Palliative Care and Euthanasia

sbic56, BSN, RN · May 8, 2005

I believe that it's appropriate to give PRN pain meds for pain. You believe, apparently, that it's appropriate to give PRNs to prevent pain from ever occurring. We differ in our definition of what PRN means. I'm comfortable with my practice and my definition. I think your definition prompts you to practice outside your scope. We differ. More posts won't help that. I'm done.

Definition, scope...is this the over riding issue? What the patient wants is empathetic care and freedom from pain in their last hours.

leslie :-D · May 8, 2005

prn= pro re nata, a latin phrase meaning 'as needed'. the times of administration are determined by the needs of the patient.

well, if i'm trying to stay ahead of my patient's pain, that to me, connotes "as needed" with the intention to prevent pain and suffering, per the needs of my patient. :stone

so no, i am not practicing outside the scope of my practice.

leslie

hollyster · May 8, 2005

Definition, scope...is this the over riding issue? What the patient wants is empathetic care and freedom from pain in their last hours.

Exactly. Comfort and compassion and dignity. Freedom from pain is the greatest blessing one can have.

Earle, Thank you very much for all the wonderful information you have posted.

I value your opinions.

req_read · Jun 7, 2005

Hi everyone,
This is my first time posting on allnurses.com. I am a final year nursing student at Napier University, Edinburgh.
Part of my coursework involves selecting one of the World Health Organisation palliative care principles. I have chosen 'intends neither to hasten or postpone death.' My essay will provide a literature review and analyse wether euthanasia has any place within palliative care - What are your views on this?
How does the above discussion relate to clinical practice?

Hi bracken,

I am of Scottish descent and would love to visit someday. But back to your original query...

As you can see, this is a touchy issue. Even experienced hospice nurses disagree... sometimes heatedly. To be honest, I would trust any one of the nurses making posts on this issue were I terminal.

There is a key issue that often gets overlooked however. The stated principle has 2 parts, although just 1 always seems to become the focus.

'intends neither to hasten or postpone death.'

We tend to get obsessed with 'hastening' part but forget about the 'postponing' part. In my practice I became convinced that pain could actually postpone death. I think it can do this by, 1- preventing the patient from resolving their unresolved issues, thereby prolonging their dying process, and 2- by capturing their attention so as to prevent such things as 'near death awareness,' which often leads to patients 'moving on' as more of a matter of choice (wanting to go there) as opposed to the out and out physical failure of their body.

Just for the record, I do not agree with euthansia, but I have given doses of narcotics that scared me silly. I do not think I ever 'pushed anyone over the edge' as the saying goes, but I've given some doses you would probably not believe. It is always tense being there with a suffering human being wanting so badly to help but wanting just as badly to not cause harm. Having been there myself I am abundantly aware of the emotional impact and hence, the emotional sensitivity/defensiveness.

But I wonder what all you pros think about pain postponing natural dying process. If that is the case, at least in certain situations, easing pain might indeed hasten death, but not natural death. It would be more a case of preventing unnatural lingering.

leslie :-D · Jun 7, 2005

Hi bracken,
But I wonder what all you pros think about pain postponing natural dying process. If that is the case, at least in certain situations, easing pain might indeed hasten death, but not natural death. It would be more a case of preventing unnatural lingering.

i strongly and firmly believe that pain prolongs the dying process.

i've had patients whose pain was unrelenting and they cried out these curdling screams of agony and no matter what meds were given, sometimes nothing works....and we would pray that they pass right there and then and it seemed forever but would last around a week.

then you have patients with the same depth of pain and the narcs work like a gem...their bodies,their minds, their souls all can relax and peacefully die. i hesitate to use 'natural' as they are dying from cancer or the end stage of some disease process.

but in its' most simplistic form, i do believe that the disease process takes over once pain is relieved, allowing nature to progress as it should.

i know i sound like a broken record, but i can't emphasize enough about the role of adrenaline and cortisol when we suffer,and how it wreaks havoc on the body. in the absence of those 2 hormones, the body can then reestablish a homeostatic state, allowing the body to progress in its' natural state, whatever the etiology.

leslie

doodlemom · Jun 11, 2005

But I wonder what all you pros think about pain postponing natural dying process. If that is the case, at least in certain situations, easing pain might indeed hasten death, but not natural death. It would be more a case of preventing unnatural lingering.

