Brainstorming, End of life and Morphine use.

PicklesRN, RN · May 22, 2005

hi, i'm a 3rd yr rn student... i've studied that mgso4 toxicity can lead to resp depression. so my silly question is with a dying patient in pain, would you still continue on giving MS going on to resp dep? i mean, it would kill the pt. i'm a bit confused with this medication...

A lot depends on how it is given. You don't run in there, push Morphine as fast as you can, then go to the next patient. You have to give it *very* slowly.

People who are in pain ... their BP, HR, and R go up so giving a little morphine may cause it to come down. However look at your statement, you are referring to toxicity. There is a difference between that and getting someone out of pain.

leslie :-D · May 22, 2005

hi, i'm a 3rd yr rn student... i've studied that mgso4 toxicity can lead to resp depression. so my silly question is with a dying patient in pain, would you still continue on giving MS going on to resp dep? i mean, it would kill the pt. i'm a bit confused with this medication...

i'm not sure what you mean by mso4 toxicity, but mso4 can indeed cause respiratory depression. most doctors will set parameters so you can't give it w/rr rate under 10.

yet there's been many a time that i've gotten orders w/o parameters or when the pain remains but their respirations are very low, we still give the mso4 to relieve their suffering, even if it does hasten death. it's all about intent.....intent to relieve pain/suffering. i have done this dozens of times. and yes, they have often died on my time but much of the pain had been resolved. and that is what my goal was.

leslie

Wetpaint712 · May 22, 2005

I am a student in an LPN program and about ready to graduate (praise God), but more than that I am a Hospice CNA that will be a Hospice LPN. I can tell you that as nurses will also tell you, Morphine does not kill the patient. Disease process kills the patient.

I know at our Hospice the nurse are more than willing to do inservice training for hospital nursing staff to educate them on the need to use Morphine. Please try to contact your local Hospice and at least inquire before you just assume they are too busy. I would think that they would prefer to take time to do education as opposed to having to come in on a Crisis Care situation and have to take hours to achieve adequete pain management. Just give it a try. I hope this helps.

I know so many nurses that are afriad to use morphine to help pain. Especially in hospice patients! I
Today I had a woman dying of cancer and very restless but otherwise unresponsive. I found out that the patient did not recieve her MS at all because the nurses on the previous shifts were to afraid of the med, and causing her death! The patient was breathing normally (except when she was painful) at 18...and was in pain!?!?!? No, instead they were doing dressing changes and manipulating her body without any analgesic at all!!!! I was floored, how kind is that!?!?!
I had a few days off, found out the situation and contacted hospice right away. By the looks of my dear sweet patient whom I have known for 3 years...I knew she had only hours if that! I got orders for 1 ml roxinol q 30m if I wished (which I did), and called the family and hospice to come in. She died with no s/sx of pain and was very peaceful looking with her family and caregivers and hospice at her side.
However I was very displeased with my fellow nurses. I have told them time and time again the reasons, use, contraidications, side effects and what not of this medication and they still won't touch it! Because of their fear...she suffered till I got there!
So, I am trying to think of someone that can come into a inservice to education my entire staff on the use of MS. I was thinking hospice but they are so busy and understaffed as of late....a pharmasist perhaps?
Just throw the ideas out folks! I even thought of paramedics or ER docs but try to get one of them to volunteer...LOL!
Thanks! We really do need more education about this issue!
(btw...one nurses excuse was that 'snowing' a patient at this time is cruel and pain is expected..it is part of death...I about fainted!).

mommymandy · May 23, 2005

thanks for the replies earle58 and pickles... your answers sure cleared out the confusion i had regarding those meds. :)

soapynurse@adel · May 23, 2005

We used morphine or oxyfast on a regular and frequent basis. We always got titrate to comfort oders, so the sky was the limit. We used usually lorazepam in conjunction because as pain increases, so does the anxiety level, respiratory rate, etc. I had one guy who was on up to 1600 mg a day of combined long acting MSContin and MSIR for breakthrough pain. We also administered lorazepam as needed, also with a titrate to comfort order.

Along with those measures, we used scop patches and recently added on Robinul tablets which work faster than the scop and dries them up pretty quickly. I would often place a patch and at the same time, give Robinul for it's almost immediate effect. It comes in tablet form, can be crushed on put in applesauce if they can swallow, mixed with a minimal amount of water to drip into their mouth, or crushed and sprinkled under the tongue. Didn't take long for it to dissolve. I've even just tucked a tablet into their cheek as it dissolves easily.

