with unstable vital signs. The patient is very near death and is a DNR.
A scenero such as a patient that is actively dying, vitals signs are poor, bp low, heart rate low, respirs low. The patient is moaning. The family says give him something, and you have doctors orders. You know the pain medicine may slow the respirations down too low and you're nervous it may even stop the respirations, but you know the patient is in some kind of distress, perhaps pain (say in a terminal cancer patient who prior to this has been in a lot of pain for months). You may even call the doctor to clarify orders, who says give it now. Do you give the pain medicine?
This is not a question about euthanasia, it's about pain and comfort measures. Is it going too far?
The same thing was taught in my bio-med ethics class. There is always a *final dose.* The intent of that dose defines whether it's pain relief, euthanasia, or murder.
Well said!
Tweety, when my mom was dying, she presented just as you describe your patient. I asked the nurse to give her some more MS and she wouldn't because her resps were something like 8. My sister and I were incensed, of course. I told her to draw it up and I'd give the damn thing myself. We ended up going over her head and the MS was given.
Specializes in Gerontological, cardiac, med-surg, peds.
The patient HAS to be terminal. The patient has to be in the last stages of dying. The patient HAS to be a DNR. The family HAS to be in agreement. The doctor HAS to have written the PRN dosage just as you are giving it, and it has to be within accepted pharmaceutical dosages. Anything done outside of those boundaries can cause a nurse to lose her license, endure a civil suit, or go to jail. (As Mattsmom81 has cautioned us). It is only common sense that giving that last dose of morphine does not "cause" death in a patient who is in the thoes of dying anyway. We KNOW that, but all too often the uneducated, hysterical, suspicious family does not.
That said, I certainly don't want to sound unsympathetic to the dying patient in pain. Every patient should be as pain-free as possible, and have a peaceful passage. This is a basic human right.
Of course the Dr has to have written the order and it needs to be given exactly within those parameters, but why does the pt HAVE to be a DNR to have their pain managed? Also, I think as far as the family is concerned teaching them about pain management is a given.... I took from the original post strictly that a concern was raised about if a dose of ordered pain med would kill the pt. Back to the family issue, yes the family has to agree to a certain extent, but also does the pt have an advance directive? or does one person have power of attorney? And being a true PATIENT advocate means trying to bring all these factors together so that the pain can be managed.
Am I way off base here???? I didn't think so but...I am always open to learning.
Specializes in Gerontological, cardiac, med-surg, peds.
In reply to the above post: "Full code" AND terminal "Aunt Mae" has just been admitted to your unit. She is on a ventilator and 4 different pressors to keep her BP in a barely liveable range. Her nephew, who has POA, insists that EVERYTHING be done for "Aunt Mae" because "she deserves it." Yep, right. Is "Aunt Mae" going to have a peaceful death???? I think not. Her last fleeting memories as she departs this life will be someone beating on her chest, breaking her brittle ribs, multiple shocks with defibrillator paddles, needle sticks, multiple medications and fluids being forced into her fragile veins. No, not a peaceful passage at all. A travesty. But a scene too often witnessed in the ICU and a very, very difficult position for the nurse to be in.
The disease is killing the patient. Reguardless they are entitled to pain relief.
Morphine is not the killer we give it credit for, if used correctly. If the patient is termainal and in pain it is likeley this is only one of many doses given over the course of the illness. The patient has developed a tollerence and even possible a dependence meaning he requires > doses. This being the case the patient is not narcotic naive. He can handle the does without it depressing respers to the point of fatality.
I have used a lot of ms with suffering patients and have yet to give a dose that has proven fatal. Did you know there is no dose ceiling on ms? Did you know it is the weakest of the narcotics?
Intent is everything.
Imagine if pain were not relieved and he died in terrible pain. Is that a better way to go?
I think enough nurses do not understand how ms works. Really undrstand, and undrstand about dependence, and tollerance.
I'm not sure about the "dosage" comment. Terminal pts. can be on hundreds of mgs. of MSO4...that would normally not be considered a pharm. appropriate dose, but in the case of someone who has been on the med for a long time and is terminal, tolerance builds up.
Thank you Agnus!! I have taken many pain management classes and am still amazed at what nurses think about narcs. I had a pt come into the hospital just a month ago...long story short his diagnosis was intractable pain and he was taking approx 400 mg of MS in 24 hrs. at home. He comes in and the PCA ordered by MD was 300 mg in 24 hrs if he hit the button at every possible allowed time...needless to say I was on the phone to MD in a hurry and he made it right....but another nurse on the floor is still upset to think that he would be given "that much". The only side effect that pt does not get used to is CONSTIPATION! And I got an order to help with that while I was on the phone. Have a great Holiday season...
Specializes in Gerontological, cardiac, med-surg, peds.
Did we read the original post differently??? Or are you not having too great a day? I am definitely missing something and refuse to get into this peeing contest....You win. Hope your day gets better...
My apologies for upsetting you, Nurse Paula. What I was trying to say was you need to be very careful in treating a terminally ill patient if the family is not behind you--especially if the patient is a full code. When I was working in a level III ICU (not TOO long ago), we encountered this situation which I described fairly frequently. Families disputing about code status, insisting "EVERYTHING" be done and the patient suffering in a sort of "no-man's" land. Can't be kept as comfortable as should due to "full-code" status. Instead of dying in peace, dying with a room full of strangers with all sorts of interventions being done. It is our job to educate families, but a coding patient is a little too late--families are often hysterical. I was reading a post on the Spectrum not too long ago (the Shady Grove Adventist case, I believe) in which a nurse's license was suspended, her name plastered all over the newspapers, and the nurse taken to court. One of the allegations was a family stating their DYING relative was given a "pain shot" by the nurse and the family member died immediately afterwards. We live in a crazy, litigious society and nurses have to be very, very careful.
A scenero such as a patient that is actively dying, vitals signs are poor, bp low, heart rate low, respirs low. The patient is moaning. The family says give him something, and you have doctors orders. You know the pain medicine may slow the respirations down too low and you're nervous it may even stop the respirations, but you know the patient is in some kind of distress, perhaps pain (say in a terminal cancer patient who prior to this has been in a lot of pain for months). You may even call the doctor to clarify orders, who says give it now. Do you give the pain medicine?
You're describing my day to a "T"
Give the medication, we all deserve to die peacefully and without pain.
(As Mattsmom81 has cautioned us). It is only common sense that giving that last dose of morphine does not "cause" death in a patient who is in the thoes of dying anyway. We KNOW that, but all too often the uneducated, hysterical, suspicious family does not.
sbic56, BSN, RN
1,437 Posts
Well said!
Tweety, when my mom was dying, she presented just as you describe your patient. I asked the nurse to give her some more MS and she wouldn't because her resps were something like 8. My sister and I were incensed, of course. I told her to draw it up and I'd give the damn thing myself. We ended up going over her head and the MS was given.