I have to agree that pain postpones the dying process. I can't tell you how many times I have seen people in agony and as soon as they get comfortable, they die. I've had that happen on several occasions when I've disimpacted a pt and then they died. as well.

stevierae · Jun 11, 2005

katillac,
i need to let you know that i find your philosophy extremely distressing.
why should you have to chase pain if you can prevent it all together?
i am strictly talking about those pts who are in much pain.
but why would any hospice nurse allow their pt to suffer for 1/2 hr, nevermind the anxieties and fears invoked by the pts.because of the anticipated pain once the mso4 starts wearing off.
and the "ethical justification" would be to stay ahead of the pain...to prevent suffering.
i've taken the liberty of providing you w/some insight re: staying ahead of pain.
http://www.juneauempire.com/stories/051000/com_hospice.html
http://www.capitalhospice.org/patients/caregiver/managing.asp#h4
http://www.silencetovoice.com/narratives.html
http://www.pathology2.jhu.edu/ovca/hospitalexperience.cfm
http://www.americanradioworks.publicradio.org/features/hospice/a3.html
do you work in hospice?
leslie

I absolutely agree with you, leslie. I found her post very alarming. NO patient should ever have to suffer with pain unnecessarily--let alone a terminal patient with intractable pain. I believe any compassionate and empathetic caregiver is absolutely obligated to stay AHEAD of the pain---not make the patient wait until he's in agony, as he soon will be--in fact, why does he have to wait until he is in pain at ALL? Why can't the meds be offered and given in a manner that the pain is kept from surfacing, and the patient can enjoy some quality time or even get some rest?

My gosh, even in nursing school 25 years ago, with routine post-op patients, we were taught to offer and even encourage the post-op pain meds that were ordered--I don't feel that we are doing our jobs and assessing acute pain accurately if a patient in acute pain has to ASK for pain medicine. And a patient with chronic pain? Or intractable pain involved with a terminal illness; such as cancer that is metastatic to bone? To allow those patients to suffer even one second with unnecessary pain is simply inhumane. Why else would we have made such strides in the arenas of chronic pain management and palliative care?

I'd be very alarmed if I was so close to end of life that I needed a hospice nurse, and that hospice nurse was stingy with the narcotics--and worried about hastening my death, which is after all, inevitable. Well, here in Oregon, at least, we have the "Death with Dignity" or "Physician Assisted Suicide" act---I don't know that I'd ever take advantage of it, but I can see why some people may need to do so. I just don't understand her philosophy.

leslie :-D · Jun 11, 2005

I absolutely agree with you, leslie. I found her post very alarming. NO patient should ever have to suffer with pain unnecessarily--let alone a terminal patient with intractable pain. I believe any compassionate and empathetic caregiver is absolutely obligated to stay AHEAD of the pain---not make the patient wait until he's in agony, as he soon will be--in fact, why does he have to wait until he is in pain at ALL? Why can't the meds be offered and given in a manner that the pain is kept from surfacing, and the patient can enjoy some quality time or even get some rest?
My gosh, even in nursing school 25 years ago, with routine post-op patients, we were taught to offer and even encourage the post-op pain meds that were ordered--I don't feel that we are doing our jobs and assessing acute pain accurately if a patient in acute pain has to ASK for pain medicine. And a patient with chronic pain? Or intractable pain involved with a terminal illness; such as cancer that is metastatic to bone? To allow those patients to suffer even one second with unnecessary pain is simply inhumane. Why else would we have made such strides in the arenas of chronic pain management and palliative care?
I'd be very alarmed if I was so close to end of life that I needed a hospice nurse, and that hospice nurse was stingy with the narcotics--and worried about hastening my death, which is after all, inevitable. Well, here in Oregon, at least, we have the "Death with Dignity" or "Physician Assisted Suicide" act---I don't know that I'd ever take advantage of it, but I can see why some people may need to do so. I just don't understand her philosophy.

sadly stevierae, she is not alone in her thinking.

there are far too many doctors and nurses that are reluctant in administering narcotics.

the irony is that they're afraid of a liability, not recognizing that they can be held liable for NOT treating pain appropriately.

that's why i am such a proponent of scheduled narcotics.

but even more important, is ongoing education re: effective pain mgmt.

this should be a mandated course in med school along with end-of-life care.

you would be startled to know of how many nurses i've worked with, that have not given prn mso4, EVEN W/THE PATIENT GROANING....fearing that they'll 'kill' the patient. thank God i was the only hospice nurse in that facility. when i wasn't there, my pts were at the mercy of the nurses from the other unit(s). for the most part, i did manage to get my patients what they needed on a scheduled basis. that prevented many potential problems.

i just don't understand how some people think. sigh..........

