I know so many nurses that are afriad to use morphine to help pain. Especially in hospice patients!
Today I had a woman dying of cancer and very restless but otherwise unresponsive. I found out that the patient did not recieve her MS at all because the nurses on the previous shifts were to afraid of the med, and causing her death! The patient was breathing normally (except when she was painful) at 18...and was in pain!?!?!? No, instead they were doing dressing changes and manipulating her body without any analgesic at all!!!! I was floored, how kind is that!?!?!
I had a few days off, found out the situation and contacted hospice right away. By the looks of my dear sweet patient whom I have known for 3 years...I knew she had only hours if that! I got orders for 1 ml roxinol q 30m if I wished (which I did), and called the family and hospice to come in. She died with no s/sx of pain and was very peaceful looking with her family and caregivers and hospice at her side.
However I was very displeased with my fellow nurses. I have told them time and time again the reasons, use, contraidications, side effects and what not of this medication and they still won't touch it! Because of their fear...she suffered till I got there!
So, I am trying to think of someone that can come into a inservice to education my entire staff on the use of MS. I was thinking hospice but they are so busy and understaffed as of late....a pharmasist perhaps?
Just throw the ideas out folks! I even thought of paramedics or ER docs but try to get one of them to volunteer...LOL!
Thanks! We really do need more education about this issue!
(btw...one nurses excuse was that 'snowing' a patient at this time is cruel and pain is expected..it is part of death...I about fainted!).
:angryfire :angryfire :angryfire :angryfire :angryfire This kind of thing makes me crazy, too! The suggestion to make pain meds scheduled rather than prn is a good one. With either type of order, maybe the staff would feel more comfortable if the doc or facility policy included hold parameters. On my old AIDS unit, house policy required these with morphine drip orders ... usually hold for rr
:chair: This has turned into a bit of a rant ... or a sermon ... understandable, maybe, but not the best way to change attitudes. Anyhow, sorry if I've insulted anyone ... Peace:flowersfo Heron
Uh, what's a CNS? I'm guessing not a central nervous system. I'll even venture to guess the N is for nurse.
So many abbreviations!
BTW, my class had a guest lecturer from hospice, and we each shadowed a hospice nurse for a day, so at least one school is addressing the issue. It's one I care about, a lot. Death is inevitable, but unmanaged pain is not.
we also had to do a clinical rotation with hospice and had a hospice speaker for a day. It really opened up my eyes for giving so much morphine when needed. At first I thought they were 'killing' the pts by giving so much morphine, but then I found out that cancer is a horrible painful disease. A nurse told me that although it does slow down the resp rate with these patients, it is given to relieve any kind of pain they may have. that way they can pass in peace without pain and their loved ones do not have to remember them in pain and grimacing (which can be very traumatic in itself). I now have no problem with administering these meds to pts on hospice.
Our PCU acted as in house hospice because the DR.s felt that the floor nurses were uncomfortable given doses of morphine that I feel do not hasten death but give the pt and family comfort in the end. I was on our hospital's pain management team and eventhough we did monthly inservices some nurses would not treat in fear of hastening death. My idea was to create an anonymous questionarrie to elicit honest responses without fear of retaliation or ridicule. In most cases it was the nurses discomfort or religious reasons that the nurse could not or would not dose pts correctly. We then came up a plan that a nurse could at report, if the pt was hospice or comfort care only,
could refuse the pt. It worked out great we praised the nurses who refused the assignments after all they were being true pt advocates by saying they were uncomfortable giving the care the pt needed,under no circumstances were they to be questioned why. What came of this was nurses were much happier and less stressed and those of us who were comfortable providing end of life care were happier. Then we started having the nurses who were uncomfortable the opportunity to watch how we cared for dying pts. without having to be responsible for the pt (on a voluntary basis.) Some of the nurses just needed to see the care and compassion is no less in caring for the dying as it is in the living. We all have our comfort zones and sometimes it is just the unknown that the nurses are afraid of.
I realise that I needed to leave the CCU and go to Hospice or research nursing after one of my Pt's spouse crocheted(sic) me a blanket and brought it to me at work. The card read we hope that you feel as much love when you are wrapped in this blanket as you made pt's name and us feel in his last days.I do not believe I have ever cried so hard. I happened to be precepting a student to what a charge nurse does, I can only imagine what her report said. I have had the blanket preserved and whenever I question whether or not I can return to nursing I remember them and all the families like them that I have been blessed to care for.
