Pain Medicine for a dying patient ...

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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?

Quoted from Ratchit . . .

"A mentor of mine somewhere along the way told me that pain is not an acceptable way to sustain a blood pressure. That voice in the back of my head has made this situation easier for me several times."

Thank you . . . . I'll keep that thought in mind too.

Give the medication.

steph

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Specializes in Psych, Med/Surg, Home Health, Oncology.

Hi

I would absolutely give the pain med. As so many people have commented, it is the intent.

I have worked Oncology for almost 28 yrs--even before Hospice, and it has always been the intent that is the key.

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Specializes in Geriatrics, Pediatrics, Home Health.

I would definately give the med. In the late 70's early 80's, I witnessed two deaths from cancer. The pt. was not given MS. WHY??? Because the dr. was afraid he would get ADDICTED!!

Give me a break, the person is DYING, and if he gets addicted, WHO CARES??? When my FIL died of cancer, [in 1990] he had hospice. The hospice Nurses gave him as much morphine as he needed. The dr. wasn't worried about addiction, he wanted to relief PAIN!!

The above is one of the reasons it took me so long to get into Nursing. There was NO WAY, I could work with a pt. knowing I had the relief they needed but NOT be allowed to give it, because they might get addicted!!

I have been in severe pain and all I wanted was relief!! I even told one ER doc. that if he didn't allow his nurse to give me relief, then I would do it myself!! :imbar I had no idea how to give a shot, but I would have done it.

PLEASE PLEASE PLEASE give the pain med as ordered. The pt. will be eternally grateful.

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Yes. Yes, I would give the med.

And I would hold the hand and mop the brow. If death happens to follow them getting medicine, then so be it. At least they aren't going out moaning and writhing in pain, they are going quietly and peacefully...without pain.

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Originally posted by VickyRN

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. :eek:

A similar situation is happening out here in California.

http://www.nbc4.tv/health/2498333/detail.html

Two nurses are facing manslaughter charges after giving a sedative, without doctor approval, to a terminal patient -- who died as a result.

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Specializes in Med/Surg. for now.

I absolutely stress that an MD order has got to be in place...and it has to be followed to the letter, I think that many nurses are afraid because of these things but even if a pt does not die, not following MD orders and giving meds without them will cost your license...The hospice that I worked for would not take a certain MD pt because he gave Tylenol Extra strength for cancer pain and would not change...so we would get them another MD that would take proper care of them. Also nurses need to keep in mind that there is a Medical Director that these kind of things can go up the chain of command to and I have had that MD a few times order meds for a pt. Usually for a MD to go against another it needs to be serious but I have seen it happen several times. Also with the pt and their families becoming more educated I believe that we will see more lawsuits about NOT managing pain and especially terminal pain....

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This comes from my 22 years of Oncology practice. I have started more morphine drip than anyone can imagine.

First of all most lingering deaths can be horribly painful. Many end up dying of starvation. In starvation, the eyes burn, the bones ache, it is quite miserable. The patient doesn't have the ability to speak, the are at a point when they can no longer speak, the just "feel"

Morphine takes care of the bone aching pain and the burning eyes. It also makes it easier to breath as Morphine is the ultimate cough medicine. I lowers the peripheral resistance of oxygen and air passes in and out easily.

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Originally posted by lizz

A similar situation is happening out here in California.

http://www.nbc4.tv/health/2498333/detail.html

Two nurses are facing manslaughter charges after giving a sedative, without doctor approval, to a terminal patient -- who died as a result.

the article has a seriouly stupid flaw

Burbank police Sgt. William Berry said the nurses, "administered a sedative to make him more comfortable. But this was a particular type of sedative that required a doctor's approval. And it was administered without the approval, and the patient expired shortly thereafter...Basically, (the nurses were) trying to do the right thing, but they did it the wrong way."

But this was a particular type of sedative that required a doctor's approval.

duh don't they all?

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After I first graduated from school, a similar situation happened to me. I was working in a LTC facility and my patient was dying and in acute pain. His VS were crap...respirations were 6. The family was sitting at the bedside and wanted me to give him something for pain. He had MS ordered. I called the doctor and explained my assessment findings...he told me to give him the MS. Again, I voiced my concerns with giving it...he said "He is dying and he hurts...give him the medicine."

Still worried, I talked this over with the RN supervisor who said..."give it, he is dying."

I was in tears...I was so upset, knowing if I gave the MS, that he would undoubtedly die. I just couldn't do it. I just could not accept the fact that I was killing someone by my action. The RN supervisor gave the MS and the patient did indeed die.

This haunted me for many years.

4 years ago, and at the age of 43, I finally came to grips with this, and now understand how smart and sympathetic both the doctor and the supervisor in the above situation really were.

I had a heart attack. The pain in my chest and arm was absolutely unbearable. My B/P was 80/40. I would have rather died than to be in that excruciating pain. I was given MS, (thank God I didn't have a nurse..like myself... that questioned whether to give or not), and I did indeed go into cardiac arrest. Although cardioversion and intubation suck like you wouln't believe, I will always be grateful for that pain relief.

Now, I would absolutely give it, because letting someone writhe in pain is not ok. I've learned that I'm not giving it to kill someone..I'm giving it to comfort them.

Of course...without question... everything must be legal and accurate...I'm not into mercy killing at all.

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Specializes in Obstetrics, M/S, Psych.

Trixxy

I loved your post. It shows how any one of us can come full circle once we understand!

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While I understand what yall are saying to a T, please keep in mind not all patients who we asess to be near death ARE DNR's, nor do they have necessarily noncurable terminal diseases.

What Vicky and I are referring to we probably see most commonly in ICU with a patient and family in shock and crises, admittedly.

Giving a MS dose to a full code COPD patient or a neuro patient with neuro induced respiratory depression..who also happens to be in pain...may INDEED cause respiratory arrest. I've seen it happen and I've seen nurses in tough situations because they went with their gut...'comfort'.

Hospice and terminal patients who are DNR are a whole 'nuther ballgame. By all means comfort is #1 priority. I administered Ativan liberally to my father in hospice care, while he was near death, for comfort. I asked my mother's nurses for a morphine drip and made her a DNR when both were dying from CA.

We have a full spectrum of considerations in our role...my goal in bringing this up is to present a little different scenario not to be antagonistic.

Merry Christmas all! :kiss

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Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

I don't think you were being antagonistic at all. If the patient isn't terminal and at the end of life, or a DNR, that changes the situation entirely. The outcome goals are different.

If the patient wasn't a DNR then treating the underlying condition that is causing the unstable vitals, etc. must be a priority. It is sad that when we know it is end of life and comfort measures are needed but the family or doc insists everything be done (and that's another thread, becuase it's a process to come to terms with loved ones end of life).

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