Hi friends- I hope I can call you that:) some wonderful people on this forum have helped me through some hard nursing times.
My anxiety has been getting the best of me lately regarding a shift I finished.
i had a palliative patient (PPS 10 %) on a night shift who was declining quickly. He had been unresponsive since early in the morning. I came on at 7 pm and he had zero output since the morning. He had a morphine infusion subcutaneously at 6 mg/hour. His family left at 1230 and I hung a new bag at at 1250 (50 mg of morphine in a 50 ml bag).
Now, I went in at 0120, half an hour after hanging the new bag, and I am ashamed to admit this, but turned it down to 4 mg/ hour (4 mls/hour). He was only breathing at a rate of 5-6 an hour. It was almost like Cheyne- stoking but it was a 15 second gap, and then a big breath, and then another gap.
I pronounced him at 0140. 40 minutes after the new bag was hung. I can't help but think I did something wrong- I know I put the right medication in the bag, but what if I accidentally infused it at 50 mls (50 mg) per hour instead of 6 mls per hour. I mean 25-30 minutes after I hung new bag, he was struggling for air.
I know there is no way to know but my anxiety is eating me alive. The hard part is, I love palliative and hospice nursing. It is so rewarding. This death is just clinging with me for some reason. I'm hoping some nurses can provide me guidance. I have no reason to believe I messed up other than the fact he died quickly after changing the bag.
You did nothing wrong. They were pallative, unresponsive, and you kept them comfortable while they passed. Secondly, i hope that this experience doesn't veer you away from using morphine for end of life patients. Morphine in no way contributes to a pallative care patient's life and they truly need it to keep them comfortable
Indeed. There is a school of thought that concerns undermedicating and actually prolonging suffering -- that the person isn't able to let go and die because the pain is so severe and keeping the neurological system active and overly stimulated. So, that's one way to think about it.
Unfortunately, I've seen patients pass on the monitor (they were monitored even though they were DNR because the families didn't believe they were in the dying process or that they had actually passed away at all) and the decline is so sudden and fairly unpredictable. You may be able to tell someone is going to die that day but definitely not the hour until that hour is upon you. There is nothing you can really do to speed that up short of a major, intentional overdose.
If you infused it at the wrong rate I think you would see more of the bag was empty than should have been, that's easily judged by your pump settings. As a separate issue your anxiety over the passing of a patient is something you'll need to deal with and maybe just get more education on palliative/end of life care so you feel more confident the next time. Honestly, it is unlikely you will over medicate a dying patient unless you make a huge error (like dumping a whole bag of morphine). At some point the patient is going to be at the tipping point and whether they received a dose of morphine or ativan in close proximity to their expiration doesn't mean you are the cause of their death, as it was inevitable.
*Hockeynursing* "Forgive me if I'm corny, it's been an emotional day."
My dear, the day that one of your patients dies, ....and you feel nothing......THAT's the day it's time to get out of this profession. I'm grateful that after 40 years my tear ducts remain fully functional (at the appropriate time, of course!).
Sounds like he was already dying. It's hospice care what do you expect. If I was the patient I would want to be snowed with way way more than 4 mg/hr of morphine. The goal is to keep them comfortable.
This, right here, is why he died when he did. Ancedotal, but I completely believe in this: Before I was a nurse, this is how my mother died and my grandmother before her. They each weren't doing well, and it was going to be "any time now," except nothing was really changing...and then family left the room to go get a meal and when we returned they had died. I wasn't present for my grandmother's death (but my mother was) but I was present for this with my mom. We'd said our goodbyes before we left for food (we didn't know if she could hear us but you never know what might happen) and when we returned...maybe 90-120 minutes later, since we'd had to go outside of the hospital...she literally took her last couple of breaths. No matter how unresponsive they might seem, I fully believe that the dying can hear what's going around them. Your pt knew his friends had gone so he could slip away.
The same happened with my father. He lingered comatose for several days. Every time we left to get a meal or sleep, he would decline a little, we would rush back, and he would stay the same the whole time we were there. This went on for 6 days until he passed just seconds before we entered his room the last time. It became clear that he couldn't leave with us there. No other way to explain this.
I have worked in LTC for many years and have observed many end of life situations and I believe the process sounds familiar and had nothing to do with the IV bag you hung, there is nothing you can do by worrying yourself to death it sounds like a natural progression of the end of life process but as usual its always safe to check your medications according to the 6 rights.
As a former Hospice nurse, it was my honor to help over 300 patient with their final journey. I've read, and understand, your anxiety. End stage patient symptoms are outside of norm as learned in nursing school, and the tendency to attach your actions with what you would describe as a negative outcome is understandable.