Sorry for the digression but back to the subject I think that the use of scop patches are a very under used intervention in comfort when a pt has a lot of secretions or the "death rattle."
Specializes in Telemetry, ICU, Resource Pool, Dialysis.
Sorry for the digression but back to the subject I think that the use of scop patches are a very under used intervention in comfort when a pt has a lot of secretions or the "death rattle."
So true. Try getting a bunch of nurses to understand that excessive suctioning of dying patients is totally unneccesary, and even leads to more mucus production. Who would want to spend their last few hours on earth with a little tube going down your nose making you cough? AND in pain because you can't tell anybody that you hurt?
I think scheduling meds is also a good suggestion. However, I have seen nurses give for instance, 2mg MS instead of 6mg which was ordered "because they're nonresponsive" People also need to be educated on the concept of tolerance. A chronic cancer patient who has been on MS Contin at home can tolerate large doses of MS without resp depression.
Does your state allow nurses to titrate med doses down without an order Pricklybear? I have never been under the impression I could just choose a dose for patients.
So true. Try getting a bunch of nurses to understand that excessive suctioning of dying patients is totally unneccesary, and even leads to more mucus production. Who would want to spend their last few hours on earth with a little tube going down your nose making you cough? AND in pain because you can't tell anybody that you hurt?
thank you, thank you and thank you. it ticks me off to no end when i see a patient being continually suctioned....especially where there are scope patches or levsin gtts.
and not one of my colleagues believed that it produced more secretions. i would inevitably get the order for either scope patch or levsin gtts. so much less invasive.
this is where a good staff developer comes in handy.....so much education is needed on an array of issues. it's ironic how we can use the nsg dx of knowledge deficit when many of us are just as needy of some education.
I know so many nurses that are afriad to use morphine to help pain. Especially in hospice patients!
Today I had a woman dying of cancer and very restless but otherwise unresponsive. I found out that the patient did not recieve her MS at all because the nurses on the previous shifts were to afraid of the med, and causing her death! The patient was breathing normally (except when she was painful) at 18...and was in pain!?!?!? No, instead they were doing dressing changes and manipulating her body without any analgesic at all!!!! I was floored, how kind is that!?!?!
I had a few days off, found out the situation and contacted hospice right away. By the looks of my dear sweet patient whom I have known for 3 years...I knew she had only hours if that! I got orders for 1 ml roxinol q 30m if I wished (which I did), and called the family and hospice to come in. She died with no s/sx of pain and was very peaceful looking with her family and caregivers and hospice at her side.
However I was very displeased with my fellow nurses. I have told them time and time again the reasons, use, contraidications, side effects and what not of this medication and they still won't touch it! Because of their fear...she suffered till I got there!
So, I am trying to think of someone that can come into a inservice to education my entire staff on the use of MS. I was thinking hospice but they are so busy and understaffed as of late....a pharmasist perhaps?
Just throw the ideas out folks! I even thought of paramedics or ER docs but try to get one of them to volunteer...LOL!
Thanks! We really do need more education about this issue!
(btw...one nurses excuse was that 'snowing' a patient at this time is cruel and pain is expected..it is part of death...I about fainted!).
Triage...
You did the right thing! They were wrong and you were right and you are right to advocate for your patients.
My Dad just died three weeks ago of colon CA and I flew into town three days before he died. I let him have anything he wanted. He was only getting OxyContin 20mg q8h and Vicodin 10/500 q4-6h but I let him have all the Vicodin he wanted. We were just getting ready to double the Oxy's but he died.
The day before he died he couldn't keep the meds down anymore so I got him Duragesic patches.
When someone is dying they should get absolutely anything they need. Good for you for doing what was right but I know how you feel about the previous care. Nurses that hold pain meds in a terminally ill person shouldn't be in hospice.
I had a care home asst that was dying of lung CA. He had requested they call me before he died, he wanted me to be there. I went to see him and he was clearly in pain and the morphine drip was gone. He had a hep-lock. I asked what happened and the nurse cringed as she told me the doc DC'd the morphine drip, his blood pressure was going too low.
