Florida, but is contacted by the hospital care team when the man is admitted. The care team believes that the dosage is dangerously high (normal doses are between 50 and 150 mg, though patients build a tolerance to it), but the patient’s doctor insists that they use it. What should the hospital care team do?
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The patient needs to be weened off of the Demerol due to the fact that he is at a toxic level and it could go into serious renal impairment. This situation describes a normative futility in that the amount of Demerol is necessary for the patient to feel the therapeutic effect, however, he will not comply with the doctor unless he has that specific amount. What the care team needs to do is educate the patient why he should not have that high of a dosage. After weening him off of the Demerol the care team should consider another drug if he is still experiences chronic headaches.
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