The Sins of Mr. Righteousness

I had never experienced AIDS until this rotation. I became acquainted with an advanced stage AIDS patient during my second week at the VAC. At that point he was receiving TPN and was moderately weak. Since then, his state has only deteriorated exponentially. He has been taken off TPN and has developed extreme nausea and vomitting. Every time he eats or takes medications, he vomits about 20 minutes afterwards. We have tried every possible anti-emetic in this patient - prochlorperazine, ondansetron, metoclopramide, etc. A specialist physician from another facility who has treated this patient before recommended dronabinol (Marinol). Marinol...sounds a lot like marijuana...and it should because dronabinol is a derivative of THC, the active ingredient in marijuana. Dronabinol can be used to increase appetite in AIDS patients and can also be used to decrease the nausea and vomiting associated with AIDS medications. Of course, dronabinol is a non-formulary product. In order for the patient to receive the medication, pharmacy has to approve its use...or the chief of medicine has to approve it. While the approval is usually given to the pharmacist in charge of the department it will be used in, this non-formulary request was given to JC. At lunch, TK, Ms. Resident, and I approached JC in regards to the request. The three of us had spent a portion of the morning researching the product and its appropriateness. We were recommending its use. When approached, JC informed everyone in the inpatient pharmacy that, and I quote, "No one would be receiving THC while he was a pharmacist at the VAC." He then went on to say, "What do they think they're going to do...make him so high he can't remember he's sick?" Ms. Resident, TK, and I were very upset by these comments. Low and behold, JC denied the request and recommended the use of ondansetron (which the patient failed miserably on). I was not disheartened, because I had a feeling the chief of medicine would take care of this problem...and she did. She also slammed pharmacy for its poor chart review and blinded ignorance. Ms. Resident and I wanted to put an addendum on her note saying, "We concur with medicine." This follows right in line with pharmacists pushing their personal beliefs on patients. JC is a staunch Republican with strong views. He let his personal views on marijuana and possibly even AIDS dictate his decision. Clinical information was not even evaluated by JC. It is insanely ridiculous that this patient would be denied a medication because it may cause euphoria. For God's sake, morphine can cause euphoria! I suppose JC would feel that patients in unretractable pain should be denied morphine due to the chance for euphoria. After receiving medicine's reply, I made a trip to the patient's room to see him. He was lying in bed with his eyes rolled back in his head and trembling in pain. I couldn't help but think to myself that if he did receive a little bit of euphoria from the dronabinol, it wouldn't be such a bad thing. I doubt he will survive to receive a dose anyway. The medication won't arrive until Wednesday, and I'll be very surprised if he makes it to then.