I was just as angry with her for not advocating for him or calling me and letting me do it. Anything. The family didn't know what to do so they were of little help in that situation. I can't believe people sometimes. They are supposed to be caring individuals. Dick had hours left, not months... to pull the pain meds because his blood pressure was too low was cruel and heartless.
As for an inservice what about a pain management MD? They can ease concerns of overdosing while explaining the basic needs of patients.
My late mother in law had very strong feelings about how she wanted to die. She told me because I am a nurseand knew I would do what ever it took for her. She didn't want to do this with her children because she was afraid they would try to lengthen her life at all cost. She was very specific about how her wishes would be carried out. She wanted to die at home with us so I got a hospice that was pro choice on this. My husband I got a lawyer and had legal documents made for this purpose. She died peacefully in her bed and I administered her narcotics every four hours. All my in-laws love me and everything I did and I am forever in this family. They are all a bunch of loving people who were raised by a very loving open minded mother.
I would NEVER,EVER hold narcotics from a dying patient. It is a barbaric senseless practice.
Does your state allow nurses to titrate med doses down without an order Pricklybear? I have never been under the impression I could just choose a dose for patients.
I cannot speak for Pricklybear but we are usually given a scaled dose such as 2mg to 10mg PRN for comfort. So the dose is up to the nurse as long as it is in the scale.
Here is a story I have about a personal experience with a family member who was dying. It was my father. As an LPN at the time as well as a daughter, it was a hard thing to endure. I know this story is long....I wrote it for an English class.......but hope you can see this also from a family's point of view.
(Names have been changed.....except my father's)
"It was a busy Tuesday morning, much like the usual morning on a nursing unit. There were medications to pass, elderly to get up and to the dining room for breakfast and Arlene and I were running around, trying to keep on some sort of schedule. As I approached the nursing desk, I could hear her mumbling to herself. "What is the matter?" I asked, noting the frustration on her face. "Oh it is that family in room 145. I cannot make them happy this morning." "Why?" I asked. "What is their concern?" Arlene sighed a heavy, frustrated sigh and said, "Oh Josephine is in pain. I told her family that she had all the pain medication she could have. She doesn't
have orders for anything else. The family said the medication isn't holding
her and that she needs more. They can't seem to get it through their heads that I can't give her anymore." I asked Arlene if she had called the doctor for stronger medication. "She is dying Arlene, maybe she has more pain than you realize." " I will call him when I have a minute." was the reply.
"Oh, here they come again, I wish I could hide. They act like I have no other residents to care for." As Josephine's daughter approached the desk, I could see tears in her eyes. I felt my heart tug and I was drawn back to that awful day in August of 2000 when I received the phone call from my mother.
"The nursing home just called and they say your father had an unresponsive episode and we should come right away." "What happened?" I asked. I realized mom didn't know anymore than that and I went to tell my boss I had to leave and go see my father at the nursing home across town. I called my brother who lived out of state and told him about the call from mom. My brother asked if it was serious, should he be concerned. I told him I didn't have any details, but my gut reaction would be to get on the next plane and come as fast as he could.
My heart was racing and I felt an uncontrollable panic as I raced toward the nursing home. My father has always been a strong force in my life. I felt like I couldn't drive fast enough to get by his side and make sure he was being cared for as I felt my father should. When I arrived at his room, my father was laying in the bed, looking frail, vulnerable and not at all
comfortable.
If you had known my father as little as 2 years before, you would not believe it was the same person. My father was brilliant, an internationally renowned surgeon of Urology. He has published papers all over the world, has saved hundreds of peoples lives and was respected by
most everyone who had known him. He was a fisherman, a civil war buff and he built model trains. More than that though, he was a son, a husband, a cousin, a father, a grandfather and a friend. Right now though, as I stood at his bedside he was my daddy and I felt a need to help him get comfortable.
You see, my father and I had this special bond. Diabetes does horrible things to one's body. It causes cardiac, kidney and skin problems for one. When my father's kidneys finally failed in 1992, I gave him one of my kidneys. He had given me life, shouldn't I do the same for him? The surgery was a great success, but didn't cure the diabetes and the problems continued. He had strokes that robbed him, not of one side of function, but tiny motor function which required him to quit doing the surgery he so loved. Then if that wasn't enough, the diabetes caused him nerve pain that finally robbed him of his ability to walk. The final blow was when his memory started to fail, and we were told that he had something called cerebral atrophy, which causes parts of the brain to harden and quit working. He couldn't even tell me he had pain.