I didn't have so much trouble with nurses, but in assisted living facilities, the med techs can't use a titrating dose, it has to be a fixed dose and time period. So we just made the prn order so that it could be given very frequently. I did actually have some med techs, though, who were afraid to give the morphine. I had one tell me one day that I wanted her to go back and give the morphine so the lady would die. Then on a more positive side, we had patients in a local nursing home and they, the nurses, were very much on board as far as pain control and they could use titrating orders. One nurse had a patient who was not hospice, but obviously needed some of the meds we often used. She called the primary MD, told him what she needed and he agreed immediately. Yay for her!!!!!!!!!

It's very much a struggle sometimes, but I was very committed to keeping my patients comfortable as well as sticking to a very rigid bowel program. We had one assisted living who adapted their bowel program to our recommendations so that no one would end up being impacted on their unit, hospice or not. These girls in the particular facility were very much on board with our program and they never hesitated to give meds.

A little bit off topic, but still important....we used a topical phenergan gel for nausea and sometimes also lorazepam. It didn't work for everyone, but it usually worked in my patients.

Sorry to be so long winded. Hope this info is helpful.

Alice in the beautiful Shenandoah Valley

txspadequeenRN, BSN, RN · May 23, 2005

I refuse to let a patient die in pain. I had a a patient yesterday tell me that she had been in so much pain for the last several days and no one paid attention to her...:angryfire :angryfire :angryfire . Well this fat nurse got on it, and after 4 doses of Roxanol (1 ml each) over the course of 4 hours, the patient said "ohhh Thank you". Now, why did it have to come to that? What ever I have to do , is what I do .. Call hospice or move the nurses station to the pt room so I can give meds every 15 or 30 min (according to order of course) then that's what we do.....

lpnshortygurl · May 23, 2005

Some people are not going to agree with me on this but I feel the reason some nurses do not give pain meds is because they don't want the person to die on their shift. Don't want to do the paper work. I too have been in a situation where the nurses wouldn't give pain med to dying resident and when asked about it the reply was " I don't want them to die on my shift." Needless to say the person did die but was not always pain free except for when a couple of us nurses were there to give the resident meds. I just don't get it. If it was their loved one I am sure they would not be concerned about what shift she/he died on as long as their loved one was not in pain.

that is just horrible! :angryfire I know this also happens with certain nurses where I work although there reasoning is "are they really in that much pain?? hospice prescribes this to everyone" Yes, hospice does give "EVERYONE" at our facility Roxanol, but it is prescribed for a reason, USE IT!

lpnshortygurl · May 23, 2005

I refuse to let a patient die in pain. I had a a patient yesterday tell me that she had been in so much pain for the last several days and no one paid attention to her...:angryfire :angryfire :angryfire . Well this fat nurse got on it, and after 4 doses of Roxanol (1 ml each) over the course of 4 hours, the patient said "ohhh Thank you". Now, why did it have to come to that? What ever I have to do , is what I do .. Call hospice or move the nurses station to the pt room so I can give meds every 15 or 30 min (according to order of course) then that's what we do.....

We have a lady where I work who is on 4.5 ml of Roxanol q1h and She needs it! Her whole face lights up when I walk in that facility because she knows I will be willing to give it as prescribed if she needs it, Which she does due to her diagnosis. But alot of people will not give it like that saying "its too much" because she also has 2 duragesic patches q72hr etc. But I can see that this woman truly is in pain! she rarely sleeps and doesn't request it nearly as much as she would like too because she doesn't want to "bother the nurses" she says! That is awful!

soapynurse@adel · May 24, 2005

I can't for the life of me think of the name of this scale, but it is often used in patients with dementia/or who are unresponsive. You gauge it by moaning, grimacing, restlessness, etc. I'll try to dig out a copy and post it here. If I had staff in a facility or a family who couldn't tell if the patient was in pain, I made a copy of this scale to leave with them. The hospital nurses didn't seem to thrilled, but agreed to post it at bedside.

Keep up the good work ladies and gentlemen. I wish I was still in the trenches with hospice.

