Morphine gtt/Comfort Care

  1. 6 We have a comfort care/end of life set of orders at our hospital . I had a patient last night who was on this gtt - all day the nurse had kept her on 2mg/hr - when I got out of report, I went to assess the pt who had labored resp ... the morphine gtt had an order which states what to start the gtt at (usually 1mg/hr) and titrate PRN for discomfort/respiratory issues Q 15min - u can increase the gtt by the current dose + 25% of that dose. There is no "limit" set on the order sheet. Throughout the night she would have labored resp... pulse ox was always ok (usually 93-94% on NC). When day shift nurse came back I told her I had titrated the drip up to 8.5 and she could probably use another increase since she was starting to become labored again. Nurse looked @ me like I was a murderer and basically told me I was hastening this womans death.

    Any advice on this? Is there something I am missing here? Whats the point of being on a morphine drip with titration orders if u arent going to use it?
    Last edit by NurseyPoo7 on Aug 27, '09
  2. Visit  NurseyPoo7 profile page

    About NurseyPoo7

    NurseyPoo7 has '7' year(s) of experience and specializes in 'Acute Care'. From 'USA'; Joined Jul '08; Posts: 300; Likes: 218.

    16 Comments so far...

  3. Visit  Tait profile page
    0
    Sounds like a bit of a sticky wicket to me, but if you are following the protocol it makes sense? I would talk to my manager/supervisor about this one.

    Best of luck,

    Tait
  4. Visit  Whispera profile page
    1
    Was the woman dying already? And you were maintaining comfort through the comfort kit? That's what it's there for and morphine drops have no ceiling other than what provides comfort for the dying patient. As I've seen it, though, docs usually specify a maximum.

    If the patient wasn't already dying and in hospice services, then that's another story....
    Last edit by Whispera on Aug 27, '09
    justiceforjoy likes this.
  5. Visit  heron profile page
    9
    Your coworker needs to review the basics of opioid dosing ... the amount needed to produce lethal respiratory depression is different for each patient and can't be known ahead of time until you give the dose and respers drop.

    Would she be more comfortable if the MD gave parameters? ie, hold drip if respers are less than 4/min.

    BTW, although the morphine will likely continue until death, it isn't the morphine that's killing the pt, it's the disease process.
    mc3, carolinapooh, Straydandelion, and 6 others like this.
  6. Visit  rn/writer profile page
    6
    If the patient is dying and hospice isn't already involved, that might be a good thing to consider and suggest.

    Many nurses and physicians are afraid of pain meds. They worry about addiction. They don't understand the difference in how people in pain metabolize opiates. And they don't get the concept that respiratory depression and, yes, even death can be a side effect of achieving comfort, although death should never be the goal.

    The patient has a better chance of being properly medicated with someone who does understand these principles, as it appears you do. But if your peers and those above you don't get it, you may have a fight on your hands.

    Thank you for advocating for you patient. You gave her a good night of relief.
    carolinapooh, Thanet, nightshiftnut, and 3 others like this.
  7. Visit  NurseyBaby'05 profile page
    2
    Quote from heron
    BTW, although the morphine will likely continue until death, it isn't the morphine that's killing the pt, it's the disease process.
    Thank you, thank you, thank you!

    It's cruel to let someone suffer his/her last hours in respiratory distress when you have the means to make him comfortable.

    You did good, Nurse!

    On the flip side, I have had family members ask me to, um "hasten things" to which I've bluntly responded "We don't euthanize." That starts a storm of backpedaling like you wouldn't believe. Then I point out that the pt is not suffering. Respirations are easy, no grimacing, agitation, appears comfortable, etc. Then I let the family member know that it's okay to take a walk if he needs a break. Sometimes I think people purposely wait until someone leaves to "go." I also jokingly say to my co-workers that I believe that they all know when change of shift is (despite being unconscious) . . . . .
    crissrn27 and shaCNS like this.
  8. Visit  leslie :-D profile page
    3
    Quote from rn/writer
    Many nurses and physicians are afraid of pain meds. They worry about addiction. They don't understand the difference in how people in pain metabolize opiates. And they don't get the concept that respiratory depression and, yes, even death can be a side effect of achieving comfort, although death should never be the goal.

    The patient has a better chance of being properly medicated with someone who does understand these principles, as it appears you do. But if your peers and those above you don't get it, you may have a fight on your hands.
    truer words never written.
    you would be amazed at the number of nurses/md's who FEAR morphine.
    no matter how much inservice they get, their minds are made up and they will NOT administer 'that' fatal dose.
    even at the cost of pt suffering.

    you'd be better off getting orders q shift, with a specific dosage for ea shift.
    this way, the order wouldn't be left to the judgment of the nurse, and he/she would have to follow it.
    so whatever dosage the pt is getting relief from, get orders for that dose.
    make the order for only 8-12 hrs, so they would have to be renewed for either the same or increased dose.
    i know it's a pain, but this will ensure the pt will be getting some relief, as opposed to a tawdry 2 mg.

    afterall, this should be about the pt's needs and not the nurse's fears.

    thank God for you and nurses like you.
    seriously.

