Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.
The Commissioner received a complaint on behalf of the complainant's stepfather and mother. The complaint is that:
- In late December 1997 the provider was rude to the consumer's wife when she asked the provider to visit her ill husband at night.
- In early February 1998 the provider increased the consumer's morphine dose from 60mg twice a day to 120mgs twice a day, after which the consumer had difficulty breathing, became grey and very sleepy. In addition, the complaint is that the provider did not advise the consumer's wife to discontinue giving the consumer morphine elixir as required.
The complaint was received on 19 February 1998 from the complainant. An investigation was undertaken and information was obtained from:
- The Provider, a General Practitioner
- The Complainant
- The Dispensing Pharmacist
The Commissioner also received advice from a general practitioner with experience in palliative care.
Outcome of Investigation
One night in late December 1997 at 10.45, the consumer's wife telephoned a Medical Centre about her husband who was vomiting and had abdominal pain. The consumer's wife reached the provider who was the doctor on call for that period. The complainant reported that the provider expressed anger at her for not ringing earlier and refused to come out unless they had cash to pay for the visit and subsequently did not make a visit. This complaint was put in writing to the provider two weeks later in January 1998, and the provider responded in writing with an apology and an explanation.
The provider said in his written response that he had asked the consumer's wife why she had not phoned earlier and that the consumer's wife had responded by saying she had been out all day and had just got home. The provider also advised the consumer's wife in his letter that as it was near midnight at holiday time there would be a premium. The consumer's wife immediately responded by saying, "don't bother about it then"and disconnected the call before he could respond. The provider said in the letter he considered going anyway but felt that the consumer's wife had ended the contact and told him not to come.
The provider then apologised for her suffering saying he would never refuse to visit on account of the patient being unable to pay and expressed regret for his actions. The provider advised that the premium he referred to would have been about five dollars more than the usual visit fee.
The second complaint occurred in February and concerned the consumer's pain management and morphine administration. The consumer had by this time been diagnosed with pancreatic cancer and was in considerable pain. The consumer was at this time receiving 80mg of morphine sulphate tablets (MST) twice a day with morphine elixir (1 mg/ml) 10ml to be given two hourly if necessary.
The provider, as the on-call doctor, visited the family at the request of the District Nurse one day in early February. He prescribed an increase in morphine from 220 to 310mg over 24 hours. This increase took into account the morphine elixir the consumer had been receiving as well as the MST tablets. The provider prescribed 150mg of MST at night and a further 100mg of MST for the morning dose and the correct doses of MST were given to the consumer overnight.
The general practitioner advising the Commissioner noted that:
...the dose of morphine 150mg [at night] prescribed as part of the total 24 [hour] dose ordered by [the provider] was appropriate within palliative care guidelines and that it was not [the provider's] intention that the elixir should have been continued unless the pain occurred.
However, the provider did not discuss the administration of the morphine elixir with the family nor did he provide the family with a comprehensive pain management plan. As a result, the family continued to administer 10ml of the morphine mixture every two hours additional to the extra MST he had been given. Later the provider advised the Commissioner it would have been appropriate to administer the elixir if the consumer was experiencing "break-through"pain but not to give it as a matter of course. The instructions on the bottle of morphine were to take 10ml two hourly as necessary. This has been confirmed by the dispensing pharmacist who produced the label for the elixir. The general practitioner advising the Commissioner states that:
"morphine elixir is used purely for breakthrough pain and the responsibility for discussing this... with the patient and the family must lie strongly with the doctor initially instituting the MST tabs... [however] it was important that [the provider] ascertain their [the family's] understanding of this and discuss the elixir's role... considering the markedly increased dose [of MST] he prescribed.
The next morning the family noticed deterioration in the consumer's condition. He had become grey and was having difficulty breathing. They called their usual GP who discontinued the morphine. The need for hospice care was discussed and a referral made. The provider then visited the next day as the on-call doctor and discovered the consumer was still sedated and gave an injection of narcane to reverse the morphine's effect. The provider advised that no more morphine was to be administered except the elixir and then only if the consumer was near to normal consciousness. The provider further commented that the consumer's doctors reported that the consumer's pain had been difficult to control even after admission to the hospice. Other drugs such as methadone have been administered because of the consumer's sensitivity to morphine.
In response to the Commissioner's provisional opinion the provider advised that he did provide a pain management plan as he worked out the required doses of MST, wrote this down for the consumer's wife, and asked their usual GP to visit the next day to review the pain relief. The provider acknowledged that there were some deficiencies as he did not leave written instructions regarding the use of additional morphine elixir nor could he recall giving verbal instructions to the District Nurse or the consumer's wife.
The Code of Health and Disability Services Consumers' Rights
The following Rights are applicable:
Right to be Treated with Respect
1) Every consumer has the right to be treated with respect.
Right to Services of an Appropriate Standard
4) Every consumer has the right to services provided in a manner that minimises the potential harm to, and optimises the quality of life of, that consumer.
Opinion: No Breach
In my opinion there was not a breach of Right 1(1) of the Code of Health and Disability Services Consumers' Rights. The provider responded to the first part of the complaint that he was rude to the consumer's wife by promptly submitting a written apology to the complainant and the family, explaining his actions. I accept that there was a misunderstanding between the provider and the consumer's wife, but this did not amount to a breach of the Code of Rights.
In my opinion there has been a breach of Right 4(4) of the Code of Rights. The provider did not explain the use of morphine elixir to the consumer's family for breakthrough pain, and did not leave a clear pain management plan that included the administration of morphine elixir with the family. The provider was responsible for the situation occurring where the family over-administered the elixir during the night, and this caused the consumer's inappropriate sedation.
The provider has acknowledged that in hindsight "the dose increment of morphine I organised [...] was too large and contributed to [the consumer's] sedation on [the following two days.] My decision to increase his dose was however based on his clinical condition, his pain levels and a desire to help him overcome the pain".
The provider is to submit a written apology to the consumer's family for his breach of the Code. The apology should be sent to this Office within one month and the Commissioner will forward it on to the complainant. A copy will remain on the investigation file.
A copy of this will be sent on to the Medical Council of New Zealand.
For further information, contact: HDC Communications Section (09) 373 1060 or by email: firstname.lastname@example.org