Syringe driver terror

[milly]

Hello

I know that there will be allot of people disagree with me here

Am I only nurse that is quite simply terrified of syringe drivers?

I just feel like I'm helping someone die. I didn't want to be a nurse to help someone die.. I wanted to be able to provide comfort and health..

Are they really agents of death?

How can you make peace with it all ?

Please help me.. If got to get involved with it all tomorrow and I can't sleep..and I'm on the verge of a panic attack already..

Milly

[Julius Seizure]

What is a syringe driver? Just a pump that infuses syringes of medication, or something else?

[TriciaJ, RN]

Julius Seizure said:

What is a syringe driver? Just a pump that infuses syringes of medication, or something else?

I'm thinking it's like a PCA without the patient controlled part. Like a PCA with a basal rate only.

[HeySis, BSN, RN]

Julius Seizure said:

What is a syringe driver? Just a pump that infuses syringes of medication, or something else?

Yes, we don't call them that at our facility... if they are using a syringe full of morphine, fentanyl or some kind of "caine" we call it a PCA. Anesthesia uses them to keep giving a steady drip of propofol in the OR.

I had a patient once that was using a PCA and the amount of morphine he was getting per hour would have taken down baby elephant... but he had been on morphine so long and was in serious pain that he was still awake and talking. It's not the medication that killed him... it was the brain tumor. By keeping the morphine PCA continuously giving him morphine and then allowing him to bolus himself (and clinician boluses on top) we allowed him to spend some valuable time with his family, rather then writhing in pain.

[Agatha12]

Are you going to take part in assisted suicide or whats the problem? Syringe driver is just a type of pump. I have no idea why just syringe with medication involve such emotions?

[hppygr8ful, ASN, RN, EMT-I]

milly said:

I had hoped for some encouragement..

Iv hardly slept. Can hardly breathe and I just want to cry.. Hoping beyond all hope that I manage to survive today without a panic attack.

Perhaps you could be more specific about what is causing your panic. When my son was born he went straight to the NICU seizing and a similar device was used to titrate anticonvulsants to that the lowest effective dose could be maintained and he was less tranquilized and had lower chance of complications from those drugs.

I have also seen them used in Hospice situations when they ease the discomfort of the dying process. I had an issue with this practice at first but came to see the benefit of easing the dying persons distress and discomfort during the dying.

Lastly my dad who lived in a very rural area had walking Chemo where he would go to infusion center and the device was attached to his port and he left. The infusion would take two days to infuse rather than 3 hours. He had fewer side effects and the home care nurse would drive out to the farm and disconnect when it was done.

Having seen the benefits of this device I would not have qualms about it's use. Still I think if forum members had a better idea of what is actually causing your distress we could be more supportive.

Hppy

[milly]

I don't suppose it's the machine itself that scares me, iv used them in different ways like sliding scale insulin and heparin infusions, with not an ounce of worry.

The problem comes when it is mixed up with palliative care. Thing being is the vast majority of people who end up with them for that purpose dies. I know there is a school of thought that stat doses and syringe drivers are so very close to euthanasia. That is something that totally adds up when I think about it logically.

It's not about ego. Or a lack of empathy. I want to be able to sleep at night knowing if do e the best for my patient's i can. And for the record I strongly believe that these patients are the people who we need to advocate for more so than any other. But I also want to be safe and protect both them and my own registration.

I don't understand how the rules change so much. For instance morphine in a surgical scenario, if respiration rate is below 12 it is contraindicated as it suppresses the breathing further and that is dangerous.. Yet in a palliative scenario it doesnt seem to matter because they are dying any way...

How do I know that these medications which are very potent and quite a cocktail doesn't play a part in the poor souls demise... I don't know how to wrestle with my conscience on this point. I do indeed plague myself torturing myself wondering if my so called caring act isn't some how killing someone under another guise. And that terrifies me ..I just want to have peace with it. There are hundreds who are incredibly blasea I want to be like that too..

[NRSKarenRN, BSN, RN]

In many areas of US, syringe driver pumps are not used on patient care units due to them not being tamper proof. Instead, self contained CADD PCA pump most popular in Philadelphia PA area as allows patient to be ambulatory or move around in bed more freely.

