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??

NurseLoveJoy88 said:
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.

1 Votes
Specializes in PICU, NICU, L&D, Public Health, Hospice.
NurseLoveJoy88 said:

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.

Specializes in BNAT instructor, ICU, Hospice,triage.
NurseLoveJoy88 said:

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.

1 Votes

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.

1 Votes
Specializes in NICU.

Asystole- very well written, very professional, and very educational. Thank you for your post.

I work in NICU, and I wish we had a better understanding of this as a whole on our dying patients, who have no voice to make requests. So many times I will see no added pain control for a baby that is on a Fentanyl drip. Typically they have been on the drip for weeks, at the same dose, and have a very high tolerance at that point. Nothing disturbs me more, than to watch a little one agonal breath for hours, while some of our docs are afraid to give more narcs for fear of respiratory depression and chest wall rigidity.

1 Votes
Specializes in LTC, Nursing Management, WCC.

Remember the Principle of double effect. " [...] is a set of ethical criteria for evaluating the permissibility of acting when one's otherwise legitimate act (for example, relieving a terminally ill patient's pain) will also cause an effect one would normally be obliged to avoid (for example, the patient's death)."

This set of criteria states that an action having foreseen harmful effects practically inseparable from the good effect is justifiable if upon satisfaction of the following:

  • The nature of the act is itself good, or at least morally neutral;
  • The agent intends the good effect and not the bad either as a means to the good or as an end itself;
  • The good effect outweighs the bad effect in circumstances sufficiently grave to justify causing the bad effect and the agent exercises due diligence to minimize the harm. (Double-Effect Reasoning: Doing Good and Avoiding Evil, p.36, Oxford: Clarendon Press, T. A. Cavanaugh)

http://en.wikipedia.org/wiki/Principle_of_double_effect

I would not have held the morphine. I understand why some get skittish. The BON for my state has written a "white page" regarding this very topic. We are to give it.

1 Votes

I'm not sure if anyone is still commenting on this post. But I'll leave my two cents anyways. I've run across the same situation. I can say that I've done some research and have seen some of the scientific data. It appears that morphine bevaves differently in the terminally ill versus the patient say in distress caused by something like a broken arm. But, there are only a handful of studies on this matter. I have read a few post regarding this situation that has suggested but not mentioned the phrase "Ethical Dilema". It would seem the reason for the dilema starts with us all at nursing school. Everybody put a hand in the air if you've heard the following, "If respirations are below 12, hold the morphine because its a respitory depressant." So it sounds like the NLN and ANA and AMA along with the surgeon general need to revamp the standard of educating nurses on the administration of morphine. Some docs, are saying what we have been taught is an old veiw of morphine. If this is the case, then why hasn't the standard of educating nursing students regarding morphine been revised? In February of this 2013 I had two of my med techs graduate the LVN program and they are still being taught what I was taught. Having said that, all nurses have also been taught, in end of life care (i.e. palliative care), if the patient ask for it, give it. However, I can understand how some nurses can still be left with a dilema with respect to a patient who can not verbalize wether they need pain meds or not. I'm sure this is the reason that the ANA wrote what they wrote in their code of ethics regulations. While it gives a nurse direction in what to decesion to make, we have to remember, having a regulation on a code of ethics may relive your legal concerns but you may still struggle with wether what you have done is truly ethical just because ANA said so. Not to discount the ANA, the point is you may do what is legally right and still feel ethically challenged by it. I'm so glad to see that while some prejudged what others in this post have said, they were able to come around later to see (albeint not agree) with the other points of view. Thanks to everyone for this post on this subject, I've learned a lot!

1 Votes
midprinz said:
SNIP

I do not think the standard of 12 respers has been changed due to a still disturbingly high rate of overdose. This however does not apply to palliative care where the rules on the actively dying patient change.

I have never seen an order to hold relating to respers in a patient when we are controlling pain in the actively dying patient. Unfortunately, most nurses do not receive much education in palliative care so continue to treat this special population like the general population.

In the ethical dilemma one simply has to weigh the pros and the cons.

The potential to allow your patient to experience excruciating pain in the face of certain death (torture) outweighs any concern for possibly speeding up death by a far margin. Better to medicate too heavily than too little.

You are right though, there are not enough studies on the end of life but most of those existing still say that we generally under-medicate at the end of life.

1 Votes

What a great thread and very interesting to hear so many professional perspectives. I agree the hospice nurse was wrong in her explanation of why we give morphine but appreciate how hard they have to work to get a lot of nurses to feel comfortable about giving enough morphine to keep an actively dying patient pain free. It can be so hard to start a night shift with a patient in pain and severe distress, and can take over an hour to get their pain under control again. It is so hard for families also to watch their loved one in pain and distress.So much to learn about death and how best to keep our patients comfortable. Thanks to everyone who took the time to post.

I personally would have given the morphine. If the patient is actively dying, why not? You can't really know for sure whether they are in pain or not. I am very PRO morphine at a time like this. HOWEVER, you definitely have rights and should never do what you are not comfortable doing as a nurse. Try to use your own judgment, and certainly only do what you are ethically comfortable doing, but don't get in the way of a hospice nurse doing what she and the patient/patient's family wish to have done.

1 Votes
Specializes in Med/Surg & Hospice & Dialysis.

My concern with withholding any opioid or benzo, is many of our hospice patients have been on long term opioid/benzo therapy, abruptly discontinuing these meds can cause miserable withdrawal symptoms that the patient may not be able to express. They may also show

Subtle signs that we may not recognize such as a tremor or shivering type movement.

1 Votes

The only scenario where I would not give an actively dying pt morphine (even taking bardypnea into account) would be if they were showing absolutely no signs of pain/discomfort/distress whatsoever.

Stop and think back on all the actively dying pts you've had, and you'll realize that's pretty rare.

1 Votes
+ Add a Comment