Giving PRN pain meds to hospice patient

[A2024]

I was got in trouble due to I gave morphine to patient is complaining of gen body pain. to give overview on the patient. Patient is hospice in LTC I was assessing patient and has complain of pain 10/10. I check the order and there is only morphine, Ativan as usual meds for hospice patient and I did not see or remember if patient has acetaminophen. so in short I gave morphine. within the day I received message from the DON as far as I remember there is no single order to call family member before administering the PRN pain meds or any sort of meds. what is your thoughts on this situation can you guys enlighten me if there wrong on my action.

[JKL33]

What was the message from the DON?

[canoehead, BSN, RN]

It seems like if there is a PRN order you should be able to use it.

[delrionurse]

You followed the order, there was no order or knowledge for you to call family before giving a PRN pain medication. She complained of 10/10 pain. You gave Morphine. It's justified. Who gives Tylenol for 10/10 pain? Tylenol is for mild pain, not severe pain as the pt was complaining of. 

[heron, ASN, RN]

There's a deep and abiding fear of opioids especially in nursing homes. The roots of that fear are deep, complicated and tangled. The taproot lies in the fact that starting an elder on morphine for end-of-life care requires time, critical thinking, and "buy-in" by all staff caring for that resident.

To switch metaphors, the choke points are time and buy-in. LTC nurses can be, and often are, critical thinking superstars. But initiating opioids with an elder as an end-of-life intervention requires hourly administration of tiny doses and observation of effects to establish the proper dose for an individual. Not something LTC nurses have time to do well, if at all.

Buy-in is an even bigger problem. LTC is one of the most heavily regulated industries that exist. Those regs focus almost exclusively on maintaining life and function. So do health caregivers. Switching gears to maintaining comfort and allowing death to occur is harder than you might think. Then, there is the fact that many people, nurses and other caregivers included, regard that switch as "giving up,” lack of love for the elder, or even outright murder. Add the inevitable process of grieving and one can see how OP got caught in a storm she didn't see coming.

OP, your first move should be to learn the basics of the dying process and end-of-life care, then look at the resources you already have available. If the resident is on hospice, she has a hospice nurse assigned to her case ... pick that nurse's brain. Then document, document, document and advocate, advocate, advocate.

Have you talked to the family yet?

[beachynurse, ASN, BSN]

Please don't beat yourself up about giving the Morphine. The patient is a Hospice Pt, and due to the pain level you were justified in giving the Morphine. I think it is very sad for those with chronic pain to have to suffer the way they are because of the fear of prescribing opioids. I understand the need for monitoring, but I feel as though the pendulum has swung way too far in the wrong direction. No one should have to have the level of pain that incapacitates, when the pain can be controlled and the patient can have some quality of life. 

[kbrn2002, ADN, RN]

The resident is enrolled in Hospice? If so there is a terminal diagnosis and the family should be well aware of the poor prognosis and the plan for comfort care including pain control, educating and supporting family is a big part of what Hospice does. Unless there is a specific order to contact family before administering the pain medication you did absolutely nothing wrong. MS is an entirely appropriate medication for pain control at end of life and often prescribed for Hospice patients in doses that a nurse unfamiliar and uneducated with hospice orders may not be comfortable giving. The goal is comfort, nobody should be concerned with high opioid dosing to support end of life care. If your DON is concerned with the Hospice orders maybe put a request with the Hospice agency to offer the DON and any other staff caring for the patient some education. Sounds like the DON could benefit from this.

[pmabraham, BSN, RN]

You did the right thing. Stand strong!

[guest1039278]

Maybe I am just an idiot, but from what I gathered, the patient had 10/10 pain and a PRN morphine order which you implemented. 

I truly do not see what the problem is. 

Being on hospice does not change how 10/10 pain is supposed to be interpreted. 

[heron, ASN, RN]

Barriss Offee said:

Maybe I am just an idiot, but from what I gathered, the patient had 10/10 pain and a PRN morphine order which you implemented. 

I truly do not see what the problem is. 

Being on hospice does not change how 10/10 pain is supposed to be interpreted. 

It should be that simple but, more often than not, it isn't. Without more info from OP, it's impossible to guess what might be the problem.

Meanwhile, OP seems to have seagulled.