Morphine and Hospice Patients that are dying

[suzi0612]

Hello, I am a new nurse and I recently graduated with my RN and taking RN boards soon but working as a LPN at a long-term care facility. I got to take care of a patient that is dying and is hospice. We have a morphine order that reads like this in our mar: 10-20mg morphine sulfate sublingual every hour as needed for pain/dyspnea. I was doing some research online and I see a lot of orders every 4 hours not every hour. What are normal morphine orders in dying patients, is this dose to high? Any input would be greatly appreciated. I was just curious! Thank you.

[tewdles, RN]

suzi0612 said:

Hello, I am a new nurse and I recently graduated with my RN and taking RN boards soon but working as a LPN at a long-term care facility. I got to take care of a patient that is dying and is hospice. We have a morphine order that reads like this in our mar: 10-20mg morphine sulfate sublingual every hour as needed for pain/dyspnea. I was doing some research online and I see a lot of orders every 4 hours not every hour. What are normal morphine orders in dying patients, is this dose to high? Any input would be greatly appreciated. I was just curious! Thank you.

This is not too high of a dose. It is common to start dosing at 5 mg Q1-4 prn for the opiate naive patient, but it can go up from there. We currently have a patient who is taking 200mg Q2-4 hr for her pain. She is still a "walkie/talkie" even at those high doses and she manages her meds herself with a bit of help from her spouse.

Most of the time we use ATC orders for painful patients in LTC, too many opportunities for those scared of the drugs to opt out of giving the prn which results in suffering.

Thanks for asking. Good luck.

[catlvr]

Hi Leslie, thanks for bringing this up. I work in subacute/ltc, and have had a quite a few hospice pts on mso4. I'm a bit of a nut about pain, and tend to medicate in anticipation if I know the patient well enough; I do my best to keep everyone comfortable. I've discussed this with other nurses on my assignment, who have said that they don't want to be the one to give the dose that "kills them". I've asked if they prefer to have a patient in pain, and one told me that she gives tylenol instead. Oye.

As you know, ltc nurses are often worked beyond the point of reason; some days, we barely have time to get the "routine" meds given, let alone assess and treat pain. That's why I beg the hospice nurse to establish routine orders, rather than PRN orders, when the time comes that the pt would benefit from around the clock pain mgmt. So often, we have agency staff who do not know the pts and prns can be missed - routine orders solves that problem.

On the other hand, we have an opoid tolerant pt (on 6 mg of dilaudid for years for back pain) who is severely kyphotic and sob, and increasingly anxious. She said that the mso4 really helps all of her symptoms, but the MD refuses to give routine orders - said that she doesn't want the pt to be gorked. If I understand correctly (and I am always open to being educated!) mso4 is one of those meds that is most useful when given on an around the clock basis, and not just prn. (The pt doesn't ask for meds because she doesn't want to "bother" the nurses, bless her sweet heart.) Any thoughts?

TIA, e

leslie ? said:

the reality from my time in ltc is, whether the dosage is for 5-10 or 10-20mgs, many of the nurses do not give the prn's whether the pt needs it or not.

i am not trying to offend, but this was my reality, and it made me furious.

i begged the dr. to write a scheduled order, appropriate for each pt.

regardless of degree, training, eduction, inservices, there are still way too many nurses who fear giving mso4.

of course there are nurses (obviously including ltc) who are solely concerned for pt's well-being, and give freely and w/o hesitation.

one long-time nurse had the (bad) judgment to write in her nsg notes (not verbatim) to the effect of, 'pt received 5mg sl roxanol x 2 this shift. moaning and crying out continued. will continue to monitor.'

i mean dammit, nurse COULD have given more, but outright refused to.

ok, off my soapbox.

i wasn't aware that ltc regs allowed ranges...

that they had to be x amt only...none of this 5-20 for mild, mod, severe pain.

that's my only question about the order.

i sure hope this pt is getting the relief she needs.

leslie

[nerdtonurse?, BSN, RN]

To the OP: bless you for trying to do the best thing for your dying patient. Your first "death" when you're out of school is scary -- I was worried how I would react. I did fine, the patient passed peacefully, and the family was content. Just keep them comfortable as you can, and realize we all die our own way, in our own time, and on our own schedule. I've been present when a lot of end stage everything patients have passed in the years since, but I can still see that little lady's peaceful face after she passed away.

[nursel56]

There is an irony to it -- but it seems to me the area that needs the most inservice or nurses and educating of families is that condition that will not get better. It makes me sad when a nurse is told by a fellow nurse "you are killing your patient". It happens pretty often that a nurse will post having been through something like that so I'd imagine the misinformation is even more prevalent in the healthcare world at large.

When the mother of one of my homecare pts (also on 24/7 skilled nursing) passed away one of the sisters told my sweet nurse friend "you killed my mother" because she had given Ambien the night before. I don't normally go all in for rows of crying faces but it seems appropriate for these situations. ?

Bottom line = we need you up on that soapbox!!

[DelanaRN, MSN, APRN, NP]

Our standard E-kit has an order for Roxanol 10-20 mg/ml SL/PO q1h PRN.

It makes it much easier to control the pain/soa in a crisis without having to call the doctor. I always educate my families to try 0.50 ml initially and to see how that effects the patient. Sometimes they need to go up to 1.0 but we re-evaluate in 30 minutes to see the results of that initial dose.

[IowaKaren]

Hmmm, it seems where I worked, they would start the Morphine Sulfate at 2.5mg (20mg/ml) and that was such a tough dose to even measure and give, much less count out between shifts (narc count for NH). It seemed to never touch the pain but when you first get the order, our Docs would be so conservative and unyielding about it. I never hesitated to call the on-call hospice nurse about these slighted orders, then the doc. I always wondered why they would be so conservative in the first place. Its not like we couldn't evaluate their pain level and medicate appropriately but seemed that the pain medication was always too conservative. I wished they would just stop that small 2.5mg dose and at the very least start at 5mg/0.25ml MSO4 hourly prn but was usually started every 4 hours prn.

[tewdles, RN]

5mg is the typical starting dose of morphine for the opiate naive patient. Too many physicians are not well educated on palliative medicine.

[czyja, MSN, RN]

IowaKaren said:

Hmmm, it seems where I worked, they would start the Morphine Sulfate at 2.5mg (20mg/ml) and that was such a tough dose to even measure and give, much less count out between shifts (narc count for NH).

Fascinating. How do you measure .125 ml? I suspect it cannot be done outside of a laboratory setting. Seems odd that your pharmacy signs off on an order like this.

[IowaKaren]

Most the time we took it out of the E-Narc Kit so,...

[ellen 12]

The doctor charted morphine to be given as required. So the goal is to treat symptoms with a relatively small dose until the dose is effective. Sublingual is an unusual way to give morphine, if the patient has lost their swallow - we use a pump in a measured 24 hours dose s/c.

[Penelope_Pitstop, BSN, RN]

czyja said:

Fascinating. How do you measure .125 ml? I suspect it cannot be done outside of a laboratory setting. Seems odd that your pharmacy signs off on an order like this.

There are syringes that come in 0.5 mL and the marks make it easy to measure out such small doses.

Often, when we have patients on OxyFast or the like, pharmacy measures out the doses for us and have ready made syringes in the AccuDose, so we don't have to worry about that.

[Hospice Nurse LPN, BSN, RN]

ellen 12 said:

Sublingual is an unusual way to give morphine, if the patient has lost their swallow - we use a pump in a measured 24 hours dose s/c.

We use the SL route 99% of the time. If pain is uncontrolled, we'll start an infusion pump.