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??

[loriangel14, RN]

Pretty much all of our palliative patients are on PCAs with a continuous basal amount being delivered so it's not an issue of having to go in and give anything. Mostly they are on hydromorphone

[JustinMars]

I should point out that just because someone is dying, that does not necessarily mean they are always in pain. I had family members arguing with each other the other day that their family member was in pain or not in pain. One sister wanted me to give morphine and the other sister did not. I told them both that I did not feel the patient was in pain at that time and that she was resting peacefully. I held the morphine, but if I thought she was in pain at all, I would have given it instantly. It really is the nurse's call.

[Mamandrea6]

By saying she was judging is implying that she made a subjective decision. She objectively did not see signs of distress and saw decreased resps. We have policies in place in hospice that speak to this- to monitor closely for resp. depression. Your own values should not interfere with what is ethical practice.

[Mamandrea6]

Ethically and professionally you MUST look for respiratory depression and act accordingly. Your answer is well written, but incorrect. Hospice policies reflect exactly what this paper explains: Research review from Can Fam Physician. 2010 Jun; 56(6): 544–546. PMCID: PMC2902941 titled "Killing the symptom without killing the patient" Romayne Gallagher, MD CCFP on the topic states the bottom line on this topic to be:

"Respiratory depression is often not precisely defined, and many clinicians are not clear on what it is. Respiratory depression is defined as a rise in peripheral PCO2 and a fall in peripheral oxygen, as well as a reduction in the rate of respiration. It is always preceded by sedation, and the process of sedation through to reduction and cessation of breathing takes at least 5 to 15 minutes.

Studies show that appropriate doses of opioids do not cause respiratory depression.

Studies of the relationships between opioid dose, change of dose, and use of sedatives and time to death in patients with advanced illness have found no significant relationships.

Giving naloxone to patients using opioids who are not experiencing respiratory depression can cause severe distress, as the symptom relief is suddenly reversed. If a patient is using opioids and respiratory depression is suspected, a 1 in 10 dilution of naloxone can be used to reverse respiratory depression without losing symptom relief."

Thus giving opioids without monitoring respiratory depression is inappropriate.