[handyrn]

I've had this question for a very long time but have always been afraid to ask it. I think I am ready to ask but I ask that when you answer, please be kind and realize that I am not asking with ill intentions. I am an RN and have always worked in LTC. Every once in a while we get hospice patients in the nursing home, or one of our current residents get put on hospice. When we have someone on hospice they are usually put on liquid morphine, usually half to one ml per hr prn. The hospice nurses that work with us and the families as well as our DON encourage us to use the meds if the patient looks as though they are at all uncomfortable. As I give the morphine (and sometimes ativan with it) I can watch the patient calm down, slow down, and also their resps slow, which is expected, as morphine will do. So here is the problem, as I am giving more and more of the med, I can usually predict their time of death. For example, the family will tell me that it is time that mom can have more morphine and they think she should have it just to make sure she is not in any pain. As I am giving it, my thought to myself is: this will be the last dose because mom will be gone within the next hour. This dose will slow her breathing to a stop. I am usually correct. Then I feel bad. I feel as though I am Dr. Kavorkian performing an assisted suicide. So my question is, how do I justify this within myself? How can I tell myself that I am not performing assisted suicide? What makes what we do here legal but what Dr. Kavorkian did illegal? Please be kind-I just don't get the difference. I feel like I am doing something wrong.

[sharrie]

Your are giving this medication because your patients are end stage disease and in pain. They are going to die regardless of what you do, but by giving them medication to keep them pain free you are allowing the patient and their families a dignified and pain free death.


It is a side effect of the drugs we give is that it causes respiratory depression, but if the patient didn't have it they would still die, but they would die a horrible, stressful and possibly painful death.


I know which one I would prefer.

[Allow Mystery]

Dear handyrn
Excellent question and concern! My humble opinion is that the morphine may hasten the process (does anyone really know for sure). I usually try to maintain an actively dying patient with oxygen up to 4 lpm and Ativan on a q6 schedule, and this frequently allows for a unstressful transition without/minimal amount of morphine. My rule of thumb is that if the respiratory rate is below 24/minute I do not use/encourage morphine.
If pain is an issue at this stage, usually with movement, then I will use/
encourage morphine at 0.25 ml (5mg) and titrate if necessary.

You could also present a question; Does oxygen use prolong the transition?
Oxygen use with an actively dying patient is usually more acceptable and
encouraged. My humble opinion is that oxygen may prolong the transition
(does anyone really know for sure), but I'm reticent to encourage caregivers/family to discontinue oxygen for fear of a more stressful transition.

One other thought about morphine; my humble opinion is that the use
of morphine may allow the patient to relax enough to quit struggling for
life which may hasten the transition, and may not be a pharmacolgical/
physical issue.

I hope others share their thoughts and opinions.

Thanks for asking! Take care!

[earle58]

i can't say that i automatically give mso4 q hr, whether they need it or not.
if pt is still displaying any form of agitation, restlessness, i give it w/o apprehension.
and i also keep ahead of pain.
but i won't give it q hr if pt is in a good place...
let me tell you...
i consider rr >20, still a sign of discomfort and will give the morphine until rr around 10-12.
once breathing is steady, nonlabored and face/body relaxed, no need to give q hr.
if i did that, in absence of any outward signs, i would feel like i'm hastening process in spite of pt being comfortable...
and i wouldn't be able to make peace w/myself.
but, there are many perspectives on this.
mine is only 1.

you need to be able to justify why you're doing what you're doing.
if you're going on an assumption, the water is much murkier.

leslie

[aimeee]

Originally Posted by earle58

i can't say that i automatically give mso4 q hr, whether they need it or not.
if pt is still displaying any form of agitation, restlessness, i give it w/o apprehension.
and i also keep ahead of pain.
but i won't give it q hr if pt is in a good place...
leslie

This is my practice as well

Originally Posted by earle58

once breathing is steady, nonlabored and face/body relaxed, no need to give q hr.
if i did that, in absence of any outward signs, i would feel like i'm hastening process in spite of pt being comfortable...
leslie

When asked to do this I have gently explained that the medicine works for up to four hours so there was no need to give hourly doses unless it did not appear to be providing enough comfort.

If the family continued to be distressed about it however, I have given another dose with a clear conscience. If it was that important for the family to feel that the patient would not suffer, then I felt I was still within the principle of double effect.

