MORPHINE and Dying Patients - page 17

Curious about the administration of pain medication (Morphine) and possibly speeding up a patient's death.... Read More

  1. by   talaxandra
    Hi amps, welcome to allnurses.

    In general I'd agree with you - our doctors more often prescribe 1-5mg (usually 2.5-5mg) between 1-4 hourly PRN, titrated to distress, for our dying patients. Although duration of action obviously depends to a degree on route, 6/24 sounds a little long, particularly if your mother was receiving palliative care rather that active treatment.

    I'm sorry for your loss.
  2. by   amps
    I have read all the threads about Morphine and dying patients and it has given my new perspective despite me being in nursing 20+ years. Thank you all for writing. I am upset (to say the least) that my Mom seemed to suffer so much the last night of her life. I could not stay with her because each noisy, labored breath seemed like a knife thru my heart. I am angry with myself since i feel very strongly that nobody should die alone and have been with lots of other people when they died, even without being "on duty," just so they had someone there with them. But, i reacted like a loving daughter, not a well seasoned nurse. My last plea to the staff was to please make sure Mom was comfortable as possible, not to withhold morphine and not let her suffer. It wasn't until afterwards i found out that they did not give her morphine more frequently that in 6 hrs after she received her last dose when i was still there. I have to do something with my anger and my guilty remorse. I am thinking about setting up an inservice at the nursing home about dosing with morphine and other drugs and end stage palliative care so that it will be a tribute of sorts to my Mom's memory and hopefully constructive so that others don't have to suffer as i believe (witnessed) that she did. It's just too soon, the feelings are still too raw but i need to do something positive with these negative feelings!
  3. by   nlmcgee
    Dear amps, I am so sorry for your loss. I can certainly relate as I lost my mother on January 29, 2011. She was 87, diagnosed with a partial small bowel obstruction, for which she had refused surgery. Along with the obstruction she developed pulmonary distress which the doctor and nurses attributed to the obstruction (which caused stomach distention) as well as her obesity and the fact she was bedridden, not to mention CHF. Strangely enough she had almost no stomach pain, but it was the pulmonary distress which was awful to witness, not just for myself but for the staff who was caring for her. I want you to know that I was with my mom during a lot of her struggling; however, she chose to leave this world after I had stepped out of the room for a 10-minute break. The hospice nurse had advised my sister and I that mothers, particularly, are protective of their children. So when they are dying, they tend to want to depart when we are not there. She advised us to give mother some space. Mother did exactly as the nurse had said she might. We left the room for a few brief minutes, and then she left this world. So please don't feel that you abandoned your mother. As you could not bear to watch her struggle, most likely she wanted to spare you further pain as well. She knew your heart was with her. I hope this brings some solace to your broken heart and ease the guilt you are feeling.

    On the medication side; I can understand your concern that it did not get adminstered as you had requested. Perhaps the time of her death happened before her medication was due?? My mother died around noon, but her official time of death was recorded as the time the hopsice nurse officiated it; which was 1:30pm.

    I have different guilt issues. Mine stem from the fact that perhaps my mother received too much morphine which rendered her unable to communicate with us. Hospice had only talked about relief from distress and at no time mentioned that she might be rendered in a sleep state. When I called with concerns on this matter, hospice said they felt her sleeping was simply the progression of her illness rather than too much morphine. I have my doubts.
  4. by   nuangel1
    amp and nlm i am so sorry for your losses.i understand.nlm i too have witnessed pts waiting for kids to step away and pass.i have seen it a lot having worked 11 years in icu.i was with my mom on the day she died talking to her, holding her hand and giving her permission to go .the nurses were repositioning her, i was not far, in the hallway ,during those moments my mom passed.i do believe even though she had been unconscious for 2 days,that she heard me and knew i was there .at least i hope so .i still miss her and my dad soo much.always will.
  5. by   leslie :-D
    Quote from amps
    The staff gave her morphine 5mg about every 6 hrs and I (coming from an ICU background) thought giving less mg more frequently would have made her more comfortable. I have been with lots of patients during their last living moments but seeing my mom suffer so much at the end hurt beyond words. What do you think about the dosing of the morphine? Should it have been less and given more frequently?
    amps, i am sorry about your loss.
    yes, your mom should have received the morphine more frequently.
    if it was written as a scheduled order, you could always approach the dr who wrote the order and share your concerns.
    sadly, there remain many nurses who fear giving out too much morphine, and much more inservicing is needed.
    please take the time to heal, and be good to yourself.
    your mom is no longer in any sort of distress.

