Morphine doses while dying?

Xbox Live Addict · Oct 14, 2008

When I saw that order, I would have gently pulled the doc aside and told him I couldn't "C" off the order as written, wording my request in such a way as to tell him I was concerned about HIM getting sued by some overzealous family member who might get ahold of the chart, so therefore I could not follow it. What I'd be thinking is: "Angel of Death" is not in my job description.

There's more than a lawsuit at stake here. That same overzealous family member could make a criminal case for murder or manslaughter against the NURSE, if the family takes it into their heads that their loved one was directly killed by the nurse's actions, rather than being floated out as part of the natural dying process. It's all good and well for the doctor to write the order - he isn't the one who will legally have the "blood" on his hands - it is the nurse giving the medication until "respiration stops" that will take the fall. The fact that the physician wrote the order like that won't protect the nurse, since nurses are charged to challenge any inappropriate or illegal physician orders.

Whether such an accusation would stick isn't the point. That kind of accusation could cause long-lasting professional and emotional damage. And that isn't worth it.

I wonder if this doctor who wrote the order "until respiration stops" would be willing to carry out his own order.

**canoehead, BSN, RN** · Oct 14, 2008

I would definitely go to the doc and encourage him to be a little more PC with his orders.

I'd give that level of medication without a second thought if there was the faintest sign of discomfort. I'd be very proactive in asking the family to point out signs of pain or restlessness, probably would even give an extra dose for family comfort sake, just to make absolutely certain pain was controlled. I would absolutely not give meds primarily to kill someone, no matter who was requesting it, and I'd be very clear and gentle with the family about alleviating symptoms and having a gentle dignified death. there's no dignity in being put down like a dog, but being gently ushered from life with family around you shows a lot of respect for the deceased.

leslie :-D · Oct 14, 2008

working inpatient hospice with a pt load of anywhere from 1-4 x 12+ yrs, i've seen hundreds and hundreds of deaths.

so yes, i do feel qualified in saying that a 'natural' death, no disease process, is truly beautiful and painless.

but-these folks wouldn't be inpatient if they didn't have some pretty darned severe symptomology...

so i haven't seen a boatload of 'natural' deaths...but certainly enough.

and, once symptoms are contained, it's as close to natural as one is going to get.

there's nothing wrong with giving the occasional extra dose for the sake of the family.

but too often, a family member's pain is projected onto the pt.

and it's too emotional a time to be objective in them assessing pain.

what happens, is subconsciously, we are in effect treating the family's pain even when the pt is absolutely fine.

you also wouldn't believe how many families want us to dose the pt until resps stop.

"let's get this over with" type attitude.

and finally, an effective hospice nurse will never have to defer to the family in seeking s/s of pain.

this is our specialty and we treat aggressively.

so again, an occasional extra dosage is fine, no problem.

but dealing with all the families that i have, there are just such strong anxieties that many truly want to hasten death, even in the absence of suffering.

you can usually quell any fears by sensitive conversation.

dying is not just about treating physical symptoms.

it entails a lot of emotional, spiritual work as well...

for pt and families.

it really is about holistic treatment, to which drugs aren't always the answer.

leslie

Babs0512 · Oct 15, 2008

First, I would never medicate a patient to make "the family comfortable" - that would amount to a chemical restraint - no pain medication. As for the 4mg morphine q10min, not that unusual an order, we give it in PACU for post ops, picture the 250lb man who drinks a six pack a day, he would likely need a dose like this, we even would give 4mg q5 min providing VSS. However, the doctor should have put a "max dosage" on the order.

Remember, some people have been on pain medications a long time, giving them a dose that would kill you or me, often won't phase the patient.

I would never knowingly give a drug "until the patient stops breathing". I however, would medicated a patient, even near death, if the patient was c/o pain or if they appeared to be in pain (tachycardia, moaning, diaphoresis, etc..) and if their breathing stopped, then so be it. They died without pain, so I am happy to have been there to help them.

Blessings

Jo Dirt · Oct 15, 2008

I know in hospice that patients are able to receive quite a bit of morphine during the dying process, but what is the normal dose at the care facility where you work? My hospital had a recent pt that was dying d/t hem. stroke and was already passing quickly when the family went above the nurses head and called MD at home, who then came in and gave nurse verbal order for morphine 4mg q10 min for pain prn. Aside from the fact that this pt had NO s/s of pain whatsoever, the MD said to nurse (with other nurses present) "the family is tired, just give it every 10 minutes unitil respirations stop". Very thankful I was not the nurse but this has really bothered a lot of us, and I just wanted to know if anyone has had a similar order?

They just don't call it "euthanasia." I have mixed feelings about this. We recently had a patient whose wife had decided he had suffered long enough and he was put on comfort measures only. He was holding his own pretty good but then started giving him morphine. A little more and a little more, 4 mg every 1-2 hrs. PRN.

He was gone in less than 48 hours. I believe this was a brave and noble decision his wife made and I would say they had the discussion about what to do if it ever came to this before he got sick. The man died quietly and comfortably and with as much dignity as someone could have in his situation. I'm still not sure I could have administered the medication until breathing stopped. I'm focused on saving lives, being part of taking a life, even when it is for the best, is just too foreign to me. I don't think I would like knowing I gave the last dose.