One thing to keep in mind is that if this patient was previously taking pain medication on a scheduled basis orally that pain did not go away when the patient began the dying process and new discomforts have also come as part of dying. So that morphine you are giving should be at least equivalent to whatever they were taking in pill form before.

[Noryn]

Grey areas! If the pt is having any s/s of discomfort I think it is very unlikely that the morphine would hasten their death. Unless I am mistaken though the standard of care is to control pain and suffering. Hastening death is a secondary concern and acceptable risk.

But it all comes down to nursing judgement. If they are restless, or having other s/s pain--tachycardia, tachypnea then you should focus on treating their pain (within reason--do not give 100 mg bolus of morphine). Now if they are not having any active s/s pain then a prn may not be indicated.
Despite the ethical dilemma, I personally think giving a comatose patient with rr of 8 a prn bolus of morphine may be difficult to justify. Look for the sx that the prn is used for and document.

[june2009]

I'm not a hospice nurse but I am a nurse in LTC and frequently care for hospice pts. One thing I have noticed with hospice patients in need of morphine is that If you wait too long to give it, (When the discomfort is first starting), when you finally do give it, the pt. is so uncomfortable that it takes a lot of Roxanol to get them in a comfortable state. One of the hospice agencies that comes to my facility has a standing order that they can give 20mg roxanol every 20 minutes until the patients appears comfortable. I have done this myself at the direction of the on call hospice nurse.
I believe that all living organisms will fight to keep living no matter what. When you see a hospice patient, or a patient who is near death, they frequently are breathing heavy, maybe with cheyne-stokes respirations, and maybe even have the pink froth comming out of their mouth because of all of the fluid in their lungs.
Morphine can stop that discomfort. Sometimes I think that those people are struggling so hard to breath and supply oxygen to their vital organs, that they can't die. They are too anxious, uncomfortable, etc. and their natural instinct is to fight. If you give the morphineand/or ativan it relaxes them enough that they can die. There is a difference between this and euthinising your patients. Sometimes I will even tell families that when I give a high dose of morphine, that the loved one may die soon. This preps them for what is about to happen and gives them the opportunity to ask me not to give the morphine. I have never had someone say that they didn't want me to give the meds. I never withhold morphine if the patient seems uncomfortable. I don't care what their respiratory rate is.
This is if the patient is on hospice. If they aren't on hospice, the rules are very different.
Withholding morphine for respirs < 24 sounds very high to me. Even in acute care morphine is held only when resps are <8-10 per min. just my 2 cents.

[ingelein]

Ive had the experience in which it was very evident that the dying patient was going to die much sooner, than if unmedicated with the morphine 10mg every half hour.The daughter insisted that I give her totally unresponsive mother, whose respirations were very depressed, the doses q half hour.I did it because I felt the daughter would have a total breakdown if I didn't.Its such a gray area , but I do feel a bit uncomfortable with that particular death.

[angelrejen77]

I must agree with a few things already posted..Q1hr is not needed if pt does not have labored breathing or extreme pain. The body naturally goes through a chemical change generally a few days before death where pain is extreme then as time wears on generally the night prior the body language and breathing change on there own its natural euphoria so they say a much used quote (who knows for sure) but it is what I have seen over the yrs. I believe the guilt you feel is unfounded I am sorry you are so upset with your self about this issue seriously consider useing your nursing judgement on the Q1hr if its prn thats as needed so is it needed or could you simply try and talk with the family and explain the changes, but if its needed always give..Tx we do Q2prn 0.25-0.5ml with ativan Q4prn if we scehdule its generally in a LT and only q4 with prn standing and to address the oxygen issue its a comfort measure only and generally for family dying pts generally take in breath via the mouth and 02 generally through nc ummm

[Sabby_NC]

I personally have no problem giving Morphine to a dying pt that is non responsive.
They had pain before they were unconscious so does the pain abate? I doubt.
As long as I am giving the pt their pain medication on a regular schedule,
Keeping them clean and comfortable, which includes repositioning. I feel ok with what I do. I have no problem knowing the dose of Morphine I maybe giving could be the pts last.
All I know is that the pt that has total trust in me looking after them and is getting all the care, attention and medication they so rightly deserve.
I do not worry too much about RR or vital signs towards their end of life. It is secondary to giving them love and the family a special time to be right with their loved one.
Step back a wee bit and think about it if you were on the other side of the bed.
I would want some one to give me what was due on a regular schedule when I no longer was able to voice anything.
I would dearly love a peaceful, dignified death without too much pain or discomfort.