Hurrying death? - page 3

by lalalulu

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I really need some opinions please. I have a patient who is on hospice and did have some pain issues where roxanol was effective for them. However today it appears as if the doctor and family have decided its time to put him out... Read More


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    NPO and the patient could still have ice chips. Mouth swabs in cold water. The last thing that you would want is for the patient to start coughing on liquid.
    You have to document why it is you are giving ativan and pain meds. Be mindful if the patient is struggling to breathe, is antsy and appears not comfortable. The goal is peaceful and at ease, and q 2 hours and you may assess that the patient is needing something at that time. If the patient continues to appear comfortable, then a discussion with the MD needs to happen regarding the fact that you can not find reason (that you are legally responsible for) for the patient to have q 2 meds, that if it is PRN that you are going to assess q2, however, will not be medicating if the patient is appearing comfortable, however, at the first sign of the beginings of distress you will medicate accordingly. (and let the family know the same)
    Make sure you document well. The family nor the doctor would be in any position I would not think to complain that you did not give meds q 2 if you document the patient was sleeping comfortably. You, however, would have a hard time explaining why you would medicate at that time.
    And this squirting in the mouth thing.....REALLY? I am not sure that this is the way to adequately be able to manage pain and anxiety. Is there another route that can be used? The patient can not have IV access? A sub-q lock? (and ativan IM is not ideal, but perhaps more comfortable for the patient than squirting liquid in their mouth if they are NPO and not swallowing well.)
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    The Roxanol and Ativan would be administered sublingually so should not be squirted into the mouth, but rather the meds should be placed under the tongue where they are absorbed into the system. If it is possible to control pain and respiratory issues that way it is preferable to an IV, which can be very invasive for a dying patient.

    At end of life it is common to see Roxanol given Q hour; I have not had the experience of being told it must be given every hour as a scheduled med, usually it is PRN and is given according to nursing judgement.

    In my own experience, usually when the dr. orders NPO, the order refers to PO medications, which are d/c because they are not useful to a dying patient, and cannot be swallowed anyway.

    I have not had an order to specifically withhold fluids, and use my nursing judgement as far as that is concerned, but other hospice nurses might have a different experience. It can be very uncomfortable for a dying patient to receive liquids and not at all helpful.

    However, it does depend on where the patient is in the dying process. I would never withhold liquids from a patient who was alert enough to ask for them, although would probably provide sips or ice chips and good oral care.
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    Quote from lalalulu
    I really need some opinions please. I have a patient who is on hospice and did have some pain issues where roxanol was effective for them. However today it appears as if the doctor and family have decided its time to put him out of his misery. I have no problem keepin pt comfortable But I really feel like I'm forcing pt to die. Roxanol and Ativan ordered q2h routine even if pt sleeping, they want me to squirt meds in mouth. And made npo even though he was requesting drink just yesterday. The pt is elderly, and was miserable but I guess I feel like I'm putting a dog down or something. Other hospice pts I haven't had routine orders like this.

    I just feel morally and legally weird about this issue. Does anyone else ever have an issue with doctors orders for end of life pts?
    I've had one instance where family member, a son and daughter, kept pushing for the staff to purposefully overdose their father.

    The Palliative Care MD and everyone else who they pushed for this entered their request into notes and explained to the family in no uncertain terms that this would NOT be done and that meds would continue to be used appropriately. I had the patient for a few shifts and got to know them a little bit. We ended up talking at length about end of life issues and policies. It turned out they were completely unaware that we don't OD people on purpose. They thought it was a normal part of hospice care and just wanted it to end quickly for him.

    I told them, "If I wanted to kill him painlessly and instantly, I wouldn't even use the things we are giving him now, these drugs just don't work that way. You know your dad, he did things his own way and on his own time, correct? Well, this is no different. We will keep him comfortable, but he is still running the show."

