Morphine and End Of Life

[MelissaLPN]

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??

[ErinS, BSN, RN]

Just my two cents. It is important to remember that a patient who is actively dying may no longer show those 'typical' signs of unmanaged pain. In fact, many patients who are alert do not show sings of unmanaged pain. However, an actively dying patient who has been on routine morphine was likely started on that morphine for a reason. If the source of the pain has not gone away (for example, pain from a tumor, and the tumor is still there), it is safe to assume the pain has not gone away. I encourage you to err on the side of symptom management instead of fear when caring for a dying patient. I hope this helps, and I am sorry the hospice nurse was abrupt. Being a hospice nurse myself, it can be harrowing to face the same questions about practice day in and day out, but it is our job to provide that education that allows you to feel that what you are doing is ethical.

[nurse2033, MSN, RN]

I'm amazed at the variety of responses to this thread. As a group we seem to have widely differing views on this. I would just say, don't be blinded to points of view outside your own. It's the patient we need to focus on, and the family. I recently had a dying patient and the family was just begging for more meds to end (as they saw it) her suffering. I had no problem with given dilaudid and ativan that was ordered by the physician. The patient had been in agony from a necrotizing tumor. In this case I was lucky in that the patient's needs and the family's need were in alignment. They were so thankful that I was in there every 20 minutes or so giving meds. After talking with the doctor we turned off her dilaudid PCA and went to PRN pushes, just to avoid overdosing her into arrest. I can say I felt really good about her care when I went home. She died peacefully surrounded by family, isn't that what we all would want?

[07302003, ASN, RN]

OK Hospice RN's, Chappy had a good point...

If a patient is experiencing progressive, end of life hepatorenal dysfunction, does this change the need for ATC morphine, if the body isn't able to eliminate it?

I know every case is different, but I'm just curious if that comes into play sometimes.

[07302003, ASN, RN]

From the point of view of a med-surg or critical care RN, where we are focused on saving lives and patient safety, it is hard to switch to hospice-care frame of mind when we are assigned an in-patient on hospice. Although I do everything to make sure the patient is comfortable, the family is taken care of, and advocate for more drugs when necessary, twice I felt like my IV push of morphine put the patient over the edge, since they died soon after, and it was not a good feeling. I actually felt pretty awful.

And my whole reason for writing that was to point out that most of us have a specialty, competency in a certain area. Many of us were lucky to find mentors to help us grow professionally. When hospice is not your specialty then you're just doing the best you can, and it's very hard (especially on med surg when you have one patient in hospice actively dying and 5 other patients with all kinds of issues). Hospice RN's show up at our hospital, talk to the family, write orders, but there's no one in-house to use as a resource or bounce issues off of.

I work at a small hospital now, but when I was at a bigger hospital hospice patients went to the oncology floor - the staff there had more end of life expertise than, for example, the nephrology floor...

[Chin up]

07302003 said:

From the point of view of a med-surg or critical care RN, where we are focused on saving lives and patient safety, it is hard to switch to hospice-care frame of mind when we are assigned an in-patient on hospice. Although I do everything to make sure the patient is comfortable, the family is taken care of, and advocate for more drugs when necessary, twice I felt like my IV push of morphine put the patient over the edge, since they died soon after, and it was not a good feeling. I actually felt pretty awful.

And my whole reason for writing that was to point out that most of us have a specialty, competency in a certain area. Many of us were lucky to find mentors to help us grow professionally. When hospice is not your specialty then you're just doing the best you can, and it's very hard (especially on med surg when you have one patient in hospice actively dying and 5 other patients with all kinds of issues). Hospice RN's show up at our hospital, talk to the family, write orders, but there's no one in-house to use as a resource or bounce issues off of.

I work at a small hospital now, but when I was at a bigger hospital hospice patients went to the oncology floor - the staff there had more end of life expertise than, for example, the nephrology floor...

I gave you kudos and am so glad you wrote this post. I admit, when I read the OP post, I immediately said, I hope she is never my nurse. I then kept reading, and saw more nurses saying, she did the right thing and knew I was in trouble. I am getting up in years and I want to die comfortably and want my wishes kept. Give me my drugs please. But then the whole tone changed, and I was very glad to see other nurses coming around to what I wanted to hear, but in the meantime forgetting about the OP and her intentions. And even though I don't agree with her, your post brought understanding from her perspective. I know she did what she felt was right and she should not be demeaned in anynway. I hope we all learned something, it really is not about us and our rights, but the patients. None of us know everything, but we are learning new things every day that will help us help our patients.. Peace!

[Asystole RN]

07302003 said:

OK Hospice RN's, Chappy had a good point...

If a patient is experiencing progressive, end of life hepatorenal dysfunction, does this change the need for ATC morphine, if the body isn't able to eliminate it?

I know every case is different, but I'm just curious if that comes into play sometimes.

Morphine once administered is quickly metabolized by the liver into the metabolite (90% conversion), morphine-6-glucuronide (M6G) and morphine-3-gluuronide (M3G). M6G accounts for 10-15% of the morphine administered and has profound analgesic effects. M3G composes about 45-55% of the morphine administered and is a CNS stimulant, increasing M6G's analgesic effects and antagonizing respiratory depression.

Renal impaired patients will clear morphine and only show transient elevated rates. However, the metabolite M6G is slowly cleared and high doses for several days may induce opioid intoxication.

