Morphine gtts- end of life

txspadequeenRN, BSN, RN · Jun 17, 2008

the highest dose of roxanol i ever gave was 1cc (20mg/ml) every 15 min for a woman dying of cancer and that was not enough. thank the good lord she did not last long...

nrsang97, BSN, RN · Jun 17, 2008

I have seen MS gtts as high as 10mg/hr. Usually they are written for us as a range order like MS gtt 2-8mg/hr titrate as needed for comfort or to keep RR

txspadequeenRN, BSN, RN · Jun 17, 2008

are you referring to peds or adults?

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!

lvnsandiego · Jun 17, 2008

I worked hospice for 3+ years and our protocol for the morphine sulfate gtts was Roxanol 20mg/ml: give 5mg SL PRN q2h for mild BTP/SOB, 10 mg SL PRN q2hr for mod. BTP/SOB, 20 mg SL PRN q2h for severe BTP/SOB. We would go up from there, depending on the medication's effectiveness and pt's tolerance. Sometimes we would give it more frequently (q1h) or just increase the dose a bit, usually not more than 30 mg q2h for intractable pain/resp. distress cases. If they need lots of this PRN then their routine pain meds aren't effective.

leslie :-D · Jun 17, 2008

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!

everyone is going to present differently.

you are supposed to titrate until pain-free, less the drowsiness.

some pts are ok w/30 mg q4h, where others need 300mg bid.

there is no ceiling if titrated and monitored carefully.

i have given sev'l hundred mgs of morphine over 24 hrs.

leslie

Sue Damones · Jun 17, 2008

are you referring to peds or adults?

adults. sorry about that. :)

TazziRN, RN · Jun 17, 2008

I lost a CA pt recently that I'd gotten close to. I started him out at 6mg/hr with 3mg boluses q15min. Three weeks later, when he died, he was at 14mg/hr with 8mg boluses and it wasn't touching him. At the time of death he was on a Fentanyl drip in the hospital.

What got to me was the last day I saw him. I was sent in to draw a blood sample, and when I walked in he looked like death warmed over. His systolic was in the 60's and he was cold. I called the doc, then called 911. I know they were just following protocol, but the medics made me remove the morphine "in case that was why he was hypotensive." I pulled the medic aside and tried to explain that the pt was shutting down, not stoned, but he had to follow his protocol. Within minutes the pt was beginning to writhe in pain.

GrumpyRN63, ADN, RN · Jun 17, 2008

I lost a CA pt recently that I'd gotten close to. I started him out at 6mg/hr with 3mg boluses q15min. Three weeks later, when he died, he was at 14mg/hr with 8mg boluses and it wasn't touching him. At the time of death he was on a Fentanyl drip in the hospital.
What got to me was the last day I saw him. I was sent in to draw a blood sample, and when I walked in he looked like death warmed over. His systolic was in the 60's and he was cold. I called the doc, then called 911. I know they were just following protocol, but the medics made me remove the morphine "in case that was why he was hypotensive." I pulled the medic aside and tried to explain that the pt was shutting down, not stoned, but he had to follow his protocol. Within minutes the pt was beginning to writhe in pain.

I don't understand this scenario, he was at home(it seems)?, still getting bloods drawn,? at end of life and 911 was called? was he not a DNR at home to die?

TazziRN, RN · Jun 17, 2008

No, he wasn't a DNR. He refused Hospice and DNR, even though we all (his family included) knew it wouldn't be long. He was on home health services to manage the morphine drip. He was getting packed cells every couple of weeks in the clinic but this day he was in too much pain to be moved from home. I was asked to go in and draw a CBC to check his count. If he refused to sign a DNR then we had to do everything.

GrumpyRN63, ADN, RN · Jun 17, 2008

What a tough spot, the thought of having to resuscitate someone at that stage is horrible, thanks for clearing it up , BTW, what was the f/u, did he die, did he get coded?

TazziRN, RN · Jun 17, 2008

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.