What was the question again?

In rounds:

"Can I please have a PCA with a basal? 3 weeks. His pain is not being adequately managed."
"How much are you giving?" Sala is attending. She's here as a package deal, because her husband is such a hot-shot heart surgeon. She's pretty and smart but she's not a trauma doctor.
I show her the medication record. We've been pushing dilaudid on this chick every hour, 2 mg, since the 5th of May.
"Fentanyl drip. You think 50-100 mcgs/hr?"
I nod.
"50-100 mikes an hour. DC the dilaudid."
"DC the dilaudid?"
"The fentanyl will take care of the pain."
"Maybe."
"Okay. 1-2 dilaudid q 2."
"Why not q 1?"
"you'll over medicate."
"It's a prn med. It's administered at our discretion."
"Well, I don't want your discretion to overmedicate."
"Because that's a big plot--big nursing plot. We want to depress the respiratory drive of all our patients...."
Baggins shoots me a glance..."Relax...."
"listen, if we're going to be switching pain meds, you're can't tie my hands like this. I've got to be able to titrate this to what she needs."
"I'm not tying your hands."
"April, you always do this. The first thing you do is cut pain meds. You cut our options at the patient's expense. Trust us. We went to school, too."
Carla, who's supervising today, big box like Carla--smart and treacherous--50's, passive aggressive, lies through her teeth, "And then you say the nurses are doing drugs."
She hates Dr. Sala. It was the Dragon who said that about the nurses, not Sala. Fuck, I think. I was just about to get what I wanted out of Sala. Now Carla's queered it.
"How about just for one day? Til I can transition her to the drip and get it right" I say, ignoring Carla. I'll pay for that later, I think.
"Fine."
I leave.
My patient is in multi system failure. Lungs, kidneys, liver, heart. Broken ribs, broken pelvis, broken clavicle, c collar. GI bleeds, pancreatic bleeds, Everything. And they want to cut pain meds.
She's probably dying. I don't know. I'm not sure. Honestly, I've seen worse.
The family held a care conference today. No one wants the burden of deciding what to do. But you can't just blow this off. It's complex. There is no easy answer. They request a chaplain to pray with them. You have to navigate through fantasy and hope.
They decide to ask the patient. Who's having liver and kidney problems and who probably isn't at her sanest right now. Not that I dismiss the wishes of the patient.
"Do you want to die?" They ask her. The chaplain is with them.
Okay. I don't want to sound like the devil, but chaplains often do more harm than good. Some of them aren't very intelligent. They are often interfering and self-righteous and don't really understand pathophysiology. They tend to want simple answers and, quite frankly, our chaplains seem to be a little in love with death.
"Do you want to die?"
The patient nods.
"Praise God." The chaplain says. "Well, I guess we have our answer."
Lots of drama, people weeping over the bed.
And then I come in, like the nasty little rational spoiler I am.
"No, we don't have our answer, with all due respect." I say. "We have a little more information. You still as a family have a lot of work to do before you decide on withdrawing care. You need to take into account, for example, that she may not be in her right mind. Has anyone in the room gone through natural childbirth? " (nods) "Wouldn't you have said anything at some point during it to have it over? This is the most serious and important decision all of you will ever make. You are deciding whether she gets to keep fighting for her life or not. I am sure that Reverend Clive will pray with you for discernment. He is here to support you spiritually." I emphasize the word "spiritually" hoping that Clive will get the message.
Clive, man. Ghoul.
Later, Carla corners me. "Did I just hear that the family was going to withdraw care and you talked them out of it?"
"Clive?"
"Clive."
"Luther, man. Luther started all this. Priests don't act like this."
Carla sighs. She's Catholic, too, like I used to be. "I know. You're right. "
Wiz is at the desk listening. "They should have taken away his shoe. Did you hear those heretics even read the bible all by themselves? Come up with their own opinions about it, too..."
"Shut up, Wiz," Carla says.
"It was too easy," I say defensively. "Clive was pushing them towards withdrawing care. It's not his place. That man isn't ready to die."
"Oh, Haley," Carla says, "he's suffering..."
"He didn't understand the question. Go ask him again." I tell her.
Carla gets Dr. Sala.
"Is he with-it enough to answer questions?" A dig at me. She's mad. Sala doesn't usually take revenge, though.
"He's been on narcotics for the last month, every hour. I don't know how rational that's left him." I shoot back.
She goes in. The family's gathered around the bedside. Clive is there too, looking self righteous and smug.
"Do you want us to continue treatment?" Dr. Sala asks. "Do you want to go on?"
The patient nods.
Sala then lays out to her and everyone in the room exactly what this may entail. She doesn't make any bones about it.
Then she asks her again.
The patient nods again.
"Do you see?" I say. "She has given us two very different answers. Your work for her on this is not done." I tell them as gently as I can.
No Christmas cards for me from these guys.
Oh, well, nobody loves you cause you're easy.
That's my 1/2 hour.