The Last Dose

  1. I'm a nurse on a med-surg floor that treats inpatient hospice patients along with our variety of other patients. I have also worked for our local hospice prn. Lately, I've had a a lot of hospice patients at the actively dying phase assigned to me on the floor. I know that I am trusted with these patients because of my good relationship with our hospice providers and my love of working with hospice patients and their loved ones.

    However, I might be hung up on a few deaths and I need to know how to get past it. Over the past few weeks, I have had three deaths (the old theory about coming in threes) in which I administered the last dose of a medication to treat terminal agitation or dyspnea. I know this is a risk of the role that a nurse treating a terminal patient's symptoms runs, but I feel haunted in essence by the fact that my hand delivered a dose of a medication that was requested by family or made necessary by patient's dyspnea, pain or restlessness.

    Working this scenario may seem like Hospice Nursing 101 for old hands, but I'm still fresh to this. I truly love the work and entertain the idea of pursuing a career on a hospice inpatient unit, but I need to learn how to process the emotions of being the one who gave that last dose.
  2. 9 Comments

  3. by   Nashvillejeanne
    Ok...with 15 years in my pocket I have to tell you that someone is going to give the last dose. I always explain this to home caregivers. The guilt can be horrific.

    Number 1...the MD does NOT, I repeat NOT order a LETHAL dose. Get it, know it, repeat after me....the MD does not order a LETHAL dose. So, you could not give a lethal dose.

    The key to palliative management of symptoms dictates that you give medication at the lowest effective dose and watch for symptoms. If you are using morphine remember to watch for toxicity, and alert the MD if that occurs. New folks sometimes forget this can happen.

    You are working wtih an terminal patient in the active dying phase. You did not hasten death because it is NOT a LETHAL dose. What you did was honor their WISHES to have a comfortable passing. You made them comfortable, they were already dying.

    Take a moment and actually read the informed consent for hospice care. It generally states that the patient is CHOOSING to have their symptoms managed and to be comfortable. To not do that is to not honor their wishes and would be the same as allowing them to die a painful death. If I were a family member and my loved died with pain after I contracted with you to relieve pain, I would all kinds of angry. But that's just me

    So...I hope that helped...remember the MD does not order a lethal dose, so you did not give a lethal dose. Hang in there, sister.


    "Everything I have learned in life is from those who have no life left"
    Last edit by Nashvillejeanne on Jan 9, '15
  4. by   motherof3sons
    One thing I try to remember is that the death would have happened regardless of the meds you gave. If it is their time, it is their time.
    You made their passing comfortable and peaceful by giving those meds. Pain meds are given to make the body comfortable so the soul can leave.
    hope that helps
  5. by   caliotter3
    When I have had those disturbing thoughts, I was able to get past the doubts by processing the fact that I was doing my best to make/keep the patient comfortable at their last moments. I have never had a family member request something that would have been inappropriate, so I have not had any problems there. I would only hope that someone would not hesitate to do the same for me when the time comes.
  6. by   lifelearningrn
    It's not the dose of medication you gave that killed them, it's the disease that killed them. Think about like this: There are two scenarios that could play out.. the patient dies at 0100 peacefully, after you have administered a dose of morphine or the patient dies at 0100 with dypnsnea and pain. Either way, the patient dies at 0100. You are not hastening death, you're just making it more bearable for everyone involved.
  7. by   QuiltDog
    I have always said to myself "someone has to give the last dose". As other posters have said, the disease killed your patients, not the medication.
  8. by   Gooselady
    I noticed the nurses most fearful of giving the 'last dose' were the nurses who had the LEAST amount of systemic support -- the night shift. They felt so exposed, with such limited infrastructure support as is the case with night shift. If the plumbing goes out, I've seen night shift nurses get on their knees with a set of wrenches where I'm on the phone with maintenance! They can't call maintenance unless there is a flood, but night shift where I worked fixed the coffee machines, call lights -- they were clever because they had to be.

    The downside of that is obvious, and it was our night shifters who would turn DOWN the narcotic/benzo drips on dying patients. A couple of them I sensed would do this no matter what shift they worked and had rather distorted ideas about being that person who gave the 'last dose'. On a personal level it horrified them, like they would actively blame themselves for the patient's death. All of us had a piece of that in our minds but reasoned through it. Some people are 'cut out' for this kind of work and others can't cope with the implications, and shouldn't have to. We provided 'extra' education and contact with the Palliative care team to the night shifters after a few too many terminal drips got turned down and the families understandably freaked out. It helped quite a bit, but not for every nurse targeted.
  9. by   TammyG
    I was always happy when I could give the last dose -- because I know I kept the patient comfortable while they took their last breath. That is why I became a hospice nurse, to give people good deaths. It is possible that the last dose of a medication had an unintended secondary consequence of hastening death. This is well recognized in the ethical literature. Administering aggressive opioid therapy is ethically and legally justified through the Rule of Double Effect. If the intent is good (e.g., relief of pain and suffering), then the act is morally justifiable even if it causes a foreseeable but unintended result (e.g., hastening of death). There are specific guidelines by the Hospice and Palliative Nurses Association as well as the American Nurses Association that discuss this at length, and you might find some comfort in them.
  10. by   Red Kryptonite
    The disease kills the patient. Not you. Not the meds you give. The disease kills the patient. Repeat it and believe it, because it's true.
  11. by   Here.I.Stand
    Adding my log to the fire. Like the PPs have said, they were dying. These ones happened to die right after you gave a dose of morphine. It was their diseases that killed them; you were giving them the meds they needed, and your actions didn't kill them.