MORPHINE and Dying Patients

dukesgal · Aug 22, 2010

When my grandpa was in the hospital from complications of pneumonia, he suddenly took a turn for the worse and lost consciousness. On that last day, we knew he would not recover, but our family opted to make him as comfortable as possible. I still remember holding onto his his hand as the nurse administered that last dose of morphine and his respirations slowly decreased. He died about 20 minutes later. I don't believe it hastened his death, I just believe it was his time to go. He was comfortable and it was peaceful for our familiy to be there for him and not see him in agony. I think that particular experience has made me a better nurse and advocate for my patients to get effective pain relief.

leslie :-D · Aug 22, 2010

when my mom was in icu and unconscious, a mso4 gtt was started after we dc'd txs.

within a couple of minutes, we could see my mom's entire face relax...

my point being, never assume that folks aren't uncomfortable just because they're unconscious.

i always study/assess my pt's faces and muscle tone, even when obtunded or comatose.

i want to see total relaxation, no matter how much medication it takes.

leslie

Vancouver Son · Aug 23, 2010

Thanks all for explaining the hydra morphine. I accept it was my Mum's time to go. If anything, I wish we could have made her a bit more comfortable some hours earlier than we did. At the end of the day this is a 'nurse's' forum..so appreciate your indulgence. I hope your health care reforms in the US are true reforms that will benefit all and not turn out to be yet another game designed to line the pockets of insurance companies. Fight for it. We're fighting to keep our system against powerful lobbies. No one's mother should suffer. Best of luck to you and yours.

amps · Feb 2, 2011

My 94 1/2 year old mother recently died from respitory failure, pulmonary edema congestive heart failure, ischemic cardiomyopathy, acute and chronic renal failure and endstage dementia. Her breating was extremely labored and noisy and she was working very hard at breathing. 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?

talaxandra · Feb 4, 2011

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.

amps · Feb 4, 2011

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! :crying2:

nlmcgee · Feb 5, 2011

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.

nuangel1, BSN, RN · Feb 5, 2011

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.

leslie :-D · Feb 5, 2011

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.

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

JenniferSews · Feb 5, 2011

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.

nlmcgee · Feb 5, 2011

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.

nlmcgee · Feb 5, 2011

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.