leslie

hollyster · Jun 12, 2005

sadly stevierae, she is not alone in her thinking.
there are far too many doctors and nurses that are reluctant in administering narcotics.
the irony is that they're afraid of a liability, not recognizing that they can be held liable for NOT treating pain appropriately.
that's why i am such a proponent of scheduled narcotics.
but even more important, is ongoing education re: effective pain mgmt.
this should be a mandated course in med school along with end-of-life care.
you would be startled to know of how many nurses i've worked with, that have not given prn mso4, EVEN W/THE PATIENT GROANING....fearing that they'll 'kill' the patient. thank God i was the only hospice nurse in that facility. when i wasn't there, my pts were at the mercy of the nurses from the other unit(s). for the most part, i did manage to get my patients what they needed on a scheduled basis. that prevented many potential problems.
i just don't understand how some people think. sigh..........
I agree with you leslie. I believe that pain meds should be scheduled, not prn (and not get away with writing dose held due to drowsiness.)
I cannot understand how someone can watch a pt in agony and not treat them because they are afraid of hastening the inevitable. Nursing schools should make teaching pain relief a priority. Hospice care should be a mandatory clinical not a one or two day visit. Nurses and doctors need to realize that pallative care is not euthanasia and that pts have the right to be as comfortable as we can make them using every method at our disposal.
It makes me sad that some excellent nurses, in other repects are, uncomfortable medicating terminal pts for pain.

leslie :-D · Jun 12, 2005

hollyster,

i had a pt.s/p mastectemy w/mets to the bone.

for reasons unbeknownst to me, the nm told the pcp that she was w/o pain and had all her pain meds dc'd.

this pt.,very stoic, shared w/me her pain and asked me to "fix it".

i went above the nm, called the pcp and relayed the pt's statement as well as my observations.

he prescribed a commendable regimen, scheduled and prn for breakthrough.

since i was working a double, i gave her everything until her pain was relieved.

she and her dtr. thanked me over and over.

the pt.died that evening.

my nm, the adon and don were furious w/me for breaking the chain of command.

short of telling them to go to helll, i reminded them that i was there for the pt. and her well-being.

i got written up for insubordination and i fought it, all the way to corporate headquarters in california. i also reminded them of the legal implications of letting a pt suffer.

i was vindicated, in writing, but to this day, that incident had changed my relationship w/my nm. yes, i was judgemental since we had recently had an inservice on pain mgmt.

and i even gave this pt. mso4 with her rr at 6/min- no parameters had been ordered. yet even with breathing at 6/min, she still softly moaned.

yet i didn't hesitate to give what was needed.

and even in her obtunded state, her eyes met mine and she softly said "thank you louise" (confused w/some dementia). her dtr cried for her loss but also for me relieving her suffering.

unfortunately there aren't that many doctors who would prescribe such a liberal regimen and for him, i was grateful. i was also grateful that i was on duty for 16 hrs which gave me the control i needed. the reprimands i received didn't phase me in the least. it's all about ignorance and lack of education.

so yes,there must be much more emphasis on the issues surrounding end of life care and pain mgmt. no matter how involuntary, it is cruel to withhold a pain med for fear of persecution. absolutely no reason for it.

hopefully one of these days, doctors and nurses will appreciate the necessity of the 6th vital sign and act accordingly.

leslie

hollyster · Jun 12, 2005

Leslie

You are a true pt advocate. I too would have bypassed the NM, she is your pt and you were responsible not her. If the daughter had c/o about the pts untreated pain the NM would have put the blame on you. Your NM is just having a tiff because you not only proved that you were a better nurse but you also showed her that caring is more important than towing the party line. I wish that the nursing boards would address pain management issue and come down on nurses that under medicate for pain. How sad(not only sad but criminal IMO)

that anyone would let anyone suffer agonizing pain due to the ignorance of their caregivers. This is the one area of medicine that infuriates me. We spend billions of dollars trying to extend life but very little to finding ways to ease pts pain or to train staff how to comfort the pt and families when the end is near.

GREAT JOB LESLIE!!!!!

stevierae · Jun 12, 2005

Wow---leslie, you are truly to be admired. This is what patient advocacy should be all about. I commend you for your courage and your passion for "doing the right thing." Too many nurses are afraid of making waves, let alone bypassing the chain of command or even approaching a physican directly to effect a change in orders that would better serve the patient. Those nurses have no place in end of life care, where a patient is absolutely dependent on his nurse to advocate for him--as is our role in the first place, in ANY patient care situation. Too many nurses, sadly, seem to have forgotten or never learned that.