    They seemed to understand this, and their father passed away on my shift the next evening. They expressed deep gratitude to me for talking with them about the situation.
  4. 0
    Quote from jadelpn
    NPO and the patient could still have ice chips. Mouth swabs in cold water. The last thing that you would want is for the patient to start coughing on liquid.
    You have to document why it is you are giving ativan and pain meds. Be mindful if the patient is struggling to breathe, is antsy and appears not comfortable. The goal is peaceful and at ease, and q 2 hours and you may assess that the patient is needing something at that time. If the patient continues to appear comfortable, then a discussion with the MD needs to happen regarding the fact that you can not find reason (that you are legally responsible for) for the patient to have q 2 meds, that if it is PRN that you are going to assess q2, however, will not be medicating if the patient is appearing comfortable, however, at the first sign of the beginings of distress you will medicate accordingly. (and let the family know the same)
    Make sure you document well. The family nor the doctor would be in any position I would not think to complain that you did not give meds q 2 if you document the patient was sleeping comfortably. You, however, would have a hard time explaining why you would medicate at that time.
    And this squirting in the mouth thing.....REALLY? I am not sure that this is the way to adequately be able to manage pain and anxiety. Is there another route that can be used? The patient can not have IV access? A sub-q lock? (and ativan IM is not ideal, but perhaps more comfortable for the patient than squirting liquid in their mouth if they are NPO and not swallowing well.)
    Yes, when I worked in hospice we did use highly concentrated liquid forms of morphine and sublingual ativan on our patients who were actively dying. Most of them did not have veins that could support IV access. Besides, why cause a dying patient more pain with repeated sticks (IV, IM or SC)? Absorption/circulation of the drug may not be as efficient as oral mucosal route.
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    At the LTC facility where I teach, they frequently place a subQ line. They give ativan and morphine through that Q1-2 hours. Is that not common in other palliative situations?
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    This could be an infinite discussion. Several of you have already brought up good points and good strategies for dealing with these situations. Here's my thoughts:

    Despite our current culture, death is as much a part of life as being born and living life.
    Having (or helping to provide) a "good death" is a perfectly acceptable and admirable goal.
    There is a difference between prolonging life and prolonging death. I'm all for prolonging life, I am not at all for prolonging death.
    There are fates worse than death. Death can be a real gift for the patient and the family.

    I am not advocating going against orders. I'd also be lying if I didn't say I wish assisted suicide were legal in all 50 states. I also feel equally strong that we (as a country) can do so much better in educating people about end of life and advanced directives so there is no question what the patient would want and how they want to go. Of course, that is part of my utopia...dignity to the end.
  7. 0
    Quote from mappers
    At the LTC facility where I teach, they frequently place a subQ line. They give ativan and morphine through that Q1-2 hours. Is that not common in other palliative situations?
    I have seen records from multiple states. I see some areas where Q1-2 hour orders is more common, others the orders are PRN. I think both are likely equally as common if you average them but it tends to go with the comfort level of the directing physician.
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    [/QUOTE]"Yes, when I worked in hospice we did use highly concentrated liquid forms of morphine and sublingual ativan on our patients who were actively dying. Most of them did not have veins that could support IV access. Besides, why cause a dying patient more pain with repeated sticks (IV, IM or SC)? Absorption/circulation of the drug may not be as efficient as oral mucosal route. [QUOTE)

    I know this is a mildly older thread, but I have seen discussion about the absorption of SL/PO morphine and more importantly, WHERE it is absorbed. Much (but probably not enough) research has been done (with healthy subjects - not dying people) on the bio-availibility of nebulaize, PO, SL, IV, SC, PR equianelgesic doses of morphine.

    [/QUOTE]Pharmacology: Sublingual administration of morphine is often used to treat breakthrough pain in an attempt to hasten analgesic onset and peak; however, available data do not support more rapid absorption of morphine through the sublingual mucosa when compared with the oral route (1-3). Indeed, a number of clinical studies have found no substantial advantage to the use of SL morphine over oral morphine (4-6).

    •Mean time to maximum concentration has been shown to be shorter following PO morphine (0.8 + 0.35hr) compared with SL (1.75 + 1.30 hr), indicating that SL morphine is likely swallowed and absorbed gastrointestinally rather than through the oral mucosa. From www.eperc.mcw.edu. (Fast Facts from the EPERC).

    Morphine placed in the mouth is not well absorbed through the oral mucosa - something about its lipid insolubility and the pH of the mouth....it IS absorbed via the GI tract, but is subject to 1st pass hepatic metabolism. I have not had much sucess with clients who are not able to swallow AND in pain - will go to PR, IV or SC route (preferably not PR but it can be effective) anytime I can.
    Just my .01 cent. BTW, hospice nurses rock!


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