After seeing how overly sedated my relative Helen became with morphine, the surgeon said, “She should not have any more morphine.  I know it sounds cruel, but in an elderly patient like her, it is better to suffer the short-term pain and be able to work on mobility.  Infants and the elderly often do perfectly well just on Tylenol.  So, no more morphine.” 

Friday, without having any morphine, Helen was able to be transferred to a chair and sit up for hours.  She was thrilled to be out of bed (until she got tired).

Saturday, I arrived at 5:30 a.m., as had become my practice.  I stayed out in the hall right outside the door to Helen’s room, because she was still asleep, and the Certified Home Health Aide (CHHA) I’d arranged to have stay with her overnight was in the one available chair. 

The nurse, Simon, was in and out of the room multiple times, and when I went in around 6:30 a.m., the CHHA told me, “He injected something into her for pain.”

Tylenol is not an injection, so I went and asked Simon what he had given her.   

“Two mgs of morphine.”

“She isn’t supposed to get any morphine!  Now she won’t be able to participate in physical therapy and the odds are that she won’t be discharged today!  That means two more days in the hospital!  [The surgeon would not discharge her on a Sunday.]  Why did you give her morphine?”

Simon explained that the order for 2 mgs of morphine, as needed, was still in the computer.  It had not been discontinued.  There was also an order in the system for Tylenol, but when the CHHA pointed out that Helen was in pain and asked for treatment, Simon chose to inject morphine.   

The CHHA, having heard the surgeon’s emphatic prohibition of morphine for Helen 24 hours earlier, never dreamed that a request for pain treatment would result in anything other than Tylenol.  Then Simon injected the morphine so quickly that the CHHA didn’t have time to react before it was done.

How can you prevent similar problems with your relative’s care?

If you are your relative’s health care representative, at the beginning of each shift, review the patient’s chart to see the list of all drugs ordered.  If some that you believe were supposed to be discontinued are still there, or if any of the dosage amounts or frequencies are not what you understood they were supposed to be, or if drugs you are expecting to see are missing, explain the problem to the nurse and ask that the doctor be called.

Your diligence can make the difference between life and death, or between robust recovery and disability.