Morphine and End Of Life

If a nurse follows an order that is intended to kill a patient, how can she possibly be covered legally? Specialties Geriatric Article

I have a question, or a scenario rather that I have recently come across.

Recently at work, I had a hospice patient who was unresponsive with respiration between 7-8 bpm with long periods of apnea. Resident was thought to be in the "active" dying processes and had a order from hospice was to give morphine every two hours. I held the morphine due to hypo-ventilation and decreased LOC and notified the MD.

MD asked if he was in pain and I said there was nothing to suggest he was and that I was going to hold the medication. Fast forward several hours and the hospice nurse came to check the patient. I notified her that the morphine was held. She told me I need to give it anyways.

When I said that I was withholding it due to the risk of resp arrest. She said "that's kinda the point. He wants to die." And insisted that I must give the medication. She said that hospice could write an order to cover giving the medication regardless of resp rate.

Is this ethical?

If a nurse follows an order that is intended to kill a patient, how can she possibly be covered legally?

Hospice is not assisted suicide and if it is not explicitly for pain control, I will not give a lethal dose of morphine to hasten the dying processes.

My question to you guys is, do I have rights?

I should not be forced to do something illegal and immoral against my will. She took down my name and I think she is going to complain but I am stunned that she really thinks it is our job to medicate these patients into the grave.

I am not in the habit of assisting suicide or causing the death of another person. Am I too emotional about this situation or does this seem reasonable to you guys??

Specializes in Peds Homecare.

I totally agree with you Melissa. If the patient was resting quietly, with none of the usual outward signs of pain, and with a resp. rate of 7 to 8, with periods of apnea, I too would have held the morphine. Let's all remember the first side effect taught to us about morphine, is respiratory depression. If the hospice nurse wanted him to have it, let her give it. Giving the morphine would have certainly depressed his respirations further. The doctor didn't have a problem with it when you notified him, last I knew the dr. over rules that nurse. Oh, and thinking on your feet, good job.

1 Votes
Asystole RN said:
A common misconception is that giving morphine during the actively dying stage will hasten death.

Morphine is not given to only reduce pain, interestingly enough. Morphine reduces the amount of catecholamines that circulate, the anxiety fight or flight hormones that the body produces in times of severe stress such as in the dying process. Morphine also relaxes cardiac tissue which lowers the cardiac cell's demand for oxygen, remember the term MONA for MIs? The overall decrease in the patient's stress may account for the increased duration of the actively dying process in patients receiving proper analgesia.

During the active dying process you cannot accurately assess pain in a patient through visual, sometimes even physical assessments. As the brain starts shutting down typical responses to pain such as grimacing or anxious movement may no longer be present. I see this a lot in my current practice, we have a large population of persistive vegetative patients who elicit non typical symptoms to pain. A cardinal sign of pain in the actively dying person is labored OR irregular breathing patterns.

After a patient has been receiving morphine for several days the risks of respiration depression significantly lessen, especially in the dying patient. The stress of the dying process will actually activate the respiration drive, countering any respiration depression by the morphine. Morphine has no ceiling dosage of maximum effect, in theory the more you give the more pain is controlled, unlike other analgesics which work only so much. This is one of the reasons why morphine is considered the gold standard. I have seen patients literally on hundreds of mg of morphine per hour and still keep-on-a-ticking.

Your goal is to assist the patient to die in a dignified manner, peacefully and without pain. I am sorry that the hospice nurse misinformed you that the idea was to terminate life, obviously there was a lack of education and training. Sometimes we must do things that place the patient at significant risk of life in order to fulfill their health related goals. The nurse's intention is what primarily drives the ethical dilemma. If a patient with an illness wishes to undergo a radical surgical procedure with a 98% chance of death on the operating table there would be no ethical wrongdoing in helping the patient, it would be considered helping the patient keep hope alive. In fact this is what we are doing for the terminally ill, helping the patient die in a dignified manner is keeping their hope alive.

Always ask yourself, is this what the patient wanted? Your ethics, morals, religion, and values should have no bearing whatsoever on the patient, you are their advocate, not your own. This is the burden we bear as nurses we when were privileged with a license to serve our patients.

Things to consider on the ethics of the situation - ANA Code of Ethics

Provision 2

2.1 Primacy of the Patient's Interests

The nurse's primary commitment is to the recipient of health care services...When the patient's wishes are in conflict with others, the nurse seeks to help resolve the conflict. Where conflict persists, the nurse's commitment remains to the identified patient.

Provision 1

1.3 The nurse should provide provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail substantial risks of hastening death.

