DNR and Narcan?

Katnip, RN · May 19, 2006

No it isn't violating DNR. DNR does not mean do not treat. It means do not initiate CPR or ALS protocols if the pt goes into a lethal arrythmia.

GIJay, BSN, RN · May 19, 2006

No, that does not violate the DNR. Is the pt awake and alert, comfortable, maintaining their own airway and 02 saturation. I'm just curious if there is a standing order to give Narcan for a RR of 7.

cheers,

jay

Blee O'Myacin, BSN, RN · May 19, 2006

Narcan puts the patient into immediate withdrawal. If the morphine is being used to ease pain at the end stages of a terminal disease, I wouldn't give it. I would also question the order. Sometimes narcan comes along with morphine on computerized order sets and a resident or an intern entering orders may choose the wrong option on the menu list.

DNR doesn't mean "do not treat" like the above posters have said, but I would determine the purpose of the med and decide about the narcan based on that.

Blee

LCRN · May 19, 2006

Narcan puts the patient into immediate withdrawal. If the morphine is being used to ease pain at the end stages of a terminal disease, I wouldn't give it. I would also question the order. Sometimes narcan comes along with morphine on computerized order sets and a resident or an intern entering orders may choose the wrong option on the menu list.
DNR doesn't mean "do not treat" like the above posters have said, but I would determine the purpose of the med and decide about the narcan based on that.
Blee

I agree with the above poster...at my facility we have to types of DNR--> one is a comfort and one we provide supportive care to such as vasopressors/treatment of cardiac aarythmias/blood products. If a patient is a DNR comfort and is receiving morphine for exactly that ->comfort then giving them narcan would bring them into immediate withdrawl and a painful state.

I don't know the circumstances

Ms.RN · May 19, 2006

then how do you treat respiratory depression from morphine overdose?

Gompers, BSN, RN · May 19, 2006

then how do you treat respiratory depression from morphine overdose?

if it's a one-time dose for a non-hospice patient, you can give narcan to bring the pateint out of it.

but a hopsice patient's body has become addicted to the morphine over a long period of time, so if you give narcan, it's going to throw them into very dangerous withdrawl.

in my experience, once a hospice patient gets to the point where their pain is so severe that the amount of morphine needed to comfort them might cause respiratory depression, a decision has to be made. when this happened to my grandmother, my family had a choice - to limit the amount of morphine to ensure proper respiratory function, or to allow as much morphine as needed for pain even if it caused respiratory depression. this is not euthenasia - a lethal dose is not provided to end the patient's life. it's just that the side effect from such large doses of morphine might end up causing respiratory depression to the point of death. the docs gave our family that decision to make, and my father chose to let my grandmother get as much morphine as it took so that she did not moan when her cares were being done. yes, she probably passed away a few days earlier than she might have without all that morphine - but she died without pain. (we hope.)

PANurseRN1 · May 20, 2006

Hospice pts. do not become "addicted" to their pain medication. Addiction is a psychological craving for a substance; pts. with addiction have no therapeutical need to take the med.

Hospice pts. do become physiologically tolerant to their peds and often require titration in order to maintain pain control. This is not the same as addiction. Using the term "addicted" when describing hospice pts. is harmful because many terminally ill pts. are fearful of becoming addicted and will refuse pain meds because of it.

elthia · May 20, 2006

If it's a one-time dose for a non-hospice patient, you can give Narcan to bring the pateint out of it.
But a hopsice patient's body has become addicted to the Morphine over a long period of time, so if you give Narcan, it's going to throw them into very dangerous withdrawl.
In my experience, once a hospice patient gets to the point where their pain is so severe that the amount of morphine needed to comfort them might cause respiratory depression, a decision has to be made. When this happened to my grandmother, my family had a choice - to limit the amount of morphine to ensure proper respiratory function, or to allow as much morphine as needed for pain even if it caused respiratory depression. This is not euthenasia - a lethal dose is not provided to end the patient's life. It's just that the side effect from such large doses of morphine might end up causing respiratory depression to the point of death. The docs gave our family that decision to make, and my father chose to let my grandmother get as much morphine as it took so that she did not moan when her cares were being done. Yes, she probably passed away a few days earlier than she might have without all that morphine - but she died without pain. (We hope.)

I have the personal belief that sometimes terminal patients are in too much pain to relax enough to die. My reasoning is that if you have a pt crashing, the BP is bottoming out, they are tachycardic and starting to lose consciousness what is one thing we do?? We talk to them, we yell at them, we try to get a response out of the pt, we don't just let them pass out. ( of course this while we are putting them in trendelenberg, paging MD, pushing pressors, hanging IV bolus, etc.) A terminal pt is in too much pain to relax, they are struggling to move air, and it hurts to breathe. Give them morphine and ativan, then they relax, and normally fall asleep and drift away. Just my 2 cents after working oncology.

So, if the pt is on hospice care, I would have to have someone give me a reason better than respers of 7 before I would push narcan. If the pt is DNR but not hospice, I'll push it.

LCRN · May 20, 2006

If a client who is DNR on comfort care went into respiratory depression(resp = 7) after morphine administration, do you give narcan? Is that violating the DNR?

:idea:

I think we need to know more about the specific situation. If the above poster is calling respiratory depression resp=7 after morphine administration before narcan is given an oxygen saturation maybe should be checked. If the pulse ox is fine with decreased respirations I would not clinically push narcan. Then we can get into another discussion as to the patients co-morbidities such as sleep apnea, pleural effusions, lung ca, brain tumors/ bleeds, abdominal ascites which can all alter your respiratory rate. Before you can give an answer to this question I think you need to know more about the situation.

Lurksalot, BSN, RN · May 20, 2006

This question was asked to me by a friend who works oncology(she's precepting), and she said the nurses were arguing about what to do. The unit does have a standing order for narcan

beachmom · Nov 26, 2007

Before you narcan a person whose respirations are low, shake them and tell them to breathe. Often that's enough. (unless they are comatose, of course)

We had a chronic pain med user who had a surgery and was in terrible pain. After trying everything, the dr. told us to push morphine until pain relief was achieved (I think it was 20 mg every 30 minutes) and put a nurse with the pt. to watch her breathing. If she quit breathing, no narcan, shake her and tell her to breathe. That was the order.

Regarding DNR: this means do not do CPR if their heart stops. If we do something to harm them, we must do what we can to reverse that. Example: if the insulin we give causes them to bottom out and possibly die, we give them D50, etc.