Babs0512 · Oct 15, 2008

It's illegal to give Morphine with the intent of getting a person to stop breathing.-- however -- If you are medicating the same patient for pain and the patient inadvertently stops breathing, no law broken (assuming patient is dying and is a DNR

Blessings

patwil73 · Oct 15, 2008

Many posters have expressed some concern over the wording of the order - keep giving until respirations stop. I am wondering if perhaps the doctor didn't mean it a bit differently. I have been given similar orders and since I knew the doctor I knew what he really meant was - don't worry about low respirations. The patient needs comfort and to be pain free in his final hours.

I too have taken care of many patients like this in Hospice and ICU. What I always try and do at the start of my shift is explain to the family what our goals are (keep pt pain free) and ask what they want. I then explain what I look for when assessing for pain, so they know and can see for themselves. I finally end by asking that they come to me if they feel the patient is experiencing any signs of pain that might be unique to him - that only they as a family might know.

I explain what the medication does and what the patient's reaction to it might be (ie slower breathing). This prevents any surprises when suddenly the patient drop from 30 rr/min to 10.

Finally I disagree a bit with the sentiment that it is only about the patient here. When these situations arise the patient is actively dying and we are not bringing him back. In a lot of ways, the patient is already dead - his body simply does not realize it. So while keeping the patient as comfortable as possible our concern and care must turn to the family. To understand that a drawn out death is really hard to deal with. The longer a patient lingers on, the more a family's life must continue (work, groceries, kids, obligations, etc). Sometimes these obligations occur at the worst possible time and the family is gone when the patient passes away. The guilt here can be horrible. The thought of that happening can really affect those families and they will ask for a lot to assure that the patient dies while they are present.

So what do we do when faced with these situations? Treat only the patient? Treat according to the family? A balance of the two? I don't have the perfect answer - I only know that some expected deaths have gone better and some worse than I would have wished for. But for me, it will always be a balance between caring for the patient and caring for the family.

Hope this helps

Pat

Babs0512 · Oct 15, 2008

Pat: I stand by what I said, "I would not medicate the patient just to keep the family happy". I would medicate the patient if the patient needed the medication.

I understand that when a patient is actively dying, both the patient and family need attention. I never stated that I wouldn't assist both the patient and family with the process of grief and dying. I simply would not medicate the patient at the family's request for no reason.

Many years ago, while working in ICU, I had a ventilated patient who, when not sedated, couldn't stop bucking the vent, chewing on the tube, trying to pull out the tube, etc... I tried talking to the patient and explaining where he was and that the tube was helping him breath, to try to relax, remain calm, asked if he was in pain, etc... All to no avail. The patient just either would not or could not relax.

The family had made a request that morning, they didn't want any sedating medications giving to their father after 1200, as they wanted him awake and coherent when they came in that afternoon. I knew their wishes. I tried not to medicate their father, but he became so anxious, the vent alarms wouldn't stop sounding, and his sat's began to drop. I found myself with a choice, care for my patient and sedate him, he was clearly frantic and it was affecting the vents ability to respire him, not to mention he became tachycardia and developed an elevated BP. He was able to tell me by shaking his head "no", that he was not in pain, he simply didn't like the feeling of the ET tube and couldn't just relax and allow the vent to do it's job.

I read through my orders, and no where did I see the order "Hold medication when the family reqests it." While I tried to abide their wishes, I simply could not allow my patient to suffer - and he was suffering - any longer. I gave him the ativan and he relaxed, his sat improved, his HR normalized as did his BP. Not 5 minutes after I gave it his son showed up, and boy was he peeved that his dad was sedated. He complained to the nurse manager and I got pulled into the office. I explained the situation, and stated "I would make the same decision again - I'm here for my patient FIRST." I had documented well. I had done nothing wrong. And the family was educated as to why it was necessary to medicate their father. The son was still peeved, but then he wasn't my primary concern. He was tertiary at best.

This is what I was saying when I said that my primary concern was for the patient. There are times when caring for patients, we may upset the cart where family is concerned; while every effort should be made to try to avoid this, sometimes it is unavoidable.

Blessings

egarwo · Oct 15, 2008

i personally feel scare when i here morphine. when i was a student i learn that morphine ease dying pt pain and also learn it also depresses the pt resp so then why are still using morphine as a pain med. i will rather the doctor give it himself.:loveya:

during my clinical years at school i remember the patient son did not want the dad to take the prescribe morphine per his request but according to the order the patient was to take the morphine every 2 to 4hour if you do not give the med you will be held relable med error in this case i had no choice butto give the med to help with the pain.

Babs0512 · Oct 15, 2008

egarwo: ANY narcotic has the potential side effect of decreasing respiration's. Morphine, Demerol, Dilauded, Fentenyl...etc...

There is no need to be afraid to use these medications, if used properly, they are very safe - and they work well to help control pain.