P.S. There is much research out there on the actively dying process, analgesic use during the end of life process etc. This seems like an excellent time to research the topic. The Hospice and Palliative Care Nursing Association (HPNA) and the American Nurses Association (ANA) have excellent resources on the subject.

Thank you, very informative and well written to boot

1 Votes
Asystole RN said:
A common misconception is that giving morphine during the actively dying stage will hasten death.

Morphine is not given to only reduce pain, interestingly enough. Morphine reduces the amount of catecholamines that circulate, the anxiety fight or flight hormones that the body produces in times of severe stress such as in the dying process. Morphine also relaxes cardiac tissue which lowers the cardiac cell's demand for oxygen, remember the term MONA for MIs? The overall decrease in the patient's stress may account for the increased duration of the actively dying process in patients receiving proper analgesia.

During the active dying process you cannot accurately assess pain in a patient through visual, sometimes even physical assessments. As the brain starts shutting down typical responses to pain such as grimacing or anxious movement may no longer be present. I see this a lot in my current practice, we have a large population of persistive vegetative patients who elicit non typical symptoms to pain. A cardinal sign of pain in the actively dying person is labored OR irregular breathing patterns.

After a patient has been receiving morphine for several days the risks of respiration depression significantly lessen, especially in the dying patient. The stress of the dying process will actually activate the respiration drive, countering any respiration depression by the morphine. Morphine has no ceiling dosage of maximum effect, in theory the more you give the more pain is controlled, unlike other analgesics which work only so much. This is one of the reasons why morphine is considered the gold standard. I have seen patients literally on hundreds of mg of morphine per hour and still keep-on-a-ticking.

Your goal is to assist the patient to die in a dignified manner, peacefully and without pain. I am sorry that the hospice nurse misinformed you that the idea was to terminate life, obviously there was a lack of education and training. Sometimes we must do things that place the patient at significant risk of life in order to fulfill their health related goals. The nurse's intention is what primarily drives the ethical dilemma. If a patient with an illness wishes to undergo a radical surgical procedure with a 98% chance of death on the operating table there would be no ethical wrongdoing in helping the patient, it would be considered helping the patient keep hope alive. In fact this is what we are doing for the terminally ill, helping the patient die in a dignified manner is keeping their hope alive.

Always ask yourself, is this what the patient wanted? Your ethics, morals, religion, and values should have no bearing whatsoever on the patient, you are their advocate, not your own. This is the burden we bear as nurses we when were privileged with a license to serve our patients.

Things to consider on the ethics of the situation - ANA Code of Ethics

Provision 2

2.1 Primacy of the Patient's Interests

The nurse's primary commitment is to the recipient of health care services...When the patient's wishes are in conflict with others, the nurse seeks to help resolve the conflict. Where conflict persists, the nurse's commitment remains to the identified patient.

Provision 1

1.3 The nurse should provide provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail substantial risks of hastening death.

P.S. There is much research out there on the actively dying process, analgesic use during the end of life process etc. This seems like an excellent time to research the topic. The Hospice and Palliative Care Nursing Association (HPNA) and the American Nurses Association (ANA) have excellent resources on the subject.

Wonderful post. I hope that should myself or someone in my family ever require hospice/end of life care that we have a nurse like you to take care of us and not someone that is afraid of medicating a dying patient ?

1 Votes
Specializes in LTC.

Please forgive me if I repeat anything from other responses for I did not read the other posts.

I have worked with actively dying patients and hospice. When I was brand new on the job I had my personal fears and anxiety about administering morphine. I understand your concerns and I want to address them the best way I can.

When a patient is actively dying morphine is the drug of choice because it makes them more comfortable. It minimizes their pain and also help them to have unlabored breathing. Morphine is never used to "kill " a patient. It is simply to make them more comfortable. To hold morphine on an unresponsive actively dying patient is unethical to me. Yes morphine depresses the CNS and slows respirations however at this stage in the patients life this is what we want. I rather my actively dying patient to have a respiration rate of 7-8 than to have a rate of 30 and gasping for air. I hope this helps.

I do disagree with the nurses' response to you. She should have given you a more in depth about the indication of morphine for this client.

0 Votes
Specializes in LTC.

So I read all the posts and I see that the nurses are 50/50 on this one. I think some people are missing the point. The patient is UNRESPONSIVE and ACTIVELY dying. I've had patients like this and I have had orders to administer morphine q1h as well as q2h. Asystole gave an excellent explanation of why this is needed for our actively dying patients. Nurses do a terrible job at controlling pain for hospice patients at times for this very reason of feeling like they are hastening death by giving the morphine. It is not about us or our fears it is about providing comfort measures for the pt.