    Quote from nlmcgee
    I have different guilt issues. Mine stem from the fact that perhaps my mother received too much morphine which rendered her unable to communicate with us. Hospice had only talked about relief from distress and at no time mentioned that she might be rendered in a sleep state. When I called with concerns on this matter, hospice said they felt her sleeping was simply the progression of her illness rather than too much morphine. I have my doubts.
    nl, again, i am sorry about your loss.
    i take it you are not a nurse?
    it's unfortunate you were not told about the side effects of morphine.
    yet, i tend to doubt your mom was given too much...
    and even if it was?
    hospice's intent was to relieve her respiratory distress/suffering.
    while i don't know the case with your mom, it is very true that "sleeping" was likely the progression of her forthcoming death.
    more often than not, people do sleep more and more....often, to a state of unconsciousness, before they pass.
    i would much rather hear about pts getting too much, than not enough, when dying.

    as suggested to amps, time the time to pamper yourself, be gentle, be patient, give time a chance.

    with peace...

    leslie
  6. by   JenniferSews
    Quote from nlmcgee
    I have different guilt issues. Mine stem from the fact that perhaps my mother received too much morphine which rendered her unable to communicate with us. Hospice had only talked about relief from distress and at no time mentioned that she might be rendered in a sleep state. When I called with concerns on this matter, hospice said they felt her sleeping was simply the progression of her illness rather than too much morphine. I have my doubts.
    I know others have posted but I wanted to agree. I have had quite a few hospice and non-hospice but actively dying patients and I have watched a natural progression. I can't think of one death in which morphine was a major medication, since most of my experience is with expected and natural death. We always medicated when the patient presented or expressed discomfort but often that is once a day or so in my facility. But in every instance the patient was very sleepy even on the days when no pain medication had been administered. When hospice was not involved and no morphine was prescribed, there was still a natural decline with marked sleepiness. Sometimes the patient passed away after weeks of end of life signs without the bottle of morphine ever being opened. Usually nursing requested the order for morphine anyway, knowing that soon the patient may not be able to swallow pills and none of us wanted to watch a person we'd taken care of for years pass away in pain. Sometimes there would be an episode of clarity and energy at the end, and sometimes not. But morphine wasn't the deciding factor.
  7. by   nlmcgee
    Quote from JenniferSews
    I know others have posted but I wanted to agree. I have had quite a few hospice and non-hospice but actively dying patients and I have watched a natural progression. I can't think of one death in which morphine was a major medication, since most of my experience is with expected and natural death. We always medicated when the patient presented or expressed discomfort but often that is once a day or so in my facility. But in every instance the patient was very sleepy even on the days when no pain medication had been administered. When hospice was not involved and no morphine was prescribed, there was still a natural decline with marked sleepiness. Sometimes the patient passed away after weeks of end of life signs without the bottle of morphine ever being opened. Usually nursing requested the order for morphine anyway, knowing that soon the patient may not be able to swallow pills and none of us wanted to watch a person we'd taken care of for years pass away in pain. Sometimes there would be an episode of clarity and energy at the end, and sometimes not. But morphine wasn't the deciding factor.
    Thank you for your comments regarding sleepiness. I now remember reading about that in the hospice brochures. I suppose it is normal to come away with fears and unanswered questions after watching a loved one in the dying process. Thanks for your reply.
  8. by   nlmcgee
    Quote from JenniferSews
    I know others have posted but I wanted to agree. I have had quite a few hospice and non-hospice but actively dying patients and I have watched a natural progression. I can't think of one death in which morphine was a major medication, since most of my experience is with expected and natural death. We always medicated when the patient presented or expressed discomfort but often that is once a day or so in my facility. But in every instance the patient was very sleepy even on the days when no pain medication had been administered. When hospice was not involved and no morphine was prescribed, there was still a natural decline with marked sleepiness. Sometimes the patient passed away after weeks of end of life signs without the bottle of morphine ever being opened. Usually nursing requested the order for morphine anyway, knowing that soon the patient may not be able to swallow pills and none of us wanted to watch a person we'd taken care of for years pass away in pain. Sometimes there would be an episode of clarity and energy at the end, and sometimes not. But morphine wasn't the deciding factor.
    You are right, I am not a nurse. Thanks you so much for this explanation. I have been so worried that we might have killed my mother rather than just easing her distress. I do remember now reading in the hospice brochures that drowsiness may be a symptom during the dying process. When I sleep, I still think I'm sitting by my mother's bedside and that I need to be on guard for any sign of distress. Perhaps my mind and emotions will stop whirling over time. Thank you again for your kind reply.
  9. by   llerkl
    "Terminal illness is often accompanied by severe pain and other unpleasant symptoms that cause undue suffering. The fundamental principle of palliative care is to alleviate suffering causes by intractable symptoms such as pain, dyspnea, agitation, and anxiety. The relief of these symptoms is not considered passive euthanasia or assisted suicide".*
    *From American Society of Pain Management Nurses (ASPMN) Position Statement on End-of-Life Care*

