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Family's request v. nursing judgment

Hospice   (3,219 Views 7 Comments)
by PoetOfMyHeart PoetOfMyHeart (New Member) New Member

1,209 Visitors; 23 Posts

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Hi everybody! I am wondering what some experienced hospice nurses do/would do in the following scenario: a patient is imminent and in a LTC with family present around the clock. Roxanol 20mg/mL has been given through the night about every hour. Pt has no s&s of pain/discomfort/agitation. Family is requesting continuing the Roxanol q1hr despite the pt's respirations being between 2-5/min and no evidence of distress. I know the role of hospice is to treat the pt AND the family, and I am not shy about administering Roxanol when indicated. Having said that, my nursing judgment makes me very reticent to administer morphine unnecessarily. What would you do?

Thanks in advance! I know you all will produce some excellent answers!

~Sara~

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3 Followers; 95,617 Visitors; 36,456 Posts

I think if you stopped giving it, you might find that it was effective when given. But I could be wrong. What do your colleagues and supervisor have to say?

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Hospice Nurse LPN has 15 years experience and works as a BSN student/hospice nurse.

16,473 Visitors; 1,472 Posts

I'm with Caliotter3 on this one. Maybe the reason the pt isn't having any s/sx of distress is BECAUSE the Roxanol is working. I have a pt @ a LTC who is getting Roxanol 0.25 Q 2 hrs scheduled. The doc had to schedule it because the nurses (@ the LTC) refused to give it. This morning, the nurse asked if we could cut back on Roxanol because the pt isn't in any distress. He is bedbound and non-verbal. They were only giving pain meds if the pt could ask for it. For the first time in weeks this poor soul is comfortable. The order stands.

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ErinS works as a Hospice Case Manager.

5,100 Visitors; 347 Posts

I would agree with the other response. In my experience, patients rarely tolerate decreasing doses of medication well. The other thing to remember when assessing someone at the end of life- a low respiratory rate is to be expected, so it often is more helpful to assess for retractions. That being said, I find many of my patients do well on roxanol every few hours, but rarely need it every hour. It may just be a matter of doing more education with the family so they understand the use of meds and symptom assessment. This is a tough one. Good luck!

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1,209 Visitors; 23 Posts

Thanks everyone for the responses!

The pt never was in a pain crisis. I arrived at the case, and that's what I was given. I am a crisis care nurse and stay with the patient for a 12 hr shift, so nurses not giving the meds wouldn't be an issue. The pt pretty much just slipped into a sleep state from a slightly restless phase. I explained to the family that the Roxanol was for dyspnea and pain, not agitation, but they didn't feel the Ativan worked and thought the Roxanol was keeping her restful. They continued asking for the Roxanol q1-2hrs.

My on-call supervisor said to continue giving it to reassure the family. Since the pt is actively dying, she stated, giving the roxanol would not hasten her death. Despite some hesitation, that's what I did. I really didn't feel it was needed, at least not that frequently, without any sx. Some pt's don't need any Roxanol and just sleep peacefully until they pass away. I think that's how this lady was, and I was kind of grasping at straws when charting. The pt held on, though, through my whole shift, and I haven't received a page that she expired this morning.

Anyhoo, tons of thanks to you guys for helping out. When I counted 2 respirations/min my hazard lights went on! Just wondering what the excellent nurses in my favorite forum might have to say. ;)

:redbeathe ~Sara~ :redbeathe

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teach_hospiceRN works as a Legal review nurse.

1,355 Visitors; 12 Posts

sara,

as a home hospice nurse i find many nurses in the ltc's are not comfortable with the use of roxanol, even when the patient is exhibiting pain or other sxs. i try to explain to them and to the families that as a patient is dying they may need something to help them relax or not struggle. roxanol is a great med for this but requires alot of education all around.

i understand your delimma as the patient was not exhibiting signs when you arrived, however would it have been fair to the patient to withold the med and have her become symptomatic? no. so continuing the medicine was in her and her families best interest. it did not cause her death and even when her respirations slowed to 2 that was ok, because she was dying and you were allowing her to die without pain and suffering. kudos to you for giving her the med and hopefully this will help in the future when there is a patient in need.

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53,501 Visitors; 11,191 Posts

there really isn't any textbook answer.

had it been me, and the pt's rr were 2-5/min, i would have held off a dose and reassess in another hour...

that is IF the pt seemed completely comfortable.

i've given mso4 with very low resps, but pt continued to show distress.

but in this case and as stated, i would have waited another hour.

we need to use our nsg judgment at all times, versus succumbing to family demands.

if you explain to the family, your rationale for withholding, they're usually ok with that.

leslie

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