Examples of syringe driver pumps:

Some articles of interest

Syringe driver pump use and setup:

Syringe Drivers: Setup, Patient Use, Problem solving

Clinical protocol for the use of syringe drivers in Palliative Care

Safe practice in syringe pump management

Guidelines for Syringe Driver Management in Palliative Care

Overcoming fear of administering last dose pain medication hastening death involves coming to terms with ones immortality, understanding disease process in end stage illness, nursing ethics, end of life care and effective medications for symptom management.

Managing Pain in the Dying Patient

Managing end-of-life symptoms - American Nurse Today

84379.pdf

[Rose_Queen, BSN, MSN, RN]

milly said:

The problem comes when it is mixed up with palliative care. Thing being is the vast majority of people who end up with them for that purpose dies.

Perhaps that is because those on palliative care are on it because they are nearing death due to a disease process or old age?

Quote

I know there is a school of thought that stat doses and syringe drivers are so very close to euthanasia. That is something that totally adds up when I think about it logically.

Euthanasia is the giving of medications with the intent to cease life. Palliative care manages the symptoms of a disease process that is nearly at the end of a patient's life. The patient will die regardless; the compassionate, professional way to treat that patient is to relieve the pain, air hunger, and other unpleasant aspects of death.

Quote

It's not about ego. Or a lack of empathy. I want to be able to sleep at night knowing if do e the best for my patient's i can. And for the record I strongly believe that these patients are the people who we need to advocate for more so than any other. But I also want to be safe and protect both them and my own registration.

Doing the best for your patients who have reached the point of palliative care is managing the symptoms. As long as you act within your scope of practice and don't willfully give a dose of medication with the intent to end a life, your license should be fine.

Quote

I don't understand how the rules change so much. For instance morphine in a surgical scenario, if respiration rate is below 12 it is contraindicated as it suppresses the breathing further and that is dangerous.. Yet in a palliative scenario it doesnt seem to matter because they are dying any way...

It has to do with the purpose of the medication and planned path for the patient. In a surgical scenario, the plan is for the patient to return to a better level of health. In palliative care, the goal is to provide a death that is not torturous.

Quote

How do I know that these medications which are very potent and quite a cocktail doesn't play a part in the poor souls demise... I don't know how to wrestle with my conscience on this point. I do indeed plague myself torturing myself wondering if my so called caring act isn't some how killing someone under another guise. And that terrifies me ..I just want to have peace with it. There are hundreds who are incredibly blasea I want to be like that too..

These patients are most likely going to die, and soon, regardless. It is the goal of therapy that matters- to provide a death where symptoms are managed and the patient is kept as comfortable as possible. If this is something you cannot handle, then you would be best served by finding another nursing speciality where you will not work with patients in palliative care.

[Julius Seizure]

milly said:

I don't suppose it's the machine itself that scares me, iv used them in different ways like sliding scale insulin and heparin infusions, with not an ounce of worry.

The problem comes when it is mixed up with palliative care. Thing being is the vast majority of people who end up with them for that purpose dies. I know there is a school of thought that stat doses and syringe drivers are so very close to euthanasia. That is something that totally adds up when I think about it logically.

It's not about ego. Or a lack of empathy. I want to be able to sleep at night knowing if do e the best for my patient's i can. And for the record I strongly believe that these patients are the people who we need to advocate for more so than any other. But I also want to be safe and protect both them and my own registration.

I don't understand how the rules change so much. For instance morphine in a surgical scenario, if respiration rate is below 12 it is contraindicated as it suppresses the breathing further and that is dangerous.. Yet in a palliative scenario it doesnt seem to matter because they are dying any way...

How do I know that these medications which are very potent and quite a cocktail doesn't play a part in the poor souls demise... I don't know how to wrestle with my conscience on this point. I do indeed plague myself torturing myself wondering if my so called caring act isn't some how killing someone under another guise. And that terrifies me ..I just want to have peace with it. There are hundreds who are incredibly blasea I want to be like that too..

OP, I mean this in the most gentle way possible - it is not to be rude or to imply that you are a bad nurse. I'm sure you are a fine nurse.

But...are you sure that palliative care is the right specialty for you? You seem to have a lot of conflict about it. You also don't seem to have a very clear understanding of what palliative care is and what end-of-life care involves. Maybe a different specialty would allow you to have more job satisfaction and better sleep?

