Elderly female patients with advanced gastric cancer have multiple metastases throughout the body, interstitial pneumonia, acute coronary syndrome, etc. When the patient has an increased heart rate, rapid atrial fibrillation, and dyspnea, a doctor in a tertiary hospital gives morphine to improve the patient's breathing and relieve the patient's pain. But in the end, the patient still died due to excessive illness and ineffective treatment. Family members questioned the hospital's repeated overdose injections of morphine, which led to medical disputes...
In February 2015, an elderly woman was admitted to a local hospital for abdominal pain and discomfort for no apparent cause. Gastroscopy showed that the patient had a huge irregular ulcer of about 2 cm or more near the gastric angle of the posterior wall of the stomach, and the pathology showed gastric imprint to quit cell carcinoma.
In March 2015, in the general surgery department of a tertiary hospital, the elderly woman underwent laparoscopic exploration and radical gastric cancer resection (total gastrectomy jejunal gastry). Diagnosis of gastric ulcer-type hypodifferentiated adenocarcinoma with lymphatic metastases. After the operation, the elderly woman developed incomplete intestinal obstruction, which was symptomatic.
In early April 2015, the elderly woman developed chest tightness and wheezing, and chest x-ray showed lung infection and pleural effusion, and anti-infection treatment was ineffective. Multiple metastases of gastric cancer with interstitial pneumonia in the lungs followed by various cardiovascular diseases that were ineffective in treatment and died.
On May 4, 2015, for further diagnosis and treatment, the elderly woman went to a tertiary hospital for hospitalization again.
Pet-CT results after admission: after gastric cancer surgery, surgical anastomosis (hepatic portal) with unclear boundaries of strip metabolic hypercalculation foci (2), considering recurrence or metastasis of malignant lesions; rectal-hysterical depression peritoneal roughness and a small amount of fluid shadow, mild increase in metabolism, considering implant metastasis; superior and inferior lymph node metastasis; interstitial inflammation of both lungs. Lung function: severe mixed ventilation dysfunction; diffuse function decreased.
On May 9, 2015, the elderly woman was nauseated and vomited after oral chemotherapy drugs and stopped oral chemotherapy. The elderly woman coughed and wheezed significantly, and was treated with nebulized inhalation and hormonal asthma, considering interstitial changes in the lungs.
The elderly woman had advanced tumors, multiple metastases throughout the body, and interstitial pneumonia in the lungs, and the prognosis was extremely poor, and she explained her condition to her family, and the family expressed understanding.
On May 12, 2015, in order to clarify the nature of pleural fluid and alleviate symptoms, the doctor performed chest punctures for the elderly woman with local anesthesia with the informed consent of the family, and the puncture process was smooth.
In the afternoon of the same day, the elderly woman was found to be bruised on her left upper extremity and performed ultrasonography: no obvious blood flow was seen in the deep veins of the left upper extremity, except for thrombosis. Arterial flow rate in both upper extremities is significantly reduced. Cardiac ultrasound: left ventricular ejection fraction 33%, left ventricular segmental wall movement abnormalities. ECG: abnormal changes in T waves (rS type V1 to V3); N-terminal precursor protein of brain natriuretic peptide (10000pg/ml). Vascular surgery consultation: low molecular weight heparin calcium 0.4 ml subcutaneous injection Q12h is recommended. Cardiology consultation: acute coronary syndrome, cardiac function grade III is considered. After the administration of related drugs, the symptoms of chest tightness and shortness of breath in the elderly woman were slightly alleviated.
On May 13, 2015, the elderly woman was generally in poor condition, still had chest tightness, wheezing, and bruises on her left upper extremities improved significantly. At 9:40 a.m., the elderly woman's heart rate increased to 200 beats per minute, ecG showed rapid atrial fibrillation, and sildiran was given 0.2 mg static push, morphine 10 mg into the pot, and amiodarone hydrochloride was set aside. At about 11 o'clock, the elderly woman's heart rhythm turned sinus, her blood pressure was stable, her heart rate was about 100 beats per minute, and she continued to closely observe the changes in her condition.
At 3:00 and 17:00 on May 14, 2015, 10 mg of morphine was given subcutaneous injection. Patients with obvious daytime wheezing, accompanied by irritability, considering heart failure, respiratory failure, given sildiran 0.2 mg, furosemide 20 mg into the pot and heartache 5 mg taking, symptoms did not alleviate, at 22:35 there was loss of consciousness, heart rate decreased, breathing slowed down, after rescue ineffective death.
After the death of the elderly woman, the patient's family questioned that a third-class hospital had repeatedly injected morphine hydrochloride injection in excess of the patient's hospitalization, resulting in severe breathing difficulties in the patient, and finally died due to respiratory failure and ineffective rescue, and sued a third-class hospital to the court, demanding compensation for various losses of more than 240,000 yuan.