Hepatic impairment may reduce morphine clearance and metabolite production. The half-life of morphine may be doubled in these patients.

That being said, studies have shown that increased opioid administration in the end of life process actually increase survival rates. I refer specifically to the study by

Bengoechea, I., Gutiérrez, S., Vrotsou, K., Onaindia, M., & Lopez, J. (2010). Opioid Use at the End of Life and Survival in a Hospital at Home Unit. Journal of Palliative Medicine, 13(9), 1079-1083. Retrieved from EBSCOhost.

Their study found that patients who received at least twofold increases in their initial doses of opioids survived for a median of (22 days) vs those who did not (9 days).

To truly titrate doses of morphine in hepatic and renal failure one would have to draw blood levels of morphine, M3G, and M6G to identify areas of poor production or increased retention.

The vast majority of the terminally ill during the actively dying stage suffer from some sort of hepatic or renal failure. Titrating dosages at this stage may be unnecessary, expensive, and contrary to primum non nocere (first, do no harm). Drawing blood for the purpose of titrating levels is counter to the palliative care philosophy.

In palliative care the priorities of the nurse shift from safety first to comfort first. Any intervention that poses a risk to comfort is contraindicated, even if the patient is placed at substantial risk of life.

[ronpanzer]

Melissa,

The differing responses are both correct, because the information given is not sufficient to really know what was going on with the patient. To correctly determine the proper course, we would need to know why the morphine was being given exactly and have some information on the clinical needs of the patient.

Morphine is given ATC for controlling pain and should be continued even if there is no sign of pain, if there had been severe pain that is now well-handled. The lack of outward sign of pain would indicate good palliation of that condition. The appropriate response would be to check the chart or ask family nearby and learn what the patient's prior condition was. If the patient had been in pain that was now well-controlled, continuing it would be completely appropriate and professional and you would not be hastening death by giving it.

On the other hand, there are circumstances where morphine is given, when there is no pain, expressly to hasten death, and to pretend it doesn't happen is really naive. It doesn't happen in all hospices, but it happens in some, and there have been articles in the news about such cases. We are not here to kill, but to care for our patients. Euthanasia is illegal in every state in America. Giving a medication that would certainly prove lethal, if inappropriate, is not part of what we do, and that is part of the code of nursing in every state.

Yes, the intent is important and the clinical condition of the patient needs to be known or determined.

If a patient is comatose and apneic due to morphine overdose, and is not truly actively dying from an illness, then holding the morphine can be appropriate. If it never happened, why would every hospice "emergency kit" of medications contain Narcan to be titrated in the relief of that overdose. I've seen a patient who got a cartridge of morphine that was twice the concentration ordered by the MD and only because other nurses held that incorrect dosage was the patient saved.

Morphine can prematurely end the life of a patient if not given when clinically indicated. On the other hand, it is a true blessing to those in severe pain. And patients do become apneic with widely varying respiratory patterns at the end-of-life due to many different metabolic conditions caused by organ and system failures.

Millions of hospice patients have safely been given morphine (or other opioids) for severe pain and have had their suffering lessened thereby. To relieve suffering at the end-of-life is the mission of hospice as envisioned by Dame Cicely Saunders.

Ron Panzer

Pres., Hospice Patients Alliance

http://www.hospicepatients.org

[Heidi the nurse, BSN, RN]

Actually, euthanasia (actually assisted suicide) is legal in Oregon, Washington and Montana. There is a procedure to go through to obtain the medications for it, but it isn't illegal.

[ronpanzer]

Euthanasia and assisted suicide are not the same. Assisted suicide is when a physician writes the order for a lethal medication and the patient takes its himself or herself. Euthanasia (active) is when someone (usually a physician or nurse) gives a lethal medication with the intent to end life. Euthanasia is illegal in every state in the United States.

The original question dealt with questions about the ethical nature of giving the medication. In the case cited, the nurse had to evaluate whether to give the medication or not. The patient was not taking the medication by herself/himself to end his own life (assisted suicide).

There is a huge difference between assisted suicide and euthanasia in the involvement of health care professionals. In assisted suicide, the physician writes the order and the patient takes it, so the nurse is not involved actively giving the medication.

In euthanasia, you're giving the medication and are involved.

[Heidi the nurse, BSN, RN]

Didn't say they were the same - some describe assisted suicide as "non-active" euthanasia. Sorry if I was unclear.

[ronpanzer]

"Non-active" euthanasia is more usually called "passive euthanasia." Passive euthanasia is involved when an intervention is not done, with the intent to cause death. For example, not providing a needed medication, dialysis, artificial ventilation support, food, fluids, etc. Death happens on its own because something is not done.

Assisted-suicide is never truly "passive euthanasia" (or "non-active" euthanasia) since it involves a conscious act to give something to cause death, even though the patient takes the medication himself or herself.

In the case cited by the nurse, concern was about giving the morphine which she thought might cause death.

[Heidi the nurse, BSN, RN]

This is one of those case of too much information - and looking a Wikipedia. Yes, I agree that the OP was a question of "euthanasia". I also understand the various forms of euthanasia - voluntary, non-voluntary, unvoluntary and assisted and non-assisted. I learned more about euthanasia today than I ever thought I would need to know. As a resident of Washington State, I am happy that way out is available for the people who want it. Euthanasia or assisted suicide or death with dignity - what ever you want to call it :)