Morphine and end of life - page 4

Hey guys, 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 resp. between 7-8 bpm with long periods of... Read More

  1. Visit  tencat profile page
    2
    I have held medications when patients have had respirations of 6-8 per minute. I had one recently who was snowed on dilaudid q 3 hours ATC and we backed off, gave a long acting med (methadone), and she woke up So there are times when it is appropriate to hold meds. The hospice nurse should have been able to tell you WHY the morphine was ordered ATC and should NOT have given you the "He's dying anyway" answer. It's a fine line we walk in hospice: comfort vs. 'safety' of the patient. The challenge lies in striking a balance, and always the patient's comfort is the top priority.

    In response to ronpanzer: There are other reasons to give morphine besides for pain control. Just wanted to point that out.
    SuesquatchRN and tewdles like this.
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  3. Visit  taalyn_1 profile page
    1
    as a nursing student, I LOVE this kind of thread. It is so interesting to see how different nurses handle these types of situations. To the OP, I am glad your patient is alert and talking now, and that you are happy with your decision to withold the med at that time. I think I would have kept the med schedule myself, simply because I have seen family members who were passing get fairly high doses of morphine with no problems. BUT now after reading this thread I think it would depend on the patient and a good assessment of the patient at that time. It just seems that at that time of life, there are no easy answers. You as the nurse did what you thought was best and thats all you can really do. If you had given the med and the patient slipped off into death, I can see how you as the nurse would feel like you hastened death, but in reality you did not, you just made the passing easier for the patient. Tough call either way, but I appreciate these types of threads so much. They help me think like a nurse.
    DixieRedHead likes this.
  4. Visit  dgrate32 profile page
    7
    NurseLoveJoy88 wrote: 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 am actually a teacher but am interested in this site.

    My mother passed away on May 9, 2011 and she was given morphine during the last stages of her life. Her respiration increased at a rate over 30, and the morphine slowed the rate. When the nurse had to halt the medication for a few minutes, I noticed how she gasped for air while she wanted for the return of the morphine. At first I thought we were speeding up her death because one of the nurses came in the room to increase the dose, in which we declined. She was declined because she said, "Do you know what morphine does?" We responded, "No!" She said, "It will kill you."

    The dose was increased from 1 to 2 ml/hr on sat, and from 2 to 3 ml/hr on Sunday, she passed that Monday at day break. I often wondered if the increase in dose shortened her life. After I came upon this site, I realized we did nothing wrong. THank you.

    Deborah
  5. Visit  gentlegiver profile page
    3
    I was in your shoes a while back. I spent 45 minutes taking to a Dr about it. The Dr said that as the patient was having respiritory distress I should give the morphine. She explained that yes, the drug will surpress the respiritory system, and on a patient with already low breaths it can and does hasten the end. However, she also explained that the idea of the morphine was to keep the patient comfortable, to not allow them to struggle, that if it hastened the death but did so peacefully, it was worth the cost. She said it was not considered assisted death, and that in no way should I think I caused the death. The patient was dying, I was just keeping them comfortable as they went thru the process. I'm still not comfortable with it, but, if it really helps them die in a peacefull way.....
    My patient did die during my shift, terminal CA, I was glad I had the talk with the Dr., The family was thankful that thier loved one had a peaceful death after months of struggle.
    Last edit by gentlegiver on May 20, '11
  6. Visit  Forever Sunshine profile page
    4
    Quote from gentlegiver
    I was in your shoes a while back. I spent 45 minutes taking to a Dr about it. The Dr said that as the patient was having respiritory distress I should give the morphine. She explained that yes, the drug will surpress the respiritory system, and on a patient with already low breaths it can and does hasten the end. However, she also explained that the idea of the morphine was to keep the patient comfortable, to not allow them to struggle, that if it hastened the death but did so peacefully, it was worth the cost. She said it was not considered assisted death, and that in no way should I think I caused the death. The patient was dying, I was just keeping them comfortable as they went thru the process. I'm still not comfortable with it, but, if it really helps them die in a peacefull way.....
    My patient did die during my shift, terminal CA, I was glad I had the talk with the Dr., The family was thankful that thier loved one had a peaceful death after months of struggle.
    I would give it despite the respiratory distress. I currently have a resident who is "hanging" by a thread. I noticed that she was having Cheyne Stokes respirations tonight.

