Morphine gtts- end of life

Nurses General Nursing

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When using Morphine gtts on end of life/comfort care patients, what is the typical dose that you see ordered or titrated to? How high have you titrated in these patients?

Thanks!

He agreed to a DNR and passed away two days later with his family at his side.

The part that makes me cry is that he was scared to death of the pain. That's why he refused hospice, because he thought that when hospice stops everything, they stop everything. I asked his wife afterwards if his pain was ever brought under any control and she said No.

so the fentanyl drip didn't help either?

either way, this is precisely what i mean about titrating until pain is relieved:

and, that everyone presents differently.

an md experienced in pain mgmt, would have kept on increasing dosages (regardless of amt) until pt reported relief.

these types of stories really upset me.

leslie

Specializes in Gyn Onc, OB, L&D, HH/Hospice/Palliative.
He agreed to a DNR and passed away two days later with his family at his side.

The part that makes me cry is that he was scared to death of the pain. That's why he refused hospice, because he thought that when hospice stops everything, they stop everything. I asked his wife afterwards if his pain was ever brought under any control and she said No.

Thank God he was a DNR at the end, but it seems if Hospice services and philosophy were explained properly to him and his family, a lot of needless pain and suffering could have been avoided :scrying:, and a lot of good interventions and support systems could have been involved to give him much better quality of life instead of wasting his precious last weeks trapsing back and forth to the md's for no benefit to him and less time with his family

Specializes in Critical Care, Progressive Care.
He agreed to a DNR and passed away two days later with his family at his side.

The part that makes me cry is that he was scared to death of the pain. That's why he refused hospice, because he thought that when hospice stops everything, they stop everything. I asked his wife afterwards if his pain was ever brought under any control and she said No.

How horrid. I am glad you were there for him Tazzi.

May his memory be eternal!

Specializes in Hospice.

Hospice nurse here ... having worked in both hospice and on a dedicated AIDS unit, I've given pretty honkin' doses of morphine.

The highest oral dose I've given was 6ml Roxanol (120mg) as a prn to a lady dying of ovarian ca. The highest long-acting morphine dose was 240mg q8hrs.

The highest drip I've run was 750+ mg/hr to an AIDS pt -- an addict on high doses of methadone that needed to be compensated for when he became unable to swallow.

30+ years ago, while taking care of sickle cell pts., I began reading abt. pain management. One the books I had then cited a case of a young man receiving 1500mg/hr ... and still up walking around!

It's inherent to opiates that tolerance will develop. Luckily, the therapeutic window ... the range between the effective dose and the lethal dose ... remains unchanged, so as tolerance develops, the lethal dose rises. This is why there is no absolute ceiling to morphine dosing.

As Leslie pointed out ... we can't play it by the numbers. We keep dosing until relief is achieved or unacceptable side effects kick in ... oversedation, drug toxicity or depressed VS.

If I'm dealing with a pain emergency and have to play "catch-up" I expect to have to dose just to the point of sedation. A patient who's been in severe pain for days is exhausted and will often sleep for a considerable time when the pain is relieved. So, I've learned to do so and as the pt wakes up, back off to where the pt can wake up but still be pain free ... thus we find our maintenance dose. This can get tricky, so a strategy of dosing before pain gets severe, to prevent pain rather that suppress it, is really the best way to go about it ... pain is controlled with lower overall doses than when you have to get on top of pain that is already out of control. Getting an untrained MD to do this can be an adventure. It can get more interesting still if your pt has developed "pseudo-addiction" behaviors or is a known/suspected "seeker".

These kinds of numbers can scare the dickens out of people and this is why you really need MDs who are trained and experienced in pain mgt. You also need nurses to have the time/flexibility to watch pts. closely. Getting on top of severe pain can involve 1:1 care as you dose q15min. and monitor response, communicate w/ the MD or change to a different drug that might be more effective, ie from morphine to dilaudid or fentanyl. It's ICU-level care without the ICU staffing or support.

Specializes in Critical Care, Progressive Care.
One the books I had then cited a case of a young man receiving 1500mg/hr ... and still up walking around!.

Thank you for the great post. Sadly the knowledge you have is not widespread.

I stand in awe of the fact that we have drugs that can safely relieve any pain when properly administered. And I cannot help but be angry that so many people die in pain.

One the books I had then cited a case of a young man receiving 1500mg/hr ... and still up walking around!

a few yrs ago, i had a guy who was receiving approx 700mg/hr iv morphine, and he continued to scream in anguish.

doc wanted me to keep on titrating...

i contended that if morphine wasn't touching him now, what were the chances of it helping at a higher dose?

he ended up w/iv propofol...

leslie

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