Morphine and end of life - page 4

by MelissaLPN

83,061 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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    Melissa,

    The differing responses are both correct, because the information given is not sufficient to really know what was going on with the patient. To correctly determine the proper course, we would need to know why the morphine was being given exactly and have some information on the clinical needs of the patient.

    Morphine is given ATC for controlling pain and should be continued even if there is no sign of pain, if there had been severe pain that is now well-handled. The lack of outward sign of pain would indicate good palliation of that condition. The appropriate response would be to check the chart or ask family nearby and learn what the patient's prior condition was. If the patient had been in pain that was now well-controlled, continuing it would be completely appropriate and professional and you would not be hastening death by giving it.

    On the other hand, there are circumstances where morphine is given, when there is no pain, expressly to hasten death, and to pretend it doesn't happen is really naive. It doesn't happen in all hospices, but it happens in some, and there have been articles in the news about such cases. We are not here to kill, but to care for our patients. Euthanasia is illegal in every state in America. Giving a medication that would certainly prove lethal, if inappropriate, is not part of what we do, and that is part of the code of nursing in every state.

    Yes, the intent is important and the clinical condition of the patient needs to be known or determined.

    If a patient is comatose and apneic due to morphine overdose, and is not truly actively dying from an illness, then holding the morphine can be appropriate. If it never happened, why would every hospice "emergency kit" of medications contain Narcan to be titrated in the relief of that overdose. I've seen a patient who got a cartridge of morphine that was twice the concentration ordered by the MD and only because other nurses held that incorrect dosage was the patient saved.

    Morphine can prematurely end the life of a patient if not given when clinically indicated. On the other hand, it is a true blessing to those in severe pain. And patients do become apneic with widely varying respiratory patterns at the end-of-life due to many different metabolic conditions caused by organ and system failures.

    Millions of hospice patients have safely been given morphine (or other opioids) for severe pain and have had their suffering lessened thereby. To relieve suffering at the end-of-life is the mission of hospice as envisioned by Dame Cicely Saunders.


    Ron Panzer
    Pres., Hospice Patients Alliance
    www.hospicepatients.org
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    Actually, euthanasia (actually assisted suicide) is legal in Oregon, Washington and Montana. There is a procedure to go through to obtain the medications for it, but it isn't illegal.
    Last edit by Heidi the nurse on Mar 24, '11 : Reason: to update message.
    SuesquatchRN likes this.
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    Euthanasia and assisted suicide are not the same. Assisted suicide is when a physician writes the order for a lethal medication and the patient takes its himself or herself. Euthanasia (active) is when someone (usually a physician or nurse) gives a lethal medication with the intent to end life. Euthanasia is illegal in every state in the United States.

    The original question dealt with questions about the ethical nature of giving the medication. In the case cited, the nurse had to evaluate whether to give the medication or not. The patient was not taking the medication by herself/himself to end his own life (assisted suicide).

    There is a huge difference between assisted suicide and euthanasia in the involvement of health care professionals. In assisted suicide, the physician writes the order and the patient takes it, so the nurse is not involved actively giving the medication.

    In euthanasia, you're giving the medication and are involved.
    CCL RN likes this.
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    Didn't say they were the same - some describe assisted suicide as "non-active" euthanasia. Sorry if I was unclear.
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    "Non-active" euthanasia is more usually called "passive euthanasia." Passive euthanasia is involved when an intervention is not done, with the intent to cause death. For example, not providing a needed medication, dialysis, artificial ventilation support, food, fluids, etc. Death happens on its own because something is not done.

    Assisted-suicide is never truly "passive euthanasia" (or "non-active" euthanasia) since it involves a conscious act to give something to cause death, even though the patient takes the medication himself or herself.

    In the case cited by the nurse, concern was about giving the morphine which she thought might cause death.
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    This is one of those case of too much information - and looking a Wikipedia. Yes, I agree that the OP was a question of "euthanasia". I also understand the various forms of euthanasia - voluntary, non-voluntary, unvoluntary and assisted and non-assisted. I learned more about euthanasia today than I ever thought I would need to know. As a resident of Washington State, I am happy that way out is available for the people who want it. Euthanasia or assisted suicide or death with dignity - what ever you want to call it
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    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.
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    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.
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    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.
    SuesquatchRN, LTCangel, and taalyn_1 like this.
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    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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