Morphine and end of life - page 3

by MelissaLPN

87,830 Views | 60 Comments

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 apnea. Resident was thought to be... Read More


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    Thank you for the info provided.. It was very helpful..
  2. 9
    Quote from iceprincess868
    Wonderful post. I hope that should myself or someone in my family ever require hospice/end of life care that we have a nurse like you to take care of us and not someone that is afraid of medicating a dying patient
    100% agree. I cringed after reading the OP. Cringed. How terribly sad for this particular patient. This person is DYING for goodness sake! Give them their morphine!

    Quote from NurseLoveJoy88
    Please forgive me if I repeat anything from other responses for I did not read the other posts.

    I have worked with actively dying patients and hospice. When I was brand new on the job I had my personal fears and anxiety about administering morphine. I understand your concerns and I want to address them the best way I can.
    When a patient is actively dying morphine is the drug of choice because it makes them more comfortable. It minimizes their pain and also help them to have unlabored breathing. Morphine is never used to "kill " a patient. It is simply to make them more comfortable. To hold morphine on an unresponsive actively dying patient is unethical to me. 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 hope this helps.
    I do disagree with the nurses' response to you. She should have given you a more in depth about the indication of morphine for this client.

    Me too. Totally unethical. In the case of the OP, it's an lack of education, instead of malicious intent. Hopefully, the OP can gain some hospice education and learn from this.
    Kitty-RN, Vtachy1, sharpeimom, and 6 others like this.
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    Many of the Hospice patients that I have seen coming into the LC where I work are often in alot of pain prior to the actual final dying process. When they are in the final stage as your patient was I assume the pain is present even though there are no outward signs from the patient. Yes, I would have given the morphine, not to hasten death but to keep the patient comfortable.
    OP this sounds like a learning situation for you. You should probably find more information on why morphine is used for dying patients and reasoning behind it. If you still feel uncomfortable with the situation then maybe a different job would better suit you.
    ktwlpn, SuesquatchRN, sharpeimom, and 5 others like this.
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    Sorry this is to address my previous post. LC is LTC. After reading the post I do apologize for sounding short with you OP. What I meant was there are many different areas of nursing. If something like this feels like it goes against your ethics then maybe another area would be a better fit. It would be hard to do a job that goes against your own personal beliefs.
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    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.
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    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?
    SuesquatchRN, Chin up, CCL RN, and 1 other like this.
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    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.
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    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...
    SuesquatchRN, prinsessa, imintrouble, and 1 other like this.
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    Quote from 07302003
    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!
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    Quote from 07302003
    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.
    Last edit by Asystole RN on Mar 23, '11 : Reason: Formatting


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