Palliative Care and Euthanasia - page 7

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... Read More

  1. by   leslie :-D
    Quote from jsteine1
    It would appear that earle58 chose to read into my entire message and misinterpret it entirely. This is not a debate forum.
    i reread your post and am unsure of what i misinterpreted. my response is similiar to katillac's. i was merely responding. actually there's nothing to debate. i'm confused re: your response to me but certainly won't dwell on it. if you care to elaborate, i'm all ears.

    leslie
  2. by   Moishe Pupik
    In terminal illness patients are confronted with physical, emotional, and spiritual suffering, as well as loss of control and dignity. I believe it rational for a terminally ill, mentally competent adult to want to hasten their death. It should be the patients choice. We should not break the law, but nor should we impose our values on our patients.
  3. by   aimeee
    Quote from jsteine1
    i think passive euthenasia, if you will, occurs. for example, in a case of end-stage copd, ms in used in nebulizers extensively as well as oral administration prn. we all know the respiratory impact of morphine.
    i absolutely disagree. i believe most nurses fear the respiratory impact of morphine without regard to the dosage of morphine being used due to the cautions we continually heard in nursing school. the morphine doses used in nebulizers and orally are small, effective and safe. this is the kind of misconception that we have to continually battle against.

    i doubt any nurse here would consider giving a couple of vidodin to be "euthanasia" and yet they contain a higher equivalent dosage of narcotic than the standard dose of morphine used to relieve dyspnea in an end-stage copd patient. in our country an absolute mythology has grown up around morphine that has little to do with fact.

    furthermore, chart reviews have shown that narcotics given during the dying process according to established protocol, for the purpose of relieving pain and suffering, have no statistical effect on the length of the dying process.
  4. by   elthia
    Quote from aimeee
    i absolutely disagree. i believe most nurses fear the respiratory impact of morphine without regard to the dosage of morphine being used due to the cautions we continually heard in nursing school. the morphine doses used in nebulizers and orally are small, effective and safe. this is the kind of misconception that we have to continually battle against.

    i doubt any nurse here would consider giving a couple of vidodin to be "euthanasia" and yet they contain a higher equivalent dosage of narcotic than the standard dose of morphine used to relieve dyspnea in an end-stage copd patient. in our country an absolute mythology has grown up around morphine that has little to do with fact.

    furthermore, chart reviews have shown that narcotics given during the dying process according to established protocol, for the purpose of relieving pain and suffering, have no statistical effect on the length of the dying process.

    i totally agree. i once had a family member who was absent for the entire 2 month hospitalization until the last 3 days of the patients life. the family member then became very irate at the amount of morphine the patient was getting. the patient was dying of lung cancer, and was on a morphine drip titrate to comfort. i finally had to explain to the family that we were not "killing him" or keeping him "sedated". fatigue goes hand in hand with cancer, and when a patient is struggling to breathe, that is tiring also. i stated that "normal respirations run 12-20 breathes a minute", and i was going to keep titrating that drip until the patient's respers were down to 12-20. at the time the respers were 36-48!!! i also stated that the patient was going to die within a matter of hours to days, but on my shift i was going to do my best to make sure he died comfortably. the patient didn't always ask to have the drip titrated, but once he could breathe easier he did ask to speak to me, and some of his last words to me were "i just want to thank you for what you have done". sometimes nurses have to use alternative methods such as respiration rate and the flacc pain scale as guidelines in administering prn's, nurses need to remember that we speak for the patient when the patient is unable to speak for himself.

    fortunately, at my facility most of the doctor's will write orders stating "pt is comfort care, do not hold meds for low bp, or low respers, only hold meds for excessive sedation, notify md when meds are held".
  5. by   dinkymouse
    Quote from Katillac
    I don't think you'll get much argument from anyone that it's poor nursing judgement to fail to take action with a patient who is "sweating and struggling for every agonizing breath (because they) could not verbalize pain". However, there is a huge difference between allowing that and presuming that you know, based on a patients' diagnosis, who has pain and who does not. My education and experience have taught me that all patients are different, that I need to assess carefully using both nonverbal and verbal signs and symptoms. If my serial assessments show that my patient has persistent pain, I often approach the MD for a routine order or a long acting med. Until I get it, I continue to treat the first sign of breakthrough pain.

    By your logic, if I have a patient that gets a PRN order, I should start giving it then and give it to the max perameter routinely to eliminate the possibility that they might have pain. With opioids especially, the consequences of that can be dangerous, and I think it shows poor nursing judgement. You say that "pain is subjective" but then go on to say that you know based on diagnosis whether a patient has pain or not. So if someone with liver CA with bony mets says he has no pain, you give him the PRN anyway? Your education and experience have taught you that you know best, it seems.