The oral form and/or transdermal form of these meds can cause respiratory depression too. Yet, people are prescribed these meds daily.

I had a women come in to the ER once with 10 Fentenyl (Duragesic) patches all over her body. Her respirations were 4 / min, and EMS was bagging her. No one noticed the patches until I began undressing the patient and putting cardiac leads on her chest - that's when I found them. After taking them off, we gave her Narcan - in seconds she came up swinging!! She was upset that we screwed up her Saturday night high!! Oh well.

These meds are very safe, when used as directed.

Blessings

patwil73 · Oct 16, 2008

Pat: I stand by what I said, "I would not medicate the patient just to keep the family happy". I would medicate the patient if the patient needed the medication.
I understand that when a patient is actively dying, both the patient and family need attention. I never stated that I wouldn't assist both the patient and family with the process of grief and dying. I simply would not medicate the patient at the family's request for no reason.

Thank you for your response. If you are assisting the family with the process of grief and dying then in most cases they would not be requesting pain medications for "no reason". It has often been my experience that it is those who don't understand what is happening to their loved one or who hasn't taken the time to understand what they are feeling that are making the most outrageous demands.

I too would not medicate just to keep the family happy. I believe in a balance. Also sometimes compromise. The patient might not "need" the pain medication right then, but the family might "need" to see that we are keeping their loved one from pain. If giving the pain medication is not going to hurt the patient, I see no harm here.

One prior poster mentioned it being about intent. If you are not intending to kill the patient, then your actions are (at least according to my ethics) moral.

Many years ago, while working in ICU, I had a ventilated patient who, when not sedated, couldn't stop bucking the vent, chewing on the tube, trying to pull out the tube, etc... I tried talking to the patient and explaining where he was and that the tube was helping him breath, to try to relax, remain calm, asked if he was in pain, etc... All to no avail. The patient just either would not or could not relax.
The family had made a request that morning, they didn't want any sedating medications giving to their father after 1200, as they wanted him awake and coherent when they came in that afternoon. I knew their wishes. I tried not to medicate their father, but he became so anxious, the vent alarms wouldn't stop sounding, and his sat's began to drop. I found myself with a choice, care for my patient and sedate him, he was clearly frantic and it was affecting the vents ability to respire him, not to mention he became tachycardia and developed an elevated BP. He was able to tell me by shaking his head "no", that he was not in pain, he simply didn't like the feeling of the ET tube and couldn't just relax and allow the vent to do it's job.
I read through my orders, and no where did I see the order "Hold medication when the family reqests it." While I tried to abide their wishes, I simply could not allow my patient to suffer - and he was suffering - any longer. I gave him the ativan and he relaxed, his sat improved, his HR normalized as did his BP. Not 5 minutes after I gave it his son showed up, and boy was he peeved that his dad was sedated. He complained to the nurse manager and I got pulled into the office. I explained the situation, and stated "I would make the same decision again - I'm here for my patient FIRST." I had documented well. I had done nothing wrong. And the family was educated as to why it was necessary to medicate their father. The son was still peeved, but then he wasn't my primary concern. He was tertiary at best.
This is what I was saying when I said that my primary concern was for the patient. There are times when caring for patients, we may upset the cart where family is concerned; while every effort should be made to try to avoid this, sometimes it is unavoidable.
Blessings

This is a nice example but it is opposite of what the issue is in an actively dying patient. In your example the son wanted medicine withheld so he could presumably interact with his father - the process of holding the medication would cause harm to the patient. This is a big ethical no no in my view.

In the example of the patient dying the family wants more medication given - to relieve pain they feel he is experiencing, to perhaps shorten the anguish of watching a loved one slip away, to assauge feelings of guilt over not being around enough, etc (we may never know and it might not be just one). Giving the medication does not cause harm, (even if the ultimate outcome is death) and it relieves stress, pain, grief and fear in the family. I still find it the ethical choice here.

Hope this helps to clarify my position.

Pat

Babs0512 · Oct 16, 2008

I understand your position Pat, and I don't necessarily disagree with it. I would have no ethical dilemma either, as I watched my mother die from cerebral herniation caused from a bleed they were unable to stop. My mother was on a Morphine gtt, unresponsive, I signed DNR papers.

Mom was on 95mg Morphine per hour, after 4 days. It did not hasten her death, but if it had, I would have no qualms about it. I didn't ask for the gtt to be titrated up unless I felt Mom had pain, her HR would go up, as would her respiration's, so I felt I had some potential sign of pain, which justified upping her gtt.

Again, if the family wanted the patient medicated, and I felt the patient was having pain, I wouldn't hesitate, I just don't think we should knowingly euthanize someone.

I don't think my example was completely different from yours. In each case the family wanted something with regard for their loved one. In my example, I chose to go against the family for the good of my patient - I would do the same if my patient was dying, and the family wanted the patient medicated and I saw no sign of needing it. I have no moral qualms, but legal ones. I wouldn't do something that was legally wrong. Euthanasia is legally wrong - therefore I couldn't do it.

The discussion of whether Euthanasia should be illegal, is for another thread - for the record, I am NOT against it morally.

Blessings