Nonsensical rules are binding the hands of caregivers

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 wheelchair 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.

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 health care.  Nonsensical rules are binding the hands of caregivers.  We are facing ever steeper barriers to basic commonsense 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.

Jordan Grumet is an internal medicine physician and founder, CrisisMD.  He blogs at In My Humble Opinion.

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