Hasten end so wife won't doubt DNR decision????

Editorial Team / Admin · Oct 6, 2005

A post which discussed end of life issues over on the long term care forum got me thinking about something which occurred yesterday in the ICU unit where I am on orientation. I have reposted it here to see what you all think.
My preceptor and I cared for an end-stage COPD pt. 2 days this week. He was on BIPAP with terrible labored breathing, and I saw his LOC decline significantly during the day on Day 1. Day 2 a.m. he was unresponsive most of the morning; about noon, he was able to squeeze my hand weakly upon command, but had no other response to anything except pain at any other time.
My preceptor went in and talked to the wife about his code status and the potential use of a ventilator, which he might never come off of; this all resulted in her saying that the pt. had previously stated that he didn't want to be put on machines. When the doctor came in about 1300, he was officially made a DNR.
Now, I know this is a commonplace and commonsense scenario taking place regularly throughout this country, and that the wife needed guidance as to what to do so as to not prolong the suffering of her spouse of 51 years. It was the next thing which happened which I am looking at with a critical eye in light of the discussion of end of life care issues.
When the md wrote the DNR order, we also revamped his entire med list to reflect the new approach; again, common sense. Our unit has a formal deescalation protocol, but this was not being implemented, as this man had not been on a vent.
The new med list included morphine, of course...it was 2-4 mg, can't remember the frequency, probably q 1-4 hours. It was not the morphine drip at 10 mg/hr that's on our deescalation protocol.
At 1700, my preceptor came up to me and asked me how I felt about giving this guy morphine. The pt. was resting quietly in bed with no agitation or signs of pain or increased vitals. I asked him why, since there seemed to be no immediate indication for the morphine; he said that if this guy were to hang on too long, let's say, 3 or 4 days, the wife may start to doubt her DNR decision, and that would just add to her misery. I said, "You mean, give him morphine to slow down his breathing so he won't hang on 3 or 4 days?" My preceptor nodded. This was a new concept for me, as there seems to be quite a difference between not engaging in futile treatment and actively giving drugs to hasten the end. No one would want this COPD guy to suffer any longer than necessary, but actively giving him morphine for RR effect is a little on the proactive side, it seems.
My preceptor walked over and indicated he was giving the morphine; when I left at 1900, the gentleman's RR was down to 8.
I was thinking about this last night, and suddenly thought to myself, "How would I feel if I knew my own husband's end in this ICU was hastened by possibly a couple of days by a nurse who felt it would be detrimental to my mental well-being to let my spouse 'hang on' (in other words, die without intervention), and that this decision to consciously slow down his breathing to hasten his end was done without my consent or knowledge?"
I am becoming increasingly more uncomfortable throughout the day as I contemplate what happened. I know that what happened makes absolutely no difference to the pt.'s long term welfare; it's just that the wife had no say in this, it is dangerously close to euthansia (if not equivalent), and is the stuff lawsuits are made of. Also, when I apply the "do unto others" rule, it falls a little short.
Since I am new on the scene, I am wondering if the problem is that this is a common practice that no one talks about, and that I am just naive about what really goes on. My preceptor's motives were not bad (the euthanasia movement's aren't either), but this really blows away the idea of informed consent to medical treatment. I imagine that all sorts of things go on in ICUs across the country that no one would admit to, but I would really like to get some reactions from seasoned ICU nurses and nurse ethicists as to whether this is common practice, this guy is unusual, or I am naive enough to still be hanging on to nursing school habits and ideas, and am too "black and white" in my thinking.
ICU Newbie
BSN May 2005
NCLEX survivor July 2005

Hello, markm739,:balloons:

12 words:

In a nutshell what you were asked to do is called murder.

hrtprncss · Oct 7, 2005

Ya like she said...plus this patient should have been intubated way earlier than before...or should have established the DNR status before waiting two days....Obviously the BiPAP is not working on day 1.

txspadequeenRN, BSN, RN · Oct 7, 2005

Now I dont agree with giving morphine unless needed and your preceptor acted immoraly. However, if the patient did need the morphine and it was given his respirations still would have dipped to 8. How much morphine was given and what route? If she went and gave an unprescribed amount then yes MURDER.. However, if she followed the PRN dosage RX, then the amount she gave wont have that efffect(death) (of course following hospice standards). I am by no means defending this nurse. I believe patients go when they go . My job is to keep them pain free. But instead of just saying MURDER , I wanted to add some thought.