    I totally understand concerns though.....even though you want to keep your patient comfortable, you may feel like you don't want to be "the one" who gives "the dose" that ends up being the last one. We have an obligation to provide comfort/relief from pain, especially at the end of life. Sometimes it is just a difficult situation for all.
  10. by   tencat
    Quote from nlmcgee
    You are right, I am not a nurse. Thanks you so much for this explanation. I have been so worried that we might have killed my mother rather than just easing her distress. I do remember now reading in the hospice brochures that drowsiness may be a symptom during the dying process. When I sleep, I still think I'm sitting by my mother's bedside and that I need to be on guard for any sign of distress. Perhaps my mind and emotions will stop whirling over time. Thank you again for your kind reply.
    Be gentle with yourself and take care of yourself. You've been through a horrible ordeal.

    Morphine did nothing to your mom but make her comfortable while she was dying from a disease that couldn't be fixed. Reach out to your hospice folks if you need to talk. Just because your mom is gone doesn't mean they are not still available for you, especially the chaplain or grief counselor.
  11. by   amps
    Quote from nlmcgee
    Dear amps, I am so sorry for your loss. I can certainly relate as I lost my mother on January 29, 2011. She was 87, diagnosed with a partial small bowel obstruction, for which she had refused surgery. Along with the obstruction she developed pulmonary distress which the doctor and nurses attributed to the obstruction (which caused stomach distention) as well as her obesity and the fact she was bedridden, not to mention CHF. Strangely enough she had almost no stomach pain, but it was the pulmonary distress which was awful to witness, not just for myself but for the staff who was caring for her. I want you to know that I was with my mom during a lot of her struggling; however, she chose to leave this world after I had stepped out of the room for a 10-minute break. The hospice nurse had advised my sister and I that mothers, particularly, are protective of their children. So when they are dying, they tend to want to depart when we are not there. She advised us to give mother some space. Mother did exactly as the nurse had said she might. We left the room for a few brief minutes, and then she left this world. So please don't feel that you abandoned your mother. As you could not bear to watch her struggle, most likely she wanted to spare you further pain as well. She knew your heart was with her. I hope this brings some solace to your broken heart and ease the guilt you are feeling.

    On the medication side; I can understand your concern that it did not get adminstered as you had requested. Perhaps the time of her death happened before her medication was due?? My mother died around noon, but her official time of death was recorded as the time the hopsice nurse officiated it; which was 1:30pm.

    I have different guilt issues. Mine stem from the fact that perhaps my mother received too much morphine which rendered her unable to communicate with us. Hospice had only talked about relief from distress and at no time mentioned that she might be rendered in a sleep state. When I called with concerns on this matter, hospice said they felt her sleeping was simply the progression of her illness rather than too much morphine. I have my doubts.
    Thank you for your responses. I always see "intent" of the medication as a way of judging it's effect. If the morphine was given to ease pain, emotional distress, and decrease anxiety than it was used appropriately. Only if it was given to purposely end life was it used inappropriately no matter who gave it or how much. I have asked for a review of my Mom's last 24 hrs including the doctors orders and the staffs interpretation of response. Hopefully this will help me. I am considering sponsoring an inservise for the nursing home staff in honor of my mother's memory specifically about using drugs at the end of life to sort of turn such a negative event it into something positive.

    I too know of many instances when a person won't die until their loved ones leave but in my Mom's case it came a good 10 hours later and about 1 hr after her last dose of morphine.
  12. by   anastasia1919
    Hello, I have a question about morphine induced nightmares.

    My granddaughter was in a coma as a result of brain damage (thanks to a criminally incompetent home night nurse in Lincoln NE, who didn't know how a ventilator worked and what the alarm meant!), and to help her die peacefully and reduce air hunger, she was given large doses of morphine. I have just learnt that morphine causes awful nightmares, and I wonder whether administering morphine was the right thing to do after all. I can't bear the idea that my beautiful 3 year old died having nightmares.

    Why is morphine administered if it causes nightmares for the dying?

    Thanks to all for any comments.
  13. by   SaoirseRN
    Morphine is given because it works. I have rarely heard of people having nightmares. What I hear from those who have had morphine is they feel better because they aren't in pain. Perhaps it CAN cause nightmares, but I think the benefits of analgesic outweigh potential nightmares.

    I've given buckets and buckets of morphine to dying patients and they are comfortable. Peaceful. If they were having nightmares they wouldn't be.

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