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??

[canoehead, BSN, RN]

I think that bottom line...the patient was going to die. That was a given, but he could do it with pain or without. In my experience, when pain becomes evident in a palliative patient it can take 5-6 rounds of drugs, or more, to get it back under control. I also wonder if they are in pain but don't have the physical strength to show it at times.

RR 8-10 would not have bothered me. If normal for a sleeping adult is 12, resps wouldn't be a factor at all.

I would have given the drug. Maybe if they were waiting for some family to arrive, or if the patient still had moments of lucidity, I would have cautiously held off, but with Q5min assessments for distress. But if he's dying, and there's no turning back, give the drug, and make sure it's as painless and peaceful a process as possible.

[Finallydidit]

In LTC we often have to get orders for increased respirations, the drug of choice is usually liquid morphine the order will state "for pain" or "air hunger" even though I called d/t respirations not pain

If resp. are controlled, and no s/s of pain/distress I will hold the dose and monitor q15/min.

If the drug has been ordered for pain control, I would give it ATC just to stay on top of it.

[MelissaLPN, ASN, LPN, RN]

Just an update. Pt is still alive, he is now very alert, he was just sedated due to a bump in morphine. Now his body has adjusted to the 100% increase in morphine and he is awake and talking. I am glad I made the choice I did.

[tencat]

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.

[taalyn_1, CNA]

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.

[dgrate32]

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

[gentlegiver, ASN, LPN, RN]

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.

[Forever Sunshine, ASN, RN]

gentlegiver said:

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.

[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...

[Forever Sunshine, ASN, RN]

Asystole RN said:

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.

[tothepointeLVN, LVN]

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.

[qestout, ASN, RN]

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 :)