The court entrusted an appraisal institution to conduct an appraisal of the case. The "Appraisal Opinion" believes that the nature and progression of the disease suffered by the patient are the root causes of the damage consequences, and the fault of the doctor's medication has a slight effect on the patient's damage consequences. Here's why:
1. Low-differentiation gastric cancer has a high degree of malignancy and a poor prognosis. The exact cause of death could not be determined without an autopsy, and the patient died of circulatory and respiratory failure.
2. Morphine has a strong anesthetic and analgesic effect, which is suitable for all kinds of patients with advanced cancer, but morphine can inhibit the activity of the respiratory center of the brain, slow down the breathing, and even lead to paralysis of the respiratory center, respiratory cessation and death. It is contraindicated in patients with acute left heart failure in advanced stages and respiratory failure.
3. Nearly 2 months after radical gastric cancer resection, the patient suffered chest tightness and wheezing for more than 1 month and was admitted to a third-class hospital. Diagnosis is "acute coronary syndrome, cardiac function grade III" according to the relevant tests. Antiplatelet, anticoagulant, lipid-regulating, cardiotonic, diuretics, hormones, chemotherapy drugs and other drugs are given, and chemotherapy is stopped due to nausea and vomiting caused by taking chemotherapy drugs. The above diagnosis and treatment process is not at fault by the doctor.
4. In the early morning of May 14, 2015, the patient's condition worsened, the oxygen deficiency was obvious, and at the same time, in the absence of ventilator assisted breathing, the doctor applied morphine, which may adversely affect the development of the patient's condition, and the doctor is at fault.
In addition, in order to safeguard the legitimate rights and interests of the parties and clarify the facts of the case, the court organized an expert group of pharmacy experts, oncology experts, and forensic doctors of Beijing Municipal Forensic Appraisal Institutions in beijing, in addition to the defendant in this case, to conduct expert arguments on this case. In the end, the court dismissed all of the injured party's claims. Here's why:
1. The patient is in advanced stage of cancer, has experienced dyspnea, irritability and other symptoms, its main complaint of suffocation, wheezing is its heart failure, morphine has analgesic, sedative effect, the use of morphine for patients with heart failure can reduce their heart load, patients have signs of using morphine.
2. There are relevant operating guidelines for the use of ventilators, and the use of morphine in clinical practice is not related to auxiliary ventilator support. In addition, the use of ventilators may cause infection, and ventilators should not be used considered in the patient's physical condition.
3. The "cyanosis of the nail bed" appeared in the patient is not the "respiratory depression has been shown as cyanosis" mentioned in the morphine drug instructions, and the patient belongs to the heart failure leading to the cyanosis of the nail bed.
4. In this case, the patient's dosage and interval of several morphines met the requirements, and there were no adverse reactions after the first dose, and the subsequent 2 doses were subcutaneous injections and there were no adverse reactions. The patient's loss of consciousness, decreased heart rate, slowed breathing until death, has occurred more than 5 hours after his last use of morphine, and there is no causal relationship with morphine use. The method and dosage of morphine used by the doctor in the process of using morphine on patients are also inappropriate.
In the eyes of most Chinese, morphine is a painkiller that is used as a last resort when there is severe pain. However, in some hospitals abroad and China that are more advanced in palliative and palliative care for terminally ill patients, morphine is also a routine drug for alleviating breathing difficulties in terminally ill patients.
It is reported that the "U.S. NCCN Guidelines for the Treatment of Adult Cancer Pain" issued in the 1990s, the "Guidelines for the Palliative Treatment of Cancer Patients in the United States" and the "EAPC Opioid Cancer Pain Treatment Guidelines" in Europe clearly stipulate that morphine treatment can be applied for respiratory difficulties in patients with advanced cancer, and it is also recommended to consider increasing the dose and titration rate of morphine for acutely advanced dyspnea.
However, in China, for some terminally ill patients with advanced cancer, doctors are kind enough to use morphine but are likely to accidentally push themselves into the dock. Just because the "indications" of the morphine instructions do not mention "relieving breathing difficulties".
In particular, I remember that in the above case, the oncologist involved once said something like this in court: "You can ask in turn, why did I, the doctor, prescribe morphine to the patient?" What is my motivation? I injected patients with $3 a bottle of morphine, which was not financially beneficial. Morphine is a 'red prescription' that is strictly regulated by the state, and each one requires a registration number, which is cumbersome to use. I don't give morphine to the patient, watch her die in pain, and according to the current medical regulations, I will not be held accountable, so why should I ask for trouble? ”
Imagine if the doctors didn't give morphine to dying patients who had difficulty breathing and were in pain, who would be the most miserable? Who will be the unlucky one in the end?
Author: Universal Medical Editor: Chang Lu
【Medicine Shield Public Welfare】PSM Pharmaceutical Shield Public Welfare (public number: PSMChina), a public welfare organization jointly initiated and established by the China Over-the-Counter Drug Association, the Chinese Pharmaceutical Association, etc., gathers resources, gathers strength, and promotes the safety of public medication.
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