END-OF-LIFE Ethical Dilemmas

[AnnMarie52471]

We have all been there...a patient on a morphine drip just laying there waiting for their heart to stop...a family taking shifts, one leaves another stays so their loved one don't die alone....or the patient who is laying there, with no one there to wait with them for the end....

How many times have you been asked to "increase the morphine" on a care and comfort patient? Only to have to go on to explain that we can titrate it if we find the patient to be in any discomfort. I usually go onto explain, if the patient is moaning, grunting or such I can titrate the drip....within minutes the family is at the desk stating, "my mom/dad/loved one is moaning in pain can you increase the drip?".

You know, i know....but what to do? How to handle this situation? I can personally say, WHY EXTEND THE SUFFERING? WHY MAKE THESE FAMILY MEMBERS SIT AND WAIT FOR WHAT IS ULTIMATELY GOING TO HAPPEN ANYWAYS? I sometimes think to myself, this patient will never get up and walk, talk do anything ever again-- should I help them on their way to the "other side"? I have that ability to increase the morphine drip...but am I playing God? Am I committing the act of murder?? This is a very tough place to be in.

Personally, my dad was dying of metastatic colon cancer..he was diagnosed in June 2013, dies in December 2013. He asked me one thing, that I had the ability to do, don't let him suffer....and I DIDN'T. Was I playing God, Kavorkian? I tend not to think so. I was helping a loved one die peacefully, a loved one that had suffered for the last 6 months and was going to die whether or not I gave him an extra dose of dilaudid or ativan...a loved one that was there to take care of my scraped knee, to hold my hand when I had stitches put in my head...to give me away on my wedding day and dance the father-daughter dance....WAS HE ASKING TOO MUCH OF ME?? Are these family members asking too much of me??

Please tell me what you think.

[nurseprnRN, BSN, RN]

None of the above. This patient isn't dying from morphine, he's dying from his disease. You aren't "playing God," or "helping him on the way out" or "going too far." For what it's worth, there are many people for whom there is no God to do anything, so forget that one, too. If there is moaning in pain, increase it. Period.

I do hear your concern. I do understand that you are worried about this. Just for sake of argument, suppose that your increasing the morphine hastened a patient's death by all of ... ten minutes. How does that feel? Does it make a difference?

How about thirty minutes? An hour? Three hours? Six? Overnight? How much do you think it matters, if he is actively dying and moaning in pain, that he suffers fewer days or hours? What does he want? More hours in pain and suffering (some people do, but damn few) or fewer, when the inevitable end is clearly within sight?

I am not asking to be argumentative. We do not impose our own values on someone else; that's not why we're in nursing. The family and patient is who matters here. What do they want?

Personally, when it's me or my loved one, I want a nurse with the courage to do the right thing and to recognize death unafraid when it stares her in the face.

[nynursey_]

I agree with GrnTea. I had this exact situation occur earlier this week, and as asked, I promptly paged the physician to titrate up the Fentayl drip. The patient was nonverbal. She was moaning. Whether it was in pain or out of restlessness, she deserved to feel comfortable, and at ease. She was imminent. And it isn't for me to judge the quality or quantity of a patient's pain. My job is to ensure the comfort of this patient right up until her last breath, and I felt obligated to do so vigilantly, regardless of how many pages I had to send out to the doctor.

In your nonverbal patients, you can always rest assured that the family can help determine the pain level. They know the patient better than you do. If their impression is that the patient is not comfortable, try not to look too into it … the patient is on comfort measures. The Morphine is there for a reason. You're there to ensure their comfort. Do it. The small titrate up is not going to accelerate the end. It merely ensures that the end and the physical pain is tolerable.

[MunoRN, RN]

There is a difference between treating pain/discomfort and hastening death at the request of family. I have, on many occasions, had families ask me to give more morphine solely because the patient was still alive, and that I should keep giving additional morphine until that was no longer the case.

I'm not opposed to hastening death when appropriate, but let's not act as though the basic premises of opiates don't exist in end of life patients, which to a degree can be therapeutic and actually extend life, but can also hasten death just as it does in the 16,000 people who die every year as a direct result of opiates. I absolutely agree that it's worth hastening death if suffering exists, I'd even argue that it's worth hastening death just if that's what the patient wants. People don't always just die of their disease, the sometimes die of a combination of their disease with a dying process sped up by opiates. In other words, it's not necessarily a bad thing, lets just not play dumb about it.

[BrandonLPN, LPN]

Always hated the term "playing God".

Playing God would be pulling out a magic wand and altering the laws of reality to change what is inevitable. Administering morphine is just one of several factors that may affect the speed of the dying process. What's the alternative?

I mean, you've ALREADY affected the process by initiating the morphine drip in the first place, right? So, what, it's okay to "speed along" death, as long as you're not the one to administer that "final dose"?

I don't think nurses EVER can be said to administer morphine for the express purpose of hastening death. They were already dying. It was going to happen soon regardless. The disease process is what killed them. We give morphine to treat the symptoms. If that hastens death, it's just a side effect.