A post which discussed end of life issues over on the long term care forum got me thinking about something which occurred yesterday in the ICU unit where I am on orientation. I have reposted it here to see what you all think.
My preceptor and I cared for an end-stage COPD pt. 2 days this week. He was on BIPAP with terrible labored breathing, and I saw his LOC decline significantly during the day on Day 1. Day 2 a.m. he was unresponsive most of the morning; about noon, he was able to squeeze my hand weakly upon command, but had no other response to anything except pain at any other time.
My preceptor went in and talked to the wife about his code status and the potential use of a ventilator, which he might never come off of; this all resulted in her saying that the pt. had previously stated that he didn't want to be put on machines. When the doctor came in about 1300, he was officially made a DNR.
Now, I know this is a commonplace and commonsense scenario taking place regularly throughout this country, and that the wife needed guidance as to what to do so as to not prolong the suffering of her spouse of 51 years. It was the next thing which happened which I am looking at with a critical eye in light of the discussion of end of life care issues.
When the md wrote the DNR order, we also revamped his entire med list to reflect the new approach; again, common sense. Our unit has a formal deescalation protocol, but this was not being implemented, as this man had not been on a vent.
The new med list included morphine, of course...it was 2-4 mg, can't remember the frequency, probably q 1-4 hours. It was not the morphine drip at 10 mg/hr that's on our deescalation protocol.
At 1700, my preceptor came up to me and asked me how I felt about giving this guy morphine. The pt. was resting quietly in bed with no agitation or signs of pain or increased vitals. I asked him why, since there seemed to be no immediate indication for the morphine; he said that if this guy were to hang on too long, let's say, 3 or 4 days, the wife may start to doubt her DNR decision, and that would just add to her misery. I said, "You mean, give him morphine to slow down his breathing so he won't hang on 3 or 4 days?" My preceptor nodded. This was a new concept for me, as there seems to be quite a difference between not engaging in futile treatment and actively giving drugs to hasten the end. No one would want this COPD guy to suffer any longer than necessary, but actively giving him morphine for RR effect is a little on the proactive side, it seems.
My preceptor walked over and indicated he was giving the morphine; when I left at 1900, the gentleman's RR was down to 8.
I was thinking about this last night, and suddenly thought to myself, "How would I feel if I knew my own husband's end in this ICU was hastened by possibly a couple of days by a nurse who felt it would be detrimental to my mental well-being to let my spouse 'hang on' (in other words, die without intervention), and that this decision to consciously slow down his breathing to hasten his end was done without my consent or knowledge?"
I am becoming increasingly more uncomfortable throughout the day as I contemplate what happened. I know that what happened makes absolutely no difference to the pt.'s long term welfare; it's just that the wife had no say in this, it is dangerously close to euthansia (if not equivalent), and is the stuff lawsuits are made of. Also, when I apply the "do unto others" rule, it falls a little short.
Since I am new on the scene, I am wondering if the problem is that this is a common practice that no one talks about, and that I am just naive about what really goes on. My preceptor's motives were not bad (the euthanasia movement's aren't either), but this really blows away the idea of informed consent to medical treatment. I imagine that all sorts of things go on in ICUs across the country that no one would admit to, but I would really like to get some reactions from seasoned ICU nurses and nurse ethicists as to whether this is common practice, this guy is unusual, or I am naive enough to still be hanging on to nursing school habits and ideas, and am too "black and white" in my thinking.
ICU Newbie
BSN May 2005
NCLEX survivor July 2005

Editorial Team / Admin · Oct 7, 2005

now i dont agree with giving morphine unless needed and your preceptor acted immoraly. however, if the patient did need the morphine and it was given his respirations still would have dipped to 8. how much morphine was given and what route? if she went and gave an unprescribed amount then yes murder.. however, if she followed the prn dosage rx, then the amount she gave wont have that efffect(death) (of course following hospice standards). i am by no means defending this nurse. i believe patients go when they go . my job is to keep them pain free. but instead of just saying murder , i wanted to add some thought.

this is what the op said:

...... the pt. was resting quietly in bed with no agitation or signs of pain or increased vitals. i asked him why, since there seemed to be no immediate indication for the morphine; he said that if this guy were to hang on too long, let's say, 3 or 4 days, the wife may start to doubt her dnr decision, and that would just add to her misery. i said, "you mean, give him morphine to slow down his breathing so he won't hang on 3 or 4 days?" my preceptor nodded. .....

if the morphine was given with this rationale in mind and the patient died, this is murder.

gwenith, BSN, RN · Oct 7, 2005

Having nursed more that a few end of COPD patients - just because they are quiet does NOT mean that they are not suffering. Usually they are quiet because they are concentrating all of thier efforts into just breathing. It is torturous!

txspadequeenRN, BSN, RN · Oct 7, 2005

Yes this is true.