However, everything you've shared brings me to feel that your patient was on death's door when you hung that bag. No intervention would have extended his life, nor added to it's quality. That he left us without further suffering, and with a caring practitioner at his bedside is a blessing.
Palliative care is never easy, nor should it be taken lightly. You've accepted and demonstrate the latter. It's time to review you're feelings about this area of nursing. All patients eventually die. I've rejoiced with those whom I've graduated, knowing that someday I'd be back at their bedside, holding their hand and praying with them. If it's within you to accept the decision of these brave people and help them smile in the face of death, you must come to accept that no matter what you do, the outcome is always the same. Help them to be comfortable and meet death on their own terms.
You did not hasten this death with this low dose of medication. You just ensured that the passing was peaceful.
Too often in my many years on the wards have I seen Nurses withhold medication because they did not want to feel the how you now feel; This is to the detriment of the patient.
When my death is inevitable I hope that it is hastened by a kind nurse ; I do not want to suffer or have my loved ones suffer watching a slow deterioration: (YES ; I do have terminal cancer). You assisted this patient in their time of need, that is what we do as nurses.
Dear Hockeynurse, First, you did nothing wrong. Your patient was actively dying and you did the best thing to make him comfortable. There is always the "last dose" which is not what causes your patient to die- they were dying all along. You did the best you could to make sure he was not suffering. Please don't doubt or second guess yourself. You have many nurses, friends and family members who thank you for decreasing and ceasing his suffering.
I really don't think anything you did contributed to this. He was expected to pass, nothing you could have done to prevent that. I am not a hospice or palliative care nurse but I have had my share of "comfort care" patients and have had patients exceed 50mg/hr of morphine. In fact our limit is 200 mg/hr. I know it's a crazy amount but it's true. And if he already had a RR of 5-6 with agonal type breathing it was imminent for him to pass soon. Don't beat yourself up over a mistake you most likely never made. Know that you kept him comfortable in his last moments on earth.
Hi friends- I hope I can call you that:) some wonderful people on this forum have helped me through some hard nursing times.
My anxiety has been getting the best of me lately regarding a shift I finished.
i had a palliative patient (PPS 10 %) on a night shift who was declining quickly. He had been unresponsive since early in the morning. I came on at 7 pm and he had zero output since the morning. He had a morphine infusion subcutaneously at 6 mg/hour. His family left at 1230 and I hung a new bag at at 1250 (50 mg of morphine in a 50 ml bag).
Now, I went in at 0120, half an hour after hanging the new bag, and I am ashamed to admit this, but turned it down to 4 mg/ hour (4 mls/hour). He was only breathing at a rate of 5-6 an hour. It was almost like Cheyne- stoking but it was a 15 second gap, and then a big breath, and then another gap.
I pronounced him at 0140. 40 minutes after the new bag was hung. I can't help but think I did something wrong- I know I put the right medication in the bag, but what if I accidentally infused it at 50 mls (50 mg) per hour instead of 6 mls per hour. I mean 25-30 minutes after I hung new bag, he was struggling for air.
I know there is no way to know but my anxiety is eating me alive. The hard part is, I love palliative and hospice nursing. It is so rewarding. This death is just clinging with me for some reason. I'm hoping some nurses can provide me guidance. I have no reason to believe I messed up other than the fact he died quickly after changing the bag.
Your patient was NOT declining quickly, your patient was actively dying. YOUR job is to manage that process. You were seeing agonal respirations. If you want to stay in hospice care.. learn the basics.
Your patient was dying. Unfortunately it happened on your shift. The morphine infusion helped him to leave as peacefully as possible. The breathing you described is often not witnessed , but is normal for a patient taking their last breaths. You did nothing wrong. From all the information you gave it was expected. Your anxiety is normal because the death of any patient is stressful. Remember you actually helped him leave this world in the best care you could give, following orders, and assessing frequently. Now keep on doing what you do the best that you can. It sounds to me that you are a professional and caring nurse. Good Luck in the rest of your career.
la_chica_suerte85, BSN, RN
1,260 Posts
Indeed. There is a school of thought that concerns undermedicating and actually prolonging suffering -- that the person isn't able to let go and die because the pain is so severe and keeping the neurological system active and overly stimulated. So, that's one way to think about it.
Unfortunately, I've seen patients pass on the monitor (they were monitored even though they were DNR because the families didn't believe they were in the dying process or that they had actually passed away at all) and the decline is so sudden and fairly unpredictable. You may be able to tell someone is going to die that day but definitely not the hour until that hour is upon you. There is nothing you can really do to speed that up short of a major, intentional overdose.