    This board is read by both laypeople and professionals. I'd like to assure those reading that few nurses take this "one size fits all" approach to pain management, and few allow pain to go untreated.
    In a discussion with a doctor in my first year as a nurse he said, "It is better to put the cart before the horse, In other words it is better to prevent the pain before it gets there" I have followed these words throughout all my jobs. I have had many stoic patients who say they aren't in pain but their body is rigid with it and their vitals also emphasis the point.
  6. by   Katillac
    Quote from dinkymouse
    In a discussion with a doctor in my first year as a nurse he said, "It is better to put the cart before the horse, In other words it is better to prevent the pain before it gets there" I have followed these words throughout all my jobs. I have had many stoic patients who say they aren't in pain but their body is rigid with it and their vitals also emphasis the point.
    OK, I'm just back from a glorious vacation, so I'll bite again. How, exactly, do you "prevent the pain before it gets there"? I hope what you mean is that you give routine and/or long acting medication as ordered. That's just appropriate nursing practice.

    As to the patient whose body is rigid and their vitals abnormal but they are denying pain, how do you respond?
  7. by   md8s
    Hello, I am an LPN student at a hospice clinical site, and just want to say that these posts have really taught me alot, I was afraid that hospice was a type of undercover euthanasia, and they were allowing the people to die by pushing so many meds, but my question is do you think the line is ever crossed with some people? Do you think some nurses are just concerned about keeping the pt sedated? How much does your spiritual beliefs play in the hospice situation?
    I think it's important to follow the guidelines because they are there for a reason, but are they overstepping boundaries? I had to give pain meds Dilaudid and something else, to a patient who did not show signs of pain, but she wouldn't eat, has NHL w/mets. I'm a student under the guidance of an RN, and I didn't feel ok with it. She denied any pain, how do you say no to what you feel is not right.
    by the way Katillac I like your style.
  8. by   leslie :-D
    Quote from md8s
    Hello, I am an LPN student at a hospice clinical site, and just want to say that these posts have really taught me alot, I was afraid that hospice was a type of undercover euthanasia, and they were allowing the people to die by pushing so many meds, but my question is do you think the line is ever crossed with some people? Do you think some nurses are just concerned about keeping the pt sedated? How much does your spiritual beliefs play in the hospice situation?
    I think it's important to follow the guidelines because they are there for a reason, but are they overstepping boundaries? I had to give pain meds Dilaudid and something else, to a patient who did not show signs of pain, but she wouldn't eat, has NHL w/mets. I'm a student under the guidance of an RN, and I didn't feel ok with it. She denied any pain, how do you say no to what you feel is not right.
    by the way Katillac I like your style.
    i would be profoundly disappointed, to learn of nurses medicating, just for the sake of sedation.
    overall, no, hospice nurses do NOT do this.
    and yes, spirituality is a key determinant as to my ability in caring for the dying.
    i honestly do not think i could be an effective hospice nurse, if i didn't have my beliefs about a hereafter.

    as to the amount of pain meds, there is always a tradeoff.
    either, remain alert and experience pain or become sedated with no/minimal pain.
    even when a pt denies pain, a nurse needs to consider how to keep the pt pain-free...
    which always necessitates staying ahead of it and giving the pain meds atc.
    a very experienced hospice nurse, will consult with the doctor, if s/he feels the dosages are too much.
    it's often a very delicate balance.

    but the bottom line is, when a pt denies pain, we nurses, want them to stay that way.
    it is more difficult trying to treat pain, when it is full blown, so maintenance doses are the way to go.

    finally, i like katillac's style, too.