Having nursed more that a few end of COPD patients - just because they are quiet does NOT mean that they are not suffering. Usually they are quiet because they are concentrating all of thier efforts into just breathing. It is torturous!

txspadequeenRN, BSN, RN · Oct 7, 2005

but my point was if she was going to put him out, her dosage would need to be much higher than a prn dose. that is why i ask what the dosage was. her intensions were all wrong and immoral but the med would have had the same effect on respirations, pain or no pain ( unless pt had high sob\distress). many people still believe that if you are dying .. take a shot of morphine that will do you in. what about the hospice patients that are on routine morphine for end stage cancer pain. would you hold that if the patients exhibited no s\s pain. no!!! sometimes you have orders to hold for low respirations, but in my experience not often especially with patients on deaths door step. there are times patients need roxanol doses to get them controlled consistant for several hours. if they are dying it is because of the disease not the roxanol. one more time i am not defending this nurses thinking or actions. but she is quite ignorant to think "oh lets give him a shot of morphine and he will die".

this is what the op said:
...... the pt. was resting quietly in bed with no agitation or signs of pain or increased vitals. i asked him why, since there seemed to be no immediate indication for the morphine; he said that if this guy were to hang on too long, let's say, 3 or 4 days, the wife may start to doubt her dnr decision, and that would just add to her misery. i said, "you mean, give him morphine to slow down his breathing so he won't hang on 3 or 4 days?" my preceptor nodded. .....
if the morphine was given with this rationale in mind and the patient died, this is murder.

Home Health Columnist / Guide · Oct 7, 2005

having cared for copd, cancer lung and vent dependent patients for 20 years, i'd like to shed some rationale for use of morphine here.

my preceptor and i cared for an end-stage copd pt. 2 days this week. he was on bipap with terrible labored breathing, and i saw his loc decline significantly during the day on day 1. day 2 a.m. he was unresponsive most of the morning; about noon, he was able to squeeze my hand weakly upon command, but had no other response to anything except pain at any other time.
my preceptor went in and talked to the wife about his code status and the potential use of a ventilator, which he might never come off of; this all resulted in her saying that the pt. had previously stated that he didn't want to be put on machines. when the doctor came in about 1300, he was officially made a dnr.

what you are describing is air hungar. this patient is showing signs of actively dying here.

when the md wrote the dnr order, we also revamped his entire med list to reflect the new approach; again, common sense. our unit has a formal deescalation protocol, but this was not being implemented, as this man had not been on a vent.
the new med list included morphine, of course...it was 2-4 mg, can't remember the frequency, probably q 1-4 hours. it was not the morphine drip at 10 mg/hr that's on our deescalation protocol.

if morphine was a new med for the patient, you would not give a large dose like 10mg/hr as you would for a vented patient but start small and titrate upward as response known.

at 1700, my preceptor came up to me and asked me how i felt about giving this guy morphine. the pt. was resting quietly in bed with no agitation or signs of pain or increased vitals. i asked him why, since there seemed to be no immediate indication for the morphine; he said that if this guy were to hang on too long, let's say, 3 or 4 days, the wife may start to doubt her dnr decision, and that would just add to her misery. i said, "you mean, give him morphine to slow down his breathing so he won't hang on 3 or 4 days?" my preceptor nodded

orders were written at 1300 to include mso4 q 1-4 hours; 1700 would be 4 hours after 1st dose, so appropriate interval between drug doses. appears that after the first dose of morphine, patient had a positive response to morphine treatment, therefore a second dose would be appropriate as regular morphine's average length of action is 4 hours.

remember without the morphine, this patient was having terrible labored breathing---watching someone go through this for hours to days is excruciating to watch and allowing a patient to suffer. from my experience, i think what your preceptor was trying to say that having made the decision for dnr, if the wife continued to see the patient struggling to breathe for 3-4 days like he previously was, then she should would change her mind and want him intubated. he would and could be spared the suffering associated with terminal dyspnea with the use of morphine.