    My views on Morphine is if they have it, and are actively dying, I give it as soon as possible. Not because I want to hasten their death, but I want them to be comfortable.
    SuesquatchRN, Vtachy1, CCL RN, and 1 other like this.
  7. Visit  Asystole RN profile page
    9
    Just a reminder to everyone that keeps stating the blanket statement that giving morphine will hasten death by slowing respers, studies have proven that increased opiate administration dramatically INCREASED the life of the patient at the end of life.

    Keep in mind that keeping the patient comfortable lowers the bodies stress...
    cayenne06, kay, SuesquatchRN, and 6 others like this.
  8. Visit  Forever Sunshine profile page
    5
    Quote from Asystole RN
    Just a reminder to everyone that keeps stating the blanket statement that giving morphine will hasten death by slowing respers, studies have proven that increased opiate administration dramatically INCREASED the life of the patient at the end of life.

    Keep in mind that keeping the patient comfortable lowers the bodies stress...
    Strongly agree with this. We have a nurse who does not give the roxanol on her shift. Despite much reminders. Theres been times when we come in and we see the dying resident in "flight or fight" response. All rigid and gasping.

    I had a dying resident last night. I give the roxanol even though its PRN .. as soon as I can. Because if it was my grandmother... I'd be raving to administration if I walked in and saw her uncomfortable.
  9. Visit  tothepointeLVN profile page
    1
    I'm seen this happen many time with other hospice nurses where they won't give pain medication or antianxiety medication because it "might" hasten death.

    I'm not sure if they should be hospice nurses. I've definately come across caregivers who want the patient to stay alive so they still have a job and other nurses joking with me to "take care of the patient" because they are scheduled for 3 other shifts and they need the work.
    SuesquatchRN likes this.
  10. Visit  qestout profile page
    1
    This is a great post/answers. I'm hoping to go into hospice. They were so great to my father. I want to pay it back
    Hospice Nurse LPN likes this.
  11. Visit  lovnrsg profile page
    0
    [quote=NurseLoveJoy88;4889515]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.

    Are they unresponsive because they are on too much morphine? That was my issue. My patient was put on hospice to help control cancer pain. He was NOT told "once I give you this morphine you no longer will be able to speak to anyone or say you do not want to be put under totally." He was in pain and agreed to pain med but I am sure he never thought (and neither did I)that that moment of taking his first morphine dose that was it. He was awake and visiting family when I left and the next day I went in and he was with pinpoint pupil, vomiting, and grabbing at the air. The nurse was saying give him more he is suffering and you should have gave it to him as soon as you seen him stir. To me...that is not right. He was pushing me away and not wanting the med but I was told to give it. I have been sick every since.Maybe he would have wanted to suppress as much pain as possible but still stay aware some of the time. Is it right to decide that? I know if I ever sign up with hospice, I will say goodbye to everyone right before my first dose of morphine because that is lights out were I work.
  12. Visit  tewdles profile page
    4
    [quote=lovnrsg;5493627]
    Quote from NurseLoveJoy88
    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.