I had one very sad situation one time when a patient was transported to the hospital for terminal care. His wife felt she couldn't take care of him at home. Admittedly, she was a tiny lady, and this gentleman was a big guy. Finances were not an issue, but they didn't follow up on getting help into the home. He had made it very clear he wanted to die at home. The wife stood at the end of his bed and said, "I want him transferred to the hospital, he'll never know it anyway." So much for the patient hearing this. To make a long story short, the transport company can not transport narcotics, so the man arrived at the hosp sans his meds. Would you believe the hospital had neither the MSIR or the lorazepam intensol??????? I ended up going to a local pharmacy to pick it up and carry it back. I could have rung the neck of that hospital pharmacist. It all worked out in the end and he died very peacefully, though before his family got there that day. I did manage to catch them before they got to the room to break the news. All were very well prepared as this man had had a wonderful life and was ready to go. Ahhhh, the memories.

Alice in VA

aimeee, BSN, RN · May 25, 2005

We have a lady where I work who is on 4.5 ml of Roxanol q1h and She needs it! Her whole face lights up when I walk in that facility because she knows I will be willing to give it as prescribed if she needs it, Which she does due to her diagnosis. But alot of people will not give it like that saying "its too much" because she also has 2 duragesic patches q72hr etc. But I can see that this woman truly is in pain! she rarely sleeps and doesn't request it nearly as much as she would like too because she doesn't want to "bother the nurses" she says! That is awful!

It sounds like her pain is still not well managed if she rarely sleeps and is needing her breakthrough medication that frequently. It makes me wonder if she has bone or neuropathic pain that is not being addressed well by the narcotics. Or is she one of the many people for whom duragesic is not a great choice (very thin with inadequate subq depot...patches placed on bony prominences...oily skin that prevents good adhesion, etc)?

Bless you for giving her medication when she requests it...but it sounds like she needs her regimen adjusted further.

Laurell28 · May 27, 2005

We have a lady where I work who is on 4.5 ml of Roxanol q1h and She needs it! Her whole face lights up when I walk in that facility because she knows I will be willing to give it as prescribed if she needs it, Which she does due to her diagnosis. But alot of people will not give it like that saying "its too much" because she also has 2 duragesic patches q72hr etc. But I can see that this woman truly is in pain! she rarely sleeps and doesn't request it nearly as much as she would like too because she doesn't want to "bother the nurses" she says! That is awful!

Just a thought. If this lady is getting Roxanol every hour then her Duragesic needs to be increased or maybe a pca pump started because her current pain orders are not working.

Midwest4me · May 28, 2005

I know so many nurses that are afriad to use morphine to help pain. Especially in hospice patients!
Today I had a woman dying of cancer and very restless but otherwise unresponsive. I found out that the patient did not recieve her MS at all because the nurses on the previous shifts were to afraid of the med, and causing her death! The patient was breathing normally (except when she was painful) at 18...and was in pain!?!?!? No, instead they were doing dressing changes and manipulating her body without any analgesic at all!!!! I was floored, how kind is that!?!?!
I had a few days off, found out the situation and contacted hospice right away. By the looks of my dear sweet patient whom I have known for 3 years...I knew she had only hours if that! I got orders for 1 ml roxinol q 30m if I wished (which I did), and called the family and hospice to come in. She died with no s/sx of pain and was very peaceful looking with her family and caregivers and hospice at her side.
However I was very displeased with my fellow nurses. I have told them time and time again the reasons, use, contraidications, side effects and what not of this medication and they still won't touch it! Because of their fear...she suffered till I got there!
So, I am trying to think of someone that can come into a inservice to education my entire staff on the use of MS. I was thinking hospice but they are so busy and understaffed as of late....a pharmasist perhaps?
Just throw the ideas out folks! I even thought of paramedics or ER docs but try to get one of them to volunteer...LOL!
Thanks! We really do need more education about this issue!
(btw...one nurses excuse was that 'snowing' a patient at this time is cruel and pain is expected..it is part of death...I about fainted!).

Yes--get a pharmacist or a seasoned hospice nurse and get them educated on the importance of morphine! I just lost my step-mom to a brain tumor on May 13th--and advocated for morphine and made sure it was given--it helped her restlessness--(she denied any pain but her body language said otherwise) and did indeed aid in her peaceful passing. There is NO NEED to be worried over respiratory depression--a common fear that prevents nurses from offering it.