when respiration's decrease significantly, like down to 8, the appropriate thing to do is decrease the next dose by 1/2. however, if the labored respiration's would return, revert to previous dosage as comfort is what you are trying to achieve here.

many medical ethicists have stated that even if use of morphine shortens the patients life due to side effect of repiratory depression, it is still appropriate to use as death in terminal illness is inevitable. this is not murder.

the following resources state:

the iahpc manual of palliative care, 2nd edition

terminal care

treatment should be purely symptomatic in the last week or days of life

http://www.hospicecare.com/manual/symptoms-main.html#dyspnoea

morphine, 2 to 10 mg sublingually or 2 to 4 mg sc q 2 to 4 h prn, helps reduce tachypnea and breathlessness. low-dose morphine may blunt the medullary response to co2 retention or oxygen decline, reducing dyspnea and decreasing anxiety without producing significant respiratory depression.

http://www.merck.com/mrkshared/mmanual/section21/chapter294/294b.jsp

palliation of breathlessness

managing breathlessness in palliative care patients

the management of dyspnea in a palliative care setting: a symptom ...

inhaled opioids for the treatment of dyspnea -- ferraresi 62 (3 ...

effects of inhaled nebulized morphine on ventilation and breathlessness during

... opioids for the palliation of breathlessness in terminal illness. ...

symptoms in terminal illness

abc of palliative care. breathlessness, cough, and other respiratory problems

RN5000 · Oct 7, 2005

NRSKaren,

Thanks for this post. I learned a lot looking at these links. I respect the fact that you took the time to give us and the OP some useful, well thought out info instead of simply jumping to a conclusion, and with no further explaination declaring "MURDER". Thanks again for the links.

Tweety, BSN, RN · Oct 7, 2005

I have no problem with the giving of the morphine at that time. Just because the patient is lying quietly doesn't mean no medical intervention should be given. After all if the patient were on that protocol would you stop the drip just because he was lying quietly? Lying quietly is a sign perhaps the medication is working and should be continued to be given at regular intervals, despite the slow respirations.

(I also agree that since the patient was becoming totally unresponsive on the BIPAP that critical care interventions such as intubations or DNR status should have been addressed while the patient was crashing.)

However, I am having a problem with ""You mean, give him morphine to slow down his breathing so he won't hang on 3 or 4 days?" My preceptor nodded. ....." The patient needs the morphine so as not to needlessly suffer in the end, not to hasten it for the wife's comfort.

I would use your chain of command or ethics committee to express your concerns. I think this preceptor needs a bit of inservicing.

Good luck.

Hellllllo Nurse, BSN, RN · Oct 7, 2005

I have no problem with the giving of the morphine at that time. Just because the patient is lying quietly doesn't mean no medical intervention should be given. After all if the patient were on that protocol would you stop the drip just because he was lying quietly? Lying quietly is a sign perhaps the medication is working and should be continued to be given at regular intervals, despite the slow respirations.
(I also agree that since the patient was becoming totally unresponsive on the BIPAP that critical care interventions such as intubations or DNR status should have been addressed while the patient was crashing.)
However, I am having a problem with ""You mean, give him morphine to slow down his breathing so he won't hang on 3 or 4 days?" My preceptor nodded. ....." The patient needs the morphine so as not to needlessly suffer in the end, not to hasten it for the wife's comfort.
I would use your chain of command or ethics committee to express your concerns. I think this preceptor needs a bit of inservicing.
Good luck.

ITA.

Having been an inpt hospice nurse for 4 years, I have seen many non-responsive COPD and other pts on high doses of MS, such as 20mg sc q 2hs.

I've seen them with resps of 6-8 and hr and last for a week like that.

The MS would not have killed the OP's pt, but the fact that his preceptor thinks it would have, and therefore decided to give it is what needs to be addressed.

NRSKarenRN,

Great, great posts and resources. Saying "it's murder" Is a knee-jerk reaction and does not look at what is really happening, IMO.

I believe that:

1. The pt was not over-medicated, and his death was not caused by MS04.

2. The preceptor who thought that medicating the pt would cause his death, and the fact that she decided to give the med based on that are two glaring examples of why this nurse "needs some inservicing."