    leslie
  9. Visit  raininghere profile page
    2
    NurseyPoo7 - YOU DID THE RIGHT THING!!! That irks me so much . . . how awful to spend the last moments of our lives gasping for breath! It is impossible to know your patient's morphine tolerance from the information we have, but absolutely, titrating per your protocol (and calling the MD if, even with the protocol, you still can't get your patient comfortable). Some patient need the synergistic effect of having a bit of Ativan or Versed with the morphine. Ugh, people are so shy of medication at end of life! I had this patient in her 40s, with end-stage interstitial lung disease, and we ended up putting her on a Versed gtt at 30mg/hr (she was on Dilaudid too but I forget the dosage, something like 15-20mg/hr). She wasn't intubated. Tragically, the patient was never "comfortable," and in retrospect I wish I had asked the docs to put her on ketamine also. This patient had a long history of IVDA, and likely had developed quite a tolerance. Thankfully I have a palliative care team in my hospital that is "in the know" regarding pain management. Does your hospital have a palliative care team available? Even if they don't, someone you can get a MD or nurse from their group to give a talk at your hospital regarding pain management at end of life. I would definitely talk to your boss . . . this nurse needs some education.
    Thanet and nightshiftnut like this.
  10. Visit  JomoNurse profile page
    4
    i want to be comfortable when i'm nearing my death. titrate my morphine as high as you want as long as i'm not gasping for air. god, what a horrible way to die! can you imagine running out of breath and no being able to get up and do anything about it? awful awful awful.

    I'd MUCH rather being fly high as a kite and comfortable and live for 24 more hours, as opposed to being in respiratory distress for 48 hours.

    no patient on comfort care should ever die because nurses/MDs are afraid to give a high dose of opiods.

    i worked with a nurse that had a end of life patient with morphine. the doctor had written a maxium dosage and it was basically a titrate to comfort order. she absolutely refused to increase the morphine on the PCA to a higher dose because she said that would hasten the patient's death and she wasn't going to do that. fortunately the charge nurse stepped in and increased the morphine, and the patient passed away peacefully and comfortably.

    being a nurse and working in this field has me scared for when my time comes. i'll have no way to intervene. i could have my wishes written down on paper in permanent ink, with MULTIPLE witnesses AND have it tattooed on my forehead and i'd bet i'd still get some douchbag that would make my last moments hell. too many nurses are afraid of pain medicine.
    Last edit by JomoNurse on Aug 27, '09
    Hoozdo, Thanet, nightshiftnut, and 1 other like this.
  11. Visit  PostOpPrincess profile page
    0
    Quote from heron
    Your coworker needs to review the basics of opioid dosing ... the amount needed to produce lethal respiratory depression is different for each patient and can't be known ahead of time until you give the dose and respers drop.

    Would she be more comfortable if the MD gave parameters? ie, hold drip if respers are less than 4/min.

    BTW, although the morphine will likely continue until death, it isn't the morphine that's killing the pt, it's the disease process.
    This is correct. You did good OP.
  12. Visit  summerrose_10 profile page
    3
    NurseyPoo7 you did what any caring and compassionate nurse should do for end of life care. Keep the patient comfortable, hence the name COMFORT CARE. It is the disease process that is killing her, not the medication your giving.
    There are several hospice rooms on my wing, and thankfully several experienced hospice nurses. It is a shame there are so many nurses/md's that are not educated in end of life issues. There is no such thing as "causing addiction"...during this last journey of life.
    When my sister-in-law died of lung cancer, we were pushing 10mg of morphine q10minutes prn. The doses at end of life do seem high for the uninformed/inexperienced. You did the right thing in increasing the dosage, and it was fortunate this patient had you as her advocate. Keep up the good care.

    p.s. you may want to question pulse ox use in hospice care. what do you do with this info? is o2 being monitored per family request,facility policy?..
    Thanet, justiceforjoy, and leslie :-D like this.
  13. Visit  shaCNS profile page
    0
    Sometimes I think people purposely wait until someone leaves to "go."
    I am certain they do!
    My mother-in-law did too. We had all been in to visit: her 4 married children, and their spouses and their children. After we left, my father-in-law went to visit and after he left, he didn't even get to his car when he got the phone call to say that she had gone. We were only half way home ourselves.
    She died in a hospice and I will always be greatful to the dedicated staff who made her last days so comfortable.
    I work on a medical ward and sometimes our patients are dying. I believe dying with dignity and being comfortable are far more important than worrying about whether this next dose of morphine will "nock her off". The patient is going to die anyway. Morphine MAY "hasten the inevitable" but it id the disease NOT the drug which is killing trhe patient.
    Go ahead and give the medication: make your patients last days/hours comfortable.
    (Their family will thank you for it)
  14. Visit  rngolfer53 profile page
    0
    Quote from NurseyPoo7
    We have a comfort care/end of life set of orders at our hospital . I had a patient last night who was on this gtt - all day the nurse had kept her on 2mg/hr - when I got out of report, I went to assess the pt who had labored resp ... the morphine gtt had an order which states what to start the gtt at (usually 1mg/hr) and titrate PRN for discomfort/respiratory issues Q 15min - u can increase the gtt by the current dose + 25% of that dose. There is no "limit" set on the order sheet. Throughout the night she would have labored resp... pulse ox was always ok (usually 93-94% on NC). When day shift nurse came back I told her I had titrated the drip up to 8.5 and she could probably use another increase since she was starting to become labored again. Nurse looked @ me like I was a murderer and basically told me I was hastening this womans death.

    Any advice on this? Is there something I am missing here? Whats the point of being on a morphine drip with titration orders if u arent going to use it?
    I can't add much to what other nurses have said, except my praise to you for keeping your Pt comfortable, which was the purpose of the orders.

    Good job.


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