"Dad, are you in pain?" I asked as he thrashed in the bed. He couldn't tell me. I knew from the past that he was uncomfortable. I asked when he had last had pain medication and was told it had been about 3 hours. I sat by his bedside, talking to him, touching him and letting him
know we were there with him. He didn't seem to understand and continued to thrash. He would thrash around until he was sideways in the bed. At about 200 lb., it was hard to get him back in the bed the way he should be laying. Various family members were in and out of the room. I finally called to the nurse for more pain medication for my dad. He was thrashing around even more now, and with strong upper extremity ability, grabbed me, pulled himself into an upright position and then, unable to support his own weight, fell into my arms. I screamed for the nurse, unable to move, to help my dad lay down, to do anything other than to cradle my poor father in
my arms and feel helpless.
The nurse arrived in the room again, looking a little frustrated. "My father needs some more pain medicine right now!" I choked out through my tears as my father's head lay on my shoulder. "I am sorry, but he can't have any more pain medicine for another 15 minutes." was her reply. "Give it to him NOW." I screamed, unable to hold back the rising anger I was feeling
at that time. "He needs something now!" The nurse looked at me and said calmly, "I know he is your father, but it is my nursing license at risk if I give it to him early." "I don't give a "darn" about your license right now!" I spit out at her. At that moment I didn't care about anything but my dad. I was not a nurse that could empathize with her situation at that moment in time, I was a daughter whose father was dying and this nurse did not seem to care. The person I was looking towards for communication between me and the doctor. She walked out of the room.
Finally after what seemed like an eternity - though it was less than 5 minutes, she came back in and said in a calm, sympathetic voice, "He has an order for Ativan, should we try that and see if it helps?" We tried it and it did help until he could get more Morphine.
My father died Thursday evening with his entire family at his bedside, in a calm and peaceful manner. He took a little of each of us with him, as well as leaving a little of himself behind in each of us. Us, the wife, daughters, sons, grandchildren, and friends of Dr. Clyde Blackard. I wish I could have "fixed" things for him so that the last few days weren't so hard for him to endure. I will always have the memory of the day with that nurse, fighting for my father as he would have and had done for me before.
I looked up from the desk. "Arlene, I have a moment, I will take care of this for you." I could see I was not going to get any argument from her. "Hi Mrs. Miller, I hear Josephine is having a lot of pain." "I am putting a call out to the doctor now to see if we can't get something stronger for her so she is more comfortable. While we wait for doctor's call back, can I do
anything else for you? Anything you need?" Her daughter looked at me with a tired face that now housed a smile, and as she turned back towards her mother's room I heard her say, "No, thank you though. I know everything will be OK now.""
Some people are not going to agree with me on this but I feel the reason some nurses do not give pain meds is because they don't want the person to die on their shift. Don't want to do the paper work. I too have been in a situation where the nurses wouldn't give pain med to dying resident and when asked about it the reply was " I don't want them to die on my shift." Needless to say the person did die but was not always pain free except for when a couple of us nurses were there to give the resident meds. I just don't get it. If it was their loved one I am sure they would not be concerned about what shift she/he died on as long as their loved one was not in pain.
Cruel, sad and true. I've seen this happen to many times before also.
I cannot speak for Pricklybear but we are usually given a scaled dose such as 2mg to 10mg PRN for comfort. So the dose is up to the nurse as long as it is in the scale.
Same here, if there is a scale. I mean if there isn't. If the doctor's order is for 6mg q2h (it isn't a PRN) then 6mg should be given q2h unless a call is made to the doc to change it. That's why I like scheduled medications for pain.
heron, ASN, RN
4,660 Posts
:angryfire :angryfire :angryfire :angryfire :angryfire This kind of thing makes me crazy, too! The suggestion to make pain meds scheduled rather than prn is a good one. With either type of order, maybe the staff would feel more comfortable if the doc or facility policy included hold parameters. On my old AIDS unit, house policy required these with morphine drip orders ... usually hold for rr
:chair: This has turned into a bit of a rant ... or a sermon ... understandable, maybe, but not the best way to change attitudes. Anyhow, sorry if I've insulted anyone ... Peace:flowersfo Heron