    Are they unresponsive because they are on too much morphine? That was my issue. My patient was put on hospice to help control cancer pain. He was NOT told "once I give you this morphine you no longer will be able to speak to anyone or say you do not want to be put under totally." He was in pain and agreed to pain med but I am sure he never thought (and neither did I)that that moment of taking his first morphine dose that was it. He was awake and visiting family when I left and the next day I went in and he was with pinpoint pupil, vomiting, and grabbing at the air. The nurse was saying give him more he is suffering and you should have gave it to him as soon as you seen him stir. To me...that is not right. He was pushing me away and not wanting the med but I was told to give it. I have been sick every since.Maybe he would have wanted to suppress as much pain as possible but still stay aware some of the time. Is it right to decide that? I know if I ever sign up with hospice, I will say goodbye to everyone right before my first dose of morphine because that is lights out were I work.
    I talk to patients all the time, everyday, who take morphine or dilaudid ATC (sometimes in very large doses). "Once I give you this you will no longer be able to speak..."????? Oh my word, whoever thinks or says this is, sadly, very poorly informed.

    On a regular and routine basis I sit with patients as they receive their very first dose of morphine for comfort. I have NEVER had a patient become unresponsive or unable to speak to me because of that...never.

    Do dying patients commonly become disoriented, confused, agitated, restless, frightened? You betcha and we (hospice professionals) are anxious to use medications to provide peace and comfort to these poor souls. Could he have been vomiting from the morphine? Sure, N/V is a well known side effect that is treated with relative ease. Did you give some compazine or other antiemetic to ease this patient's discomfort? I, personally, cannot take ANY opiate without something for nausea.

    I am sorry that you felt so badly about this experience. It is not at all uncommon for hospice patients to be awake, alert, conversant, and engaged on one day and then to be minimally responsive and actively dying the next. Heck, I have had a patient get up, ambulate to the kitchen, eat a large breakfast and have a lovely conversation with his wife and then go to bed and be dead by noon. People die in their own ways, sometimes quickly, sometimes not so much. Our job, in hospice, is not to change that trajectory or time table, but to insure, to the best of our ability, that they can accomplish this last task with as much comfort and dignity as possible. When these patients live in LTC we must rely on our partnerships with nurses like yourself. Sometimes I think that hospice case managers might forget that just like we educate the family caregivers about the uses of morphine, we also need to provide that support to facility staff who are likely not as comfortable with the role of these meds.
    Last edit by tewdles on Aug 11, '11 : Reason: content
  13. Visit  Vtachy1 profile page
    5
    [quote=lovnrsg;5493627]
    Quote from NurseLoveJoy88
    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.

    Are they unresponsive because they are on too much morphine? That was my issue. My patient was put on hospice to help control cancer pain. He was NOT told "once I give you this morphine you no longer will be able to speak to anyone or say you do not want to be put under totally." He was in pain and agreed to pain med but I am sure he never thought (and neither did I)that that moment of taking his first morphine dose that was it. He was awake and visiting family when I left and the next day I went in and he was with pinpoint pupil, vomiting, and grabbing at the air. The nurse was saying give him more he is suffering and you should have gave it to him as soon as you seen him stir. To me...that is not right. He was pushing me away and not wanting the med but I was told to give it. I have been sick every since.Maybe he would have wanted to suppress as much pain as possible but still stay aware some of the time. Is it right to decide that? I know if I ever sign up with hospice, I will say goodbye to everyone right before my first dose of morphine because that is lights out were I work.

    It seems that for some reason morphine always gets the blame. Never mind the fact that they have a disease process going on! Never mind the fact that they have not eaten for weeks! Never mind that the cancer has eaten their insides out. Never mind the fact that their liver and brain is full of mets. None of that matters, it is the morphine's fault. When they get to the point that they need to morphine for end of life comfort, sometimes that is where the disease process is at its end point and of course it is the disease that causes the death, not the morphine.
  14. Visit  SuesquatchRN profile page
    5
    This has been an interesting thread. I have no problem giving the morphine. I remember asking once, "His respirations are depressed. Should I give it?" And all of my co-workers and the DON said not to worry about vitals at a time like this, that death was imminent (it was), and to keep the resident comfortable. I gave it, he certainly was alive when the next dose was due, and his breathing was much eased.


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