Once again we need to focus on this patient here.

I have been where the OP has been before. We had a pt. on hospice and the hospice nurse wanted an order for morphine q6h. However this patient was NOT actively dying. She still talked, walked, ate, and did things for herself and showed no s/s of pain. So I as her nurse questioned the order and had the MD make it PRN. My point is we have to look at the patient. Not every patient on hospice is actively dying and need morphine ATC.

0 Votes

I, personally, am a supporter of liberal medication use in hospice patients. It's not that we want to hasten death, but to keep them comfortable rather than waiting for exacerbation of symptoms before dealing with them. In this case, you really have to consider the dose and the history of morphine administration. Remember that constipation is the only side effect of morphine to which tolerance does not develop. I have seen chronic patients on doses of morphine that would snow a horse in bright-eyed, bushy-tailed states that would blow your mind. If the patient is receiving the same dose (or dose range) Q2H and has been for a number of days (i.e. a steady state is being maintained), then continuing with the established regimen is not going to exacerbate respiratory depression. I would have held the med only if there were signs of declining hepatorenal function as this would indeed cause blood levels to rise due to decreased metabolism and excretion, resulting in side effects.

1 Votes
Specializes in MICU/SICU/CVICU.

I just want to take a moment to congratulate AsystoleRN for a wonderful response. There is so much misinformation about the dying process and hospice care in general within the acute care setting. Morphine isn't given to "hasten" death: it's given to ease the transition to inevitable death. Our focus changes from fixing the problem and "saving" the patient to accepting nature's course and allowing for their passing to be more comfortable. That is a role change that can be extremely hard for some bedside, hospital-based nurses to adapt to.

1 Votes
Specializes in CVICU.

I can't really add much to asystoleRN's post except to say that in a patient with intractable pain, as happens sometimes with hospice patients, it's essential to stay on top of the pain. Once the patient is at a manageable level of comfort, you can't let the pain break back through or you'll have quite a fight on your hands trying to get it back under control. The patient may have appeared to be comfortable at the time, but it's not necessary to wait for distress - keeping pain away is as important as treating it when it shows up.

And...everything else I agree with in asystoleRN's post.

1 Votes
Specializes in Trauma Surgical ICU.

Thank you for the info provided.. It was very helpful..

1 Votes
Specializes in Cath Lab/ ICU.
iceprincess868 said:
Wonderful post. I hope that should myself or someone in my family ever require hospice/end of life care that we have a nurse like you to take care of us and not someone that is afraid of medicating a dying patient ?

100% agree. I cringed after reading the OP. Cringed. How terribly sad for this particular patient. This person is DYING for goodness sake! Give them their morphine!

NurseLoveJoy88 said:
Please forgive me if I repeat anything from other responses for I did not read the other posts.

I have worked with actively dying patients and hospice. When I was brand new on the job I had my personal fears and anxiety about administering morphine. I understand your concerns and I want to address them the best way I can.

When a patient is actively dying morphine is the drug of choice because it makes them more comfortable. It minimizes their pain and also help them to have unlabored breathing. Morphine is never used to "kill " a patient. It is simply to make them more comfortable. To hold morphine on an unresponsive actively dying patient is unethical to me. Yes morphine depresses the CNS and slows respirations however at this stage in the patients life this is what we want. I rather my actively dying patient to have a respiration rate of 7-8 than to have a rate of 30 and gasping for air. I hope this helps.

I do disagree with the nurses' response to you. She should have given you a more in depth about the indication of morphine for this client.

Me too. Totally unethical. In the case of the OP, it's an lack of education, instead of malicious intent. Hopefully, the OP can gain some hospice education and learn from this.

1 Votes
Specializes in LTC.

Many of the Hospice patients that I have seen coming into the LC where I work are often in alot of pain prior to the actual final dying process. When they are in the final stage as your patient was I assume the pain is present even though there are no outward signs from the patient. Yes, I would have given the morphine, not to hasten death but to keep the patient comfortable.

OP this sounds like a learning situation for you. You should probably find more information on why morphine is used for dying patients and reasoning behind it. If you still feel uncomfortable with the situation then maybe a different job would better suit you.

1 Votes
Specializes in LTC.

Sorry this is to address my previous post. LC is LTC. After reading the post I do apologize for sounding short with you OP. What I meant was there are many different areas of nursing. If something like this feels like it goes against your ethics then maybe another area would be a better fit. It would be hard to do a job that goes against your own personal beliefs.

1 Votes
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