A few questions, please

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    I am an RN in LTC and recently had a very dear resident die. She was on hospice at the end. I have had some very "hard'" deaths, struggling, clenching fists, severe terminal secretions, flailing. This lady did not exhibit any of this, in fact, was quite peaceful and ready for her death. Morphine, atropine gtts, lorazepam intensol were ordered. My questions, one: I was told to give morphine for secretions. My experience with pharmacology suggests no correlation with an opioid stopping secretions. Also, I was told that morphine would be out of her system within 4-6 hrs after administration. This lady had renal failure, thus I would think clearance would take longer? The reason for my post really is this, if a resident is clearly not exhibiting pain or discomfort, why use morphine and "snow" them out of precious end moments with her family? Please understand that I have absolutely no problem giving medications for pain/discomfort control. I have used them and will in the future to make sure my residents are comfortable at the end.
  2. 8 Comments so far...

  3. 1
    Mophine may reduce the work of breathing while it controls pain. It does not impact secretions.
    We do pay attention to doses as people near death, knowing that their kidneys and livers are not at 100% regardless of dx.
    Ongoing medication is not designed to "snow" patients...that is actually counter to our goals in most cases...rather it allows us to proactively maintain good control of noxious symptoms. It is not uncommon for doses of opiates to be decreased if the patient experiences as sudden change in level of consciousness.

    We value the assessments and opinions of the facility staff who often know the patient better than we do. We also know that many facility staff are not comfortable with the treatment plans for many hospice patients, so communication is very important.

    Please engage the hospice staff who visit in your facility...they can be a wonderful resource for you and your peers.
    Good luck.
    aknottedyarn likes this.
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    Typically, we apply a scopolamine patch to dry up secretions. I've never heard that morphine helped to decrease secretions. It does help with breathing at low doses that is. I had a patient on 1 mg every 30 minutes at end of life. I'm unsure of why atropine was ordered for this patient though, why would you want to increase HR at the end of life? Sometimes it can't be helped, some patients just tug at our heart strings, and can be bothersome for a lot of nurses and other healthcare professionals, there are outlets for you. Please refer to hospice or see if there are any counselors at your facility that can help you through this. So sorry for your loss.
  5. 4
    Quote from cardiacrocks
    Typically, we apply a scopolamine patch to dry up secretions. I've never heard that morphine helped to decrease secretions. It does help with breathing at low doses that is. I had a patient on 1 mg every 30 minutes at end of life. I'm unsure of why atropine was ordered for this patient though, why would you want to increase HR at the end of life? Sometimes it can't be helped, some patients just tug at our heart strings, and can be bothersome for a lot of nurses and other healthcare professionals, there are outlets for you. Please refer to hospice or see if there are any counselors at your facility that can help you through this. So sorry for your loss.
    Atropine is a fairly powerful antiach agent that we use for secretions at EoL if they aren't responding to scopolamine (same pharma class, belladonna alks) or glycopyrrolate that can be given by ophthalmic drops to the back if the throat. They have no noticeable systemic effect by that route.

    Morphine is a wonderful drug for terminal care that reduces oxygen starvation and keeps patients comfortable. It does not help the terminal secretions.
    Last edit by BostonFNP on Jan 30, '13
    popmode77, aknottedyarn, loriangel14, and 1 other like this.
  6. 0
    Quote from cardiacrocks
    Typically, we apply a scopolamine patch to dry up secretions. I've never heard that morphine helped to decrease secretions. It does help with breathing at low doses that is. I had a patient on 1 mg every 30 minutes at end of life. I'm unsure of why atropine was ordered for this patient though, why would you want to increase HR at the end of life? Sometimes it can't be helped, some patients just tug at our heart strings, and can be bothersome for a lot of nurses and other healthcare professionals, there are outlets for you. Please refer to hospice or see if there are any counselors at your facility that can help you through this. So sorry for your loss.
    a variety of anticholinergics are used for terminal secretions, including atropine. Remember that when you apply a scopolamine patch the drug is not effective immediately as it would be with atropine or levsin.

    many patients experience tachycardia at EOL with or without anticholinergics. We weigh the benefit vs. "cost" in adding drugs...death rattle vs. tachycardia and dry mouth...
  7. 3
    Thank you all for the replies. The information I received on morphine drying up terminal secretions came from a hospice nurse. After much research, going through palliative and hospice books and my old pharmacology book from nursing school, I could not find any indication that an opioid would act like an anticholinergic. I felt like I got false information and wanted to ask you who practice in hospice. I appreciate your expertise and eventually want to get into hospice. Thanks again!
    popmode77, aknottedyarn, and tewdles like this.
  8. 1
    Again...can't agree more with Tewdles. Also, if your patient has a history of chronic pain and is not being medicated with long acting pain medication for one reason or another, it is important to consider this in your pain assessment when giving prn SL doses. Getting a patient comfortable is one thing, maintaining that comfort is another--especially when she is unable to tell you, and appears comfortable at the moment. Continual assessment is so important.

    We have a physician who has done research on using levisn and other drying agents with our patients and she is finding that these are often over used as a "standard in eol care." That many patients are becoming dry, creating a new discomfort in our patients for moisture deep in the lungs or when the "death rattle" is heard--which is often times a distress for family members and not for patient's themselves. So again, assessment and benefit vs "cost" to patients.
    tewdles likes this.
  9. 0
    Hi. Are you sure the hospice nurse wasn't talking about the Atropine being prescribed for secretions? Or maybe she mixed up her meds and said Morphine but meant to say Atropine.
  10. 0
    Quote from BostonFNP

    Atropine is a fairly powerful antiach agent that we use for secretions at EoL if they aren't responding to scopolamine (same pharma class, belladonna alks) or glycopyrrolate that can be given by ophthalmic drops to the back if the throat. They have no noticeable systemic effect by that route.

    Morphine is a wonderful drug for terminal care that reduces oxygen starvation and keeps patients comfortable. It does not help the terminal secretions.
    I second this post. Atropine and Morphine were one of our standard orders when I was working hospice.


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