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?

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.

I think it's more of a nursing judgement issue. There are people who die without pain and don't need anything, there are people who do need it but rarely. I think it also depends on what part of the dying process the patient is in. In the end, there's more distress and air hunger obviously, so at that point I would medicate every chance per orders, just to keep on top of it. During the beginning stages, a patient resting quietly with no recent history of c/o or s/s of pain wouldn't get morphine willy nilly from me. I would have an issue with a supervisor walking in and demanding MSO4 be given sight unseen, but I can understand the sup wanting to make sure staff was on top of comfort for those on comfort measures.

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Specializes in SICU.
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.

Agreed, agreed, agreed, agreed, agreed.

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Specializes in Cardiology.

it is a determination of YOUR nursing judgment. She could have given them the ms04..either way

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Specializes in Acute Care, Rehab, Palliative.

I have given a PRN morphine without the patient verbalizing. Mnay palliaitve patients get to the point that they can't put in words but you know they have been having discomfort. I medicate these people proactively so they don't experience the pain or respiratory distress.I don't wait for them to be uncomfortable and THEN medicate.

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If it's not scheduled, and there are no s/s of pain, then I'd call the physician. That nurse could be charged with medical battery for giving morphine unnecessarily.

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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.

But be very sure you fully assess--by looking at someone, you can't really tell if they are in distress or not. If they have increased rr, grimicing....just be mindful that some people don't have to be shouting or moaning. Be sure to always ask.

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I have given a PRN morphine without the patient verbalizing. Mnay palliaitve patients get to the point that they can't put in words but you know they have been having discomfort. I medicate these people proactively so they don't experience the pain or respiratory distress.I don't wait for them to be uncomfortable and THEN medicate.

Right, we all do that.

I think the key point was that the OP said the residents neither asked for pain meds nor did they display signs of pain/dyspnea.

The OP was the one assessing the residents all shift. From what she said, the supervisor came on duty and immediately told the OP to medicate them without even looking at them. That is not appropiate. If I was working and a supervisor told me so-and-so needs morphine when she never even set eyes on the resident, I'd be miffed too.

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Thanks BrandonLPN because you understood my situation exactly. There were no grimaces, groans or guarding to indicate pain. All vitals were WNL. I had been on shift for 4 hours before she came on and had been closely monitoring these patients. She walked in the door and stopped at nurses desk and started demanding that the patients receive Morphine without even entering their rooms. These patients have not been receiving Morphine previously, but it is on the cart if needed. I have since talked to the DON and she agreed with me and said she would not have given it either in that situation.

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What is your facility's policy and procedure regarding hospice residents? Find this out and use it as a teachable moment .

Not all hospice patients are experiencing pain/have a need for sedation.

Administering morphine because it is ordered to prevent discomfort is wrong. There are many other palliative measures that could be used.

I agree with you, think you may have a fight on your hands.

Let us know, feel free to PM me .

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So, we administer morphine because the STATE may look at that?

What does that bring to mind?

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Specializes in LTC,Hospice/palliative care,acute care.

I have seen a problem with many nurses in LTC under medicating end of life patients. Our supervisors now must monitor the electronic medical record of every patient at end of life. The majority of my co-workers are like many who post here.They say "he looks comfortable" without doing any type of assessment and leave it at that. It's an uphill battle and sometimes when we try to deal with the problem we may go about it in a ham-handed way.Like your supervisor did, no excuse for her actions, even if she is passionate about hospice she should have taken a few minutes to talk to you about each resident.

S/L morphine liquid is short acting and generally best for breakthrough pain and symptom control (comfort) in the actively dying.It's not the first thing we go for in the last months of life-these folks need good steady pain control with extended release drugs.

Pain is woefully under treated in LTC and is something the DOH has focused on in the past. As the federal regs get more and more strict our docs are dragging their feet at ordering these meds and our residents are suffering.It's a disgrace

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OP it is hard to see if what you did was best for the patient with the limited information you've provided. If they are actively dying I would have given the PRN morphine OTC. Most of the time actively dying patients already have this standing order. If this patient was not actively dying and showed no s/s such as grimacing, restlessness and etc. then I would not have given it. Not all hospice patients require morphine. PRN order are written for a reason.

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