[blondy2061h, MSN, RN]

The patients who are receiving palliative care will die with or without symptom palliation. You state you want to do what's best for your patients. In many cases, like the post op patient you describe, that will be managing symptoms to a moderate degree and assessing respiratory status with that to aid their recovery. In palliative care patients doing what's best for the patient is aiding them in a peaceful passing on. It is a different mindset because they are different goals of care.

[macawake, MSN]

milly said:

The problem comes when it is mixed up with palliative care. Thing being is the vast majority of people who end up with them for that purpose dies.

They die because they are palliative patients. They don't die because symptoms like pain, anxiety and excessive secretions are properly treated. If you want to start being more "frugal" regarding how much you ease their symptoms, they will simply die experiencing more agony. But they will still die.

milly said:

I know there is a school of thought that stat doses and syringe drivers are so very close to euthanasia. That is something that totally adds up when I think about it logically.

What school of thought would that be? Is it supported by research?

milly said:

There are hundreds who are incredibly blasea I want to be like that too..

It's not about being blasé. I do wonder if there wasn't a little accusatory barb hidden somewhere in that statement?

milly said:

I don't understand how the rules change so much. For instance morphine in a surgical scenario, if respiration rate is below 12 it is contraindicated as it suppresses the breathing further and that is dangerous.. Yet in a palliative scenario it doesnt seem to matter because they are dying any way...

I don't know what kind of surgical scenario you're referring to, but it's certainly not the surgery itself. I assume you mean pain management for a patient recovering from surgery?

Why is it that you find it hard to accept that rules can change somewhat depending on the circumstances?

If you have a patient who is expected to live after they recovered from whatever is causing them pain, it makes sense to not take any risks at all that could negatively affect them. The risk versus benefit might in that scenario make it good practice to withhold opioids or other central nervous system depressants for the moment when they have a respiratory rate of ten. Not that you'd likely kill them just by giving them one more postoperative pain pill (whatever is prescribed), but because even the small risk involved might be considered to outweigh the benefit.

Personally I think the risk-benefit assessment changes when the potential benefit is much smaller and the potential for harm is much greater (human suffering while knowing all along that there is no chance for recovery or health at the end of the suffering). Having a strict rule, RR

milly said:

How do I know that these medications which are very potent and quite a cocktail doesn't play a part in the poor souls demise... I don't know how to wrestle with my conscience on this point. I do indeed plague myself torturing myself wondering if my so called caring act isn't some how killing someone under another guise. And that terrifies me ..I just want to have peace with it.

I don't think you can know. The research I've seen doesn't at all suggest that adequately treating symptoms in the dying patient hastens death, but how can anyone know it (as in 100% certainty) for a fact in every individual case?

Reading your post, I feel that you are making this all about you and your conscience. I've said this a hundred times before. Nursing is about the patient, it's not about the nurse.

I assume that you're new to palliative nursing? I don't work with palliative patients but I do work with treatment of pain in a sense. I wonder since treating your patients adequately causes you this seemingly high level of distress, that perhaps this field isn't the best fit for you?

I'm hoping that nurses who specialize in end of life care can offer you some helpful advice.

TriciaJ said:

I'm thinking it's like a PCA without the patient controlled part. Like a PCA with a basal rate only.

Pretty much. Although it's absolutely possible to give boluses with the syringe driver/infusion pump (and change the infusion rate). I don't know if they habitually give boluses in palliative care where I assume that they administer the meds subcutaneously and I'm guessing (?) that they might mix several compatible meds in one syringe. Several meds in one syringe would make boluses tricky as you might not want to give extra of all.

In the OR I have the drivers connected to an intravenous line. I have my syringe driver pumps "stacked", mounted on an IV pole and most often they all just contain one med each so I can have full control of the individual rates and boluses. The difference between a syringe driver and a "regular" infusion pump is basically that you draw up the medication in a syringe which you "place"/connect to the pump. With the other pumps you use medication in a bag or bottle.

We also use them in all ICUs, (NICU, PICU, adult) for basically all meds apart from hydration and nutrition.

[milly]

How do you achieve that mindset? Without being terrified of killing someone?