    leslie
  9. by   teach_hospiceRN
    wow, i have to say it took me a while to get through all of the posts, and from what i see most veered off the question that was presented. perhaps a separate thread to discuss the use of prn and pain meds would have been more appropriate. i see many strong feelings posted here and i believe that what we as nurses in hospice need to remember is what the patient wants. the discussion needs to be had with them in the care planning stage what he/she needs/wants. an honest discussion with the patient and the family need to be had regarding the use of narcotics and at what stages they are extended release with breakthrough meds ordered, sl meds such as roxanol, iv or sq morphine or dilaudid. it should always be about the patient, not what i as a nurse believe, as long as i am following the nurse practice act for my state and the guidelines of my poc.my spiritual beliefs should never interfere with my treatment of the patient.
    but back to the original question. as a student nurse 22 years ago, i also did a research paper on euthenasia. it is amazing the responses you get when discussing this topic with people. should this ever have a place in hospice? why not? what is hospice about anyway, if not the comfort of the patient. why shouldnt the patient have the right to say when enough is enough for them and be allowed a comfortable death on their own terms? we can take our dogs and cats to the vet and have them put to sleep just because they are getting old or we dont want them anymore... but a human? omg.....
    i hope one day the majority of americans will come to understand how euthanasia is a right all people should be entitled to. a part of hospice? sure, at some point it will be allowed and embraced. currently a couple of states are allowing doctor assisted deaths and i say more power to them.
    am i a nurse kovorkian? am i out here killing my patients so they dont suffer? no. im a diligent hospice nurse assessing the pain level of my patients and discussing with my patient and family the treatment options and obtaining orders and educating the pt/family on their uses. but i believe in everyone's right to determine how their end will be.
    i hope that gives you a reasonable answer studious. good luck on your paper. i too am back in school and researching a paper as well.
  10. by   md8s
    Yes, your spirituality should play a part as a Nurse! I am in it for the compassion and it is my calling. Only GOD can give and take Life. I love how HUMANS just want to think that we are so smart and we have the world in our hands that we should be able to decide if it's time for someone to go. Most people in Hospice are so out of it how could they even know when it's their time? It's comfort not killing! AND YES you are speaking of suicide/murder. The universe is vast and we don't know all the things that are out there, God has created life and I will not decide or let someone decide if it should be taken.
    And all of those GOD bashers out there, go ahead and Bash, because in the end I will be where I need to be...with God.
  11. by   patsysparksrnchpn
    Do any of you ever use anything but narcs? I am all for using morphine, methadone, whatever it takes to relieve my patient's pain, but I agree that preventative measures and long acting are optimal. I want my patient not to need breakthrough meds. I want to treat the specific pain. Morphine does not work for all pain. Adjunctive medications should be added and meds have to be tweaked and titrated. As stated in other posts, we are the advocates for the patients and cannot just look for the easy fixes. More than once, I have advocated to add adjunctive meds or change to methadone for neuropathic pain. This is why we ask so many questions about pain..where, when, what does it feel like, what makes it better, what makes it worse, and with patients unable to verbalize, go to your history, learn about the patient and prior problems that may have been exacerbated by this illness, or forgotten because of the terminal disease.. If your patient had arthritis and gerd before the dementia, stands to reason they still have it and have untreated pain. Okay, sorry, off my soapbox.
  12. by   LMT2BSN
    Here is a take on euthanasia, away from the HP/patient relationship. Helps to view issues from indirect perspectives. The last lines are very powerful. Not trying to take away from the credibility of the debate, but "god" has already been mentioned.

    The Promise
    Sharon OldsWith the second drink, at the restaurant,
    holding hands on the bare table,
    we are at it again, renewing our promise
    to kill each other. You are drinking gin,
    night-blue juniper berry
    dissolving in your body, I am drinking Fum,
    chewing its fragrant dirt and smoke, we are
    taking on earth, we are part soil already,
    and wherever we are, we are also in our
    bed, fitted, naked, closely
    along each other, half passed out,
    after love, drifting back
    and forth across the border of consciousness,
    our bodies buoyant, clasped. Your hand
    tightens on the table. You’re a little afraid
    I’ll chicken out. What you do not want
    is to lie in a hospital bed for a year
    after a stroke, without being able
    to think or die, you do not want
    to be tied to a chair like your prim grandmother,
    cursing. The room is dim around us,
    ivory globes, pink curtains
    bound at the waist—and outside,
    a weightless, luminous, lifted-up
    summer twilight. I tell you you do not
    know me if you think I will not
    kill you. Think how we have floated together
    eye to eye, nipple to nipple,
    sex to sex, the halves of a creature
    drifting up to the lip of matter
    and over it—you know me from the bright, blood-
    flecked delivery room, if a lion
    had you in its jaws I would attack it, if the ropes
    binding your soul are your own wrists, I will cut them.
  13. by   Ginapixi
    to sbic 56
    and may be some one else already responded to:
    >>I like what you had to say here, but can't it still be said that this explanation is a rationalization for giving the MS for comfort when in fact you are causing death? I remember a personal situation with a family memeber where I wish the nurse would have thought the way you do. (Wouldn't give the MS just because resps were below 10 :angryfire )

    BTW, I believe euthanasia certainly would play a part in hospice if the patient truly desires it. <<

    after all my years working with death and dying morphine has not yet killed any one! i came to that conclusion after having had a pt on 80 mg/hr IV no changes in respirations, heart rate or general disposition (and it had been the family while the pt was still in the hospital who had demanded to increase by 5 mg every couple hours and 3 weeks later pt still with us and home)
    we die when our time is up! when our heart beats are used and we are "called home"; the only question that remains for me is: with how much suffering do we die? no one wants to suffer, some times i feel patients literally cannot die if they are in too much pain; i am not sure about all the details but will find out for myself some day i am sure; then i will know if some degree of suffering may be worth while to endure.
    until then hospice is far from euthanasia! that is what i had for my cat when he was deathly ill: injection of a sedative and then he got the most wonderful medicine ever invented! in all my hospice years i never saw some one go so peaceful! no gasping for air, no pain, no struggle my cat closed his eyes while i kept stroking his head saying good bye and crying my eyes out - after it was all said and done i truly was thinking i want to die like that too when my time comes! NO euthanasia and hospice are not even related!

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