[nynursey_]

There is a difference between treating pain/discomfort and hastening death at the request of family. I have, on many occasions, had families ask me to give more morphine solely because the patient was still alive, and that I should keep giving additional morphine until that was no longer the case.

I'm not opposed to hastening death when appropriate, but let's not act as though the basic premises of opiates don't exist in end of life patients, which to a degree can be therapeutic and actually extend life, but can also hasten death just as it does in the 16,000 people who die every year as a direct result of opiates. I absolutely agree that it's worth hastening death if suffering exists, I'd even argue that it's worth hastening death just if that's what the patient wants. People don't always just die of their disease, the sometimes die of a combination of their disease with a dying process sped up by opiates. In other words, it's not necessarily a bad thing, lets just not play dumb about it.

Here is an article I'd suggest you read if your view is that increasing opioids "hastens death":

International Association for Hospice & Palliative Care - IAHPC

[eagle78]

I am not a nurse but I would like to comment on her point as it pertains to family members. My father was dying from complications from CVA. Infection had weakened his body, he was unconcious and his tempature stayed in the 100+ range. The nurses at the nursing home did not know what to do, he was DNR and so they did not think they could give him anything. I sat at his beside packing ice around his neck and in his armpits to try to cool him off. His breathing was with great effort and it was a pain to watch that. Because he was unconcious he could not communicate his pain level, but I could tell he was very uncomfortable. My mom got hospice involved, it was amazing the difference that made. He had languished for three days in the condition I described and we felt so helpless, wanting to see him comforted.

Well, when hospice came in he lasted all of about 12 hours. But, that 12 hours appeared to be the most comfortable that he had over the course of the prior three days. I say this to emphasize, if there is anything you can do to help the patient, comfort the patient, it makes a big difference to the family to see their loved ones comfortable as they make their transition.

[BrandonLPN, LPN]

You know, the description of the actively dying nursing home resident burning with uncontrolled fever strikes a nerve, personally.

When I have dying residents with high fevers, I give a Tylenol suppository. This was common practice when I worked in the hospital. Seems like common sense. When I moved to LTC I was told be several nurses there that it's "stupid" to treat a fever in a dying pt. They thought I was weird to even check a temp and that giving a tyl. suppository was unnecessary and too invasive. One nurse told me that fever is just part of the dying process.

I'm also told that regular repositioning of the dying is unnecessary. Drives me crazy. Dying people can still experience discomfort from being febrile or from laying in one position too long, right?

[MunoRN, RN]

Here is an article I'd suggest you read if your view is that increasing opioids "hastens death":

International Association for Hospice & Palliative Care - IAHPC

This is actually exactly what I was referring to. The article you posted actually states specifically that increasing opioids can in fact hasten death and often does.

As the article points out, opiates don't hasten death only when the medication is adjusted based on early signs of potentially death-hastening effects, such as somnolence, and even suggests the use of reversal agents in these situations which I would hope most Nurses would avoid. Typically, CNS/respiratory/cardiovascular depression are all accepted trade-offs for comfort and symptom management and there is no evidence that when these symptoms are tolerated (for good reason) that these symptoms don't actually have the obvious potential to hasten death.

[Mom2boysRN]

I have no issue giving increasing doses of Morphine to a dying patient for comfort care. I refuse to give Morphine simply to speed up the process of dying.

[xoemmylouox, ASN, RN]

I am not a nurse but I would like to comment on her point as it pertains to family members. My father was dying from complications from CVA. Infection had weakened his body, he was unconcious and his tempature stayed in the 100+ range. The nurses at the nursing home did not know what to do, he was DNR and so they did not think they could give him anything. I sat at his beside packing ice around his neck and in his armpits to try to cool him off. His breathing was with great effort and it was a pain to watch that. Because he was unconcious he could not communicate his pain level, but I could tell he was very uncomfortable. My mom got hospice involved, it was amazing the difference that made. He had languished for three days in the condition I described and we felt so helpless, wanting to see him comforted.

Well, when hospice came in he lasted all of about 12 hours. But, that 12 hours appeared to be the most comfortable that he had over the course of the prior three days. I say this to emphasize, if there is anything you can do to help the patient, comfort the patient, it makes a big difference to the family to see their loved ones comfortable as they make their transition.

I'm sorry to hear that your loved one suffered. To often people think DNR = do not treat anything which is just not the case. Hospice has been involved involved in the life and death of 3 of my loved ones. I wouldn't have changed a thing they did. My loved one weren't in pain or distress at the end. Who doesn't want that?

[jadelpn, LPN, EMT-B]

You can't give any more morphine than a doctor orders you to give. A range is a wonderful thing. Along with some ativan, some atropine....Continue to get orders for what you think and the family thinks eases a patient who may be in discomfort. What you can't do it give "extra doses". They need to be accounted for. You have to have witnessed wastes.

The family is so in tune with a loved one that perhaps they are noticing discomfort that sometimes as nurses we can't. Some people who are dying are far too weak to grunt and/or grimace and moan.

The goal is peaceful.