Patient expires after you give pain medication

Ruby Vee, BSN · Oct 3, 2016

Is this a homework question?

I worked in oncology and hematology for five years, back in the late 70s and early 80s. One of the issues raised in my job interviews for these positions was pain control for the terminal patient and the idea that the 10 mg. of morphine I just gave IV push might be the thing that pushed someone over the edge. Could I live with that? I found that I could.

I'm not talking about giving 10 mg of morphine IV to someone who just walked in off the street; but to folks who were dying of cancer and in incredible pain. When you're giving that much narcotic every two hours, you're going to have to realize that the patient is going to die within two hours after SOMEONE gave a dose. It might be the dose that you gave. The alternative is to let your patient endure the pain without relief.

For the families waiting at the bedside, the agony of waiting is that you KNOW your loved one is in pain. If that dose of pain medicine relieved their pain for a moment before it pushed them over the edge, it was worth it. I'm not saying that as a former oncology NURSE, I'm saying it as the daughter and granddaughter of oncology PATIENTS.

blondy2061h, MSN, RN · Oct 3, 2016

End of life patients often get pain medications q2 hours or closely there to. And they're going to expire. So they're going to expire shortly after somebody medicated them.

Guest219794 · Oct 3, 2016

We can't control when somebody dies. We can, and should, control how somebody dies.

I have, on a number of occasions, given a patient their last dose of medication.

I have been in situations in which I believed the patient and their family would be better off if the patient died. I could easily give them enough medication to hasten their death, and my documentation could support my decision.

I don't. Ever. Every time I use my assessment skills to meet the objective of keeping the patient pain free.

It has never bothered me. I have undermedicated pain in the past, and it bothered me quite a bit.

I can't think of any reason anybody should die in pain.

WKShadowNP, DNP, APRN · Oct 3, 2016

During my last visit with my dad he had been in and out of alertness due to the disease and dying process. He had the typical comfort pack of medications and his wife was educated in administering them. I was alone with him for a little while and he slept soundly until one moment when he yelped in pain. I ran into his room to find his extremely swollen legs pressing into the siderails. "Daddy, I'm here, [shadow's] here. What can I do?"

"PAIN!"

He could only eek out the word between gritted teeth and staggered breaths. On his night stand was the liquid morphine meant for buccal absorption.

'It says you can have 10 or 20mg. How much do you want?"

"20." Weaker this time, but with conviction.

I never hesitated to give it to him. I'd have given him more if he wanted. Anything. Just so he could rest peacefully.

As it was, he slept for about an hour and then when his wife returned, so did his awareness of my presence. He suddenly had to get up and spend time with me.

"[shadow] is here. I have to see her. I need to get up."

After a dinner of something I think was like KFC with all the fixin's and he tried to feed himself we put him back to bed. I forever remember his silly faces and kisses to the dog, pulling humorous expressions at me while he struggled to get the fork to his mouth. Food fell off of his ataxic grip more than did pass his lips. But he was determined to share the time with me. We knew time was short.

The following morning was my flight back home, several states away. I woke him up to kiss and hug him. His embrace was surprisingly strong for his debilitated state. His mind the most lucid, just as it had always been when well. Our last earthly show of affection and love still is indelible to my daddy's-girl heart.

The next few days of his was a watch-and-wait kind of thing. He blessedly rested with the diligent care of his now-widow. She did everything I could hope for to ensure he was comfortable. That's all I could ever ask.

So, to answer your question: Yes. There is an art to palliation and a humanity in its application. It is a bittersweet blessing to provide such comfort and it is balm to my soul that Daddy had a less horrible death than he could have.

Here.I.Stand, BSN, RN · Oct 4, 2016

If the family is present have they ever made any comments or have you felt obligated to make a comment?

When I feel the need to comment, "I'm very sorry for your loss..." works pretty well.

mrsboots87 · Oct 4, 2016

Happens all the time. My PRN job is in LTC that has a Hospice unit in the building. Terminal patients who don't need drips or acute care, live in the LTC with daily visits by a hospice nurse. The remaining care is provided by the floor unit nurses and CNAs. There have been many times a patient passes within minutes of a dose of morphine, Ativan, or combo of both. I feel happy when it happens because they went out on a cloud usually with no pain. I consider it as good a death as I could give them.

In a terminal patient, they will die any time. Sometimes it will be right after mess are given, and sometimes not. sometimea it can be hastened with meds given within ordered perameters for medication but in the high side. It's in the grey area for nursing judgement. I don't personally ever hasten a death. But I do try my best to make them comfortable. If they die after then it's just part of the job.

NurseGirl525, ASN, RN · Oct 4, 2016

It's a terminal wean. In that situation, the family is fully expecting it. Some take as little as 5 minutes, to hours upon hours. Medication does not hasten it. It's an agreed upon situation. It happens all the time. I can give Ativan and morphine every 30 minutes to an hour in a terminal wean.

I just turn and say, I'm so very sorry for your loss and I allow them some time to grieve.

Libby1987 · Oct 4, 2016

Many years ago when I sat on a hospice advisory board, I learned from the medical director that the pain is often what keeps them alive, as in overstimulated, and once controlled the body is able to relax and allow natural death to occur.

Now whether that is actually accurate or not I don't know, The medical director might have just been trying to make an impression but the thought of pain keeping someone alive just because of the intense physiological stress response is pretty awful.

HouTx, BSN, MSN, EdD · Oct 4, 2016

I am with a faith-based organization. One of our major clinical focus areas is pain control, so this issue has been thoroughly explored and clarified for staff by our Ethicist... It's all about intention. Performing interventions - including medication administration - for pain relief is a primary obligation of health care professionals. The secondary effects (e.g., resp supression) should be considered, but should never override the initial intention.

loriangel14, RN · Oct 4, 2016

I would like to add that the cause of death is not the med, it's the disease process. No one should die in pain.

CoastMedRN · Oct 5, 2016

Thank you ALL for taking time to read and comment. However, I am well aware as all of you are about the disease process, dosages, the effects etc. Also, that hospice is end if life and meds comfort but at the same time can hasten death unknowingly. My question however is if you have ever had a family ask if THAT dose resulted in the patients death ... or even if you have asked yourself that question? I am not in any manner suggesting the dose was too high or anything related. Just the situation where the patient expired soon after the dose. Not even suggesting the dose hastened death. Assuming it was just that time dose or no dose. Of course families are anticipating death. Even welcoming it. Just the PERHAPS awkward timing. Of course we give our regrets. We comfort. But wondering simply if a family member has ever asked ... and your response ... if the question asked was: "Do you think the medication was why they died at this moment"? NOT an accusation, not that the nurse did anything wrong. Merely have you ever had this situation take place. BTW I am an RN with decades experience in Critical Care etc and Hospice so not a "homework" question lol. Thanks again to you all.