Giving Morphine

Nurses LPN/LVN

Published

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?

Thanks for all of the responses. I should mention that all of these res have it ordered PRN for pain/ SOB. They have all been on Hospice for a couple of months and have shown no signs of pain or discomfort. I have been working on this unit for 2 years and have had lots of Hospice patients come and go. I am very comfortable with giving Morphine when needed. I am just not comfortable giving it when NAD is noted and just because she says so without even looking at the res.

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Specializes in Oncology; medical specialty website.
....but it's a nursing home.

​And...?

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cheers!!!,your schooling has guided you well. though, some pts may be asleep from exhaustion of the pain endured before your shift. pulse and resps may further lead you to your decision.

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Specializes in HH, Peds, Rehab, Clinical.

If its scheduled, you absolutely need to give it. A power higher than you decided that they need that morphine, to deprive them of it is wrong on a million levels. Playing "catch up" for missed morphine is not fair to those hospice clients, just because you didn't want to wake them to give it.

Nurses need to be advocates for their patients. Your supervisor seems to know her role

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Specializes in HH, Peds, Rehab, Clinical.
....but it's a nursing home.

Your point? We routinely care for hospice clients at my facility. Some are admitted very close to the end of their days.

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Specializes in Psych, Corrections, Med-Surg, Ambulatory.

I think you and your supervisor needed to have more of a conversation about the morphine. Was there a problem with poor pain control? Was she trying to be proactive? How did the standing orders read? Did she just want everyone out so she wouldn't have to do anything? I'd want to know more about her thought processes and rationale.

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I don't give PRN morphine to residents if they didn't request it and/or they're not showing any S/S of pain. What's wrong with that. Am I missing something here?

Are you all suggesting that if a resident has PRN pain medication ordered, he should be given it ATC at every possible opportunity? Just because someone's on hospice doesn't mean they're actively dying or in constant pain. I have a few hospice residents who I might not give PRN pain meds all shift because they really just didn't need it.

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Depends on what your order says. IF it is a PRN order, specific to pain/SOB, then you have to document that they have same and give the PRN based on that assessment. If they are on scheduled doses of morphine, then you need to give the med, regardless of how they present.

If it is a prn dose, it can get difficult to chase pain once the resident wakes up and find themselves in pain or SOB that you can not control easily. Not to mention the time constraints--if you can give prn morphine an hour apart, then the hour can be excrutiating for a resident to wait after that first dose.

If your RN supervisor is familiar with how the morphine is ordered, whether it is PRN or not, then I would think that she would not encourage the Med Nurse to make stuff up in order to medicate residents. However, if you are finding that your residents are waking in pain that is difficult to control, time to have conversation with the MD on an alternate plan. Whether that be scheduled morphine, with prn for breakthrough, an anti-anxiety, nausea med...Each hospice patient should have enough of medications available to be able to be comfortable, regardless if they are in a nursing home or a hospital unit. With that being said, you can not document "patient resting, no s/s of distress, then give PRN morphine.

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Specializes in ICU.

I am going to throw this out there, how did you know they were not in pain? Just because they were sleeping does not mean they were not in pain. I have watched many family members die a horrible death from cancer. Whether they were awake or asleep they were in pain. When it's end of life care, I do not see the problem with making them as comfortable as possible. It's not like these people are going to be future drug addicts or anything. They are dying and should die with comfort and dignity. As just to also say this, one of person's biggest fears is to end up in hospice or a nursing home. Many people feel like their dignity is gone when they end up there. So at least make them comfortable. Waiting for them to tell you they are in pain to me is cruel.

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Specializes in Med/Surg, Academics.

It's hard to determine from the info posted whether or not the residents needed the morphine. With pain patients, possibly look at trends. Are these patients consistently waking up in moderate to severe pain over the past few days or are they waking up to mild pain that is controlled with a dose upon waking? Trends in pain control are just as important as trends in vital signs and lab values.

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If it's scheduled, give it as ordered. You must stay ahead of the pain. If it's PRN, then the patients must be regularly assessed and taught that they must ask for meds if their pain is getting up to a #3/10. That's what I learned as a hospice nurse. If the pain gets out of control, meds take longer to work and they don't work as well. Regarding your supervisor, I think she should have assessed your patients if there was any question about pain issues, instead of berating you.

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I think you and your supervisor needed to have more of a conversation about the morphine. Was there a problem with poor pain control? Was she trying to be proactive? How did the standing orders read? Did she just want everyone out so she wouldn't have to do anything? I'd want to know more about her thought processes and rationale.

I've been wondering what more you and Sup might have discussed. Did you ask her her reasoning? Did she tell you what it was?

If not, as Supervisor, she should have done a little educating/instructing.

Certainly you could have asked her to help you understand why she thought the residents needed morphine, how she had determined they were in pain.

If hospice rules are indeed to medicate people no matter how they look, peaceful, sleeping, screaming and writhing in agony and terror, then you should medicate them at the appointed hours.

I made this mistake with my own dear Mom. Her home health nurse thought were not giving them when needed because, she said, there should have been fewer of them since the nurse's last visit. At no time did she do any real educating about pain prior to this. Once she did, we all understood that the goal was to prevent Mom's pain from getting out of control. Just because I was an RN, the HHN should not have assumed that I knew which end was up re: hospice-style pain management.

Sounds like your Sup made the same assumption about you.

I know you don't want your people suffering, so do read up, study up, ask the Supervisor, and keep your patients out of pain.

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