Giving Morphine

[jg24]

I guess I just need to vent. I work in a nursing home where I am responsible for 25 residents. Last night my RN supervisor walks through the door and (without looking at my residents) starts asking me when my 5 Hospice residents last had Morphine. I explained that I had not given any because they were all resting quietly. She told me to give them some anyway. I told her I would not because they were not in pain. She asked me how I knew that. I told her they were sleeping and showed no s/s of pain and if they did I would be glad to give it. She insisted that I give it anyway and I refused. I am not going to lie in the chart and say they showed signs of pain or SOB when they didn't. What do ya'll think?

[mingorn]

I think that if they were hospice and it was a scheduled dose you should have given it. Once a chronically ill patient is in pain it is twice as hard to get them out of pain. Just my opinion though

[Jory, MSN, APRN, CNM]

I think you are an excellent nurse and those residents are lucky to have you as a nurse.

Apparently your supervisor needs to go back to school.

[loriangel14, RN]

We generally give palliative patients morphine on a regular basis. We don't wait for them to be uncomfortable before we give it. We try to keep them from having pain by giving it before it reaches that point.The goal is for comfort and keeping the pain under control.

[Jory, MSN, APRN, CNM]

I think that if they were hospice and it was a scheduled dose you should have given it. Once a chronically ill patient is in pain it is twice as hard to get them out of pain. Just my opinion though

....but it's a nursing home.

[SaoirseRN]

We generally give palliative patients morphine on a regular basis. We don't wait for them to be uncomfortable before we give it. We try to keep them from having pain by giving it before it reaches that point.The goal is for comfort and keeping the pain under control.

This. Proactive instead of reactive.

I don't necessarily think she was necessarily right in blankety demanding you give them all morphine right now, but perhaps it was a mishandled attempt at a teachable moment?

Morphine to maintain comfort is just as valid and perhaps more so in hospice care as morphine for pain. Or think of it as preventing pain that you know they are going to have.

If you know Mr. X starts showing signs of pain at 4 hours after last dose, he likely needs morphine every 3 hours to keep him consistently comfortable.

[mingorn]

....but it's a nursing home.

So they shouldn't be comfortable?

[loriangel14, RN]

....but it's a nursing home.

That makes no difference. Do nursing homes not try to keep people comfortable?

[Cosmo&Wanda]

I care for hospice patients in a nursing home and I am directed to administer morphine as ordered regardless of their presentation because the most important thing is to keep them comfortable. A hospice patient shouldn't be allowed to reach a state of distress. When we are inspected by the state that is one of the things they look at, whether or not we are adequately providing pain management.

I'm thinking that your supervisor is probably under scrutiny regarding pain management. She was likely undergoing, or about to undergo an audit and wanted to make sure all of the hospice patients were being adequately medicated for pain. It was weird for her to demand that they all be medicated at once, but I think she was essentially giving you correct guidance.

[Princesswho]

I would have done the same thing unless she had a valid reason which it doesnt sound like she does. I think if it is PRN then they get it when it is needed and it wasnt.

[applewhitern, BSN, RN]

My son died of cancer. Sometimes you couldn't tell he was in pain because he would lie quietly in bed, with eyes closed, as if asleep. When I would ask him, he would say "I'm hurting bad, Mom." I think for some people who are in pain all the time, for so long, they are so used to it, they don't always show the pain. I would have a hard time convincing nurses to give him his dilaudid; they always wanted to give him a tiny dose, instead of the large dose he was used to getting.

[Cosmo&Wanda]

You didn't mention if the order was standing or PRN. Sometimes you might hold a standing medication because your patients don't meet criteria, but in the case of hospice you would not. It is ok to give the medication even if your patient is a 0 on the Wong-Baker scale because you are giving it as prophylaxis. If the order was PRN then yes, it is your call. In this case though I would recommend talking to the doctor and asking if he/she wanted to change it to a standing order since your supervisor seems intent on making sure your hospice patients are well medicated. Ultimately the physician has the final say on the amount and frequency of your patient's medications.