I've had this question for a very long time but have always been afraid to ask it. I think I am ready to ask but I ask that when you answer, please be kind and realize that I am not asking with ill intentions. I am an RN and have always worked in LTC. Every once in a while we get hospice patients in the nursing home, or one of our current residents get put on hospice. When we have someone on hospice they are usually put on liquid morphine, usually half to one ml per hr prn. The hospice nurses that work with us and the families as well as our DON encourage us to use the meds if the patient looks as though they are at all uncomfortable. As I give the morphine (and sometimes ativan with it) I can watch the patient calm down, slow down, and also their resps slow, which is expected, as morphine will do. So here is the problem, as I am giving more and more of the med, I can usually predict their time of death. For example, the family will tell me that it is time that mom can have more morphine and they think she should have it just to make sure she is not in any pain. As I am giving it, my thought to myself is: this will be the last dose because mom will be gone within the next hour. This dose will slow her breathing to a stop. I am usually correct. Then I feel bad. I feel as though I am Dr. Kavorkian performing an assisted suicide. So my question is, how do I justify this within myself? How can I tell myself that I am not performing assisted suicide? What makes what we do here legal but what Dr. Kavorkian did illegal? Please be kind-I just don't get the difference. I feel like I am doing something wrong.
Specializes in ICU, SDU, OR, RR, Ortho, Hospice RN.
maybe i need to clarify something.
if my pt is showing any signs of discomfort, even w/a rr of 6, i'll still give the morphine.
i'm only saying if my pt seems in a good place, i'll administer morphine enough to stay ahead of it, but am careful not to overload him/her w/it either.
at that time, it really is all about nsg judgment.
but my bottom line is, i don't give a hoot about vs if my pt is still struggling.
there have been many times i've pushed the morphine, even with long periods of apnea.
yet the grimacing persisted.
so yes, i will give it with every intent of alleviating pain/distress.
that's the only way i can make peace with myself.
leslie
You are so right Leslie.
We do the best we can for our patients but at the same time we do need to have a peace within us.
Most of the time, it seems, in nursing and in health care, death is the enemy.
In hospice, that changes, death is (of course) inevitable and often a welcome friend. When that last breath comes it IS such a relief to the family and struggling patient.
(Who knows for sure) how much Morphine quickens death, but in my mind if it does shorten that person's last hours of torment and the natural fear of death, then thank God, somewhere in this culture we are doing the right thing for those of us who are at the end of our journeys.
I have seen patients hold on until that last family member comes to say goodbye, in spite of the Morphine they've received.
Even if Morphine hastens the inevitable death by an hour or two or even a day or two, how can that be bad? It is the one place where we can be humane and not feel guilty about it. We are ending pain, fear and probable torment. That sounds like the right thing to do to me.
I agree with everything that you say. Having worked in long term care for so long, I have seen people that pray for death on a daily basis. I have seen people that we all know death would be a blessing for. I think my fears come from my christian background and knowing that someday I will be judged. I am always questioning if I will be judged as someone who did the right thing or someone who committed the ultimate sin.
Funny how our thoughts work isn't it? How they can mess with our minds like that? I mean, I know that by keeping the patients out of pain I am doing the right thing, but then I have these thoughts of if what I am doing is right since it is hastening death. It keeps me up at night for a while thinking about it after we have a case like this, but after a while, I stop thinking about it until the next one comes along. I'm probably not a good candidate for hospice nursing because it would affect my own well being too negatively, although, don't get me wrong, I think hospice nursing is wonderful and makes a world of difference to not only the patients, but also their families. One more thing-when the hospice patient is in the nursing home, hospice nurses are sure a Godsend for the nursing home staff!
I understand your fear of giving a dose of pain med and then the pt passes and you think, Oh dear Heaven, did I cause that???
I think God calls when he calls, and that pt isn't going til its time. The pt can be pain free and go calmly or the patient can suffer and go in a state of agitation, which will upset not only the patient, but the family if they are there.
Having had some acute illnesses which brought on pain worse than childbirth for me, I vote for the pain medication. I think our work to ease the suffering of the patient and give them a "good" (pain free as possible and not in a state that upsets the family) death is going to be seen as a blessing by the patient if they were able to voice it.
We have an end of life protocol that incorporates all of the medications that may be required into a standard prescription to guide the doctors, within that there is analgesia, sedation and hyoscine for the management of secretions.
I didn't agree with some of the replies you received. Morphine liquid is typically used when a pt. can't swallow anymore. We use the nonverbal pain scale 1-10 to rate the pt pain and document why the morphine was given. If the pt appears comfortable, nothing should be given~even if the family requests it. Your job at that time is to educate the family on the use of morphine. 5 minutes later, the pt may need it~the you would give it. Don't think about the side effects of the med. You wouldn't be giving it if it wasn;t needed. The benefits outweigh the side effects. Also about the oxygen, there is written literature on how oxygen can produce an undesired prolongation of life and suffering. A fan could be more beneficial to a pt than oxygen. I don't use oxygen or any other meds unless it is to benefit the pt. Hope this helps, there is a lot of education on the use of these meds.
If the pt appears comfortable, nothing should be given~even if the family requests it.
If the patient "appears" comfortable? How do you know how an unresponsive patient feels inside? I give the pain medication on schedule regardless of how comfortable I think the patient is. I do think the family has the right to request the medication be given. I'm sorry but I disagree with you
If the patient "appears" comfortable? How do you know how an unresponsive patient feels inside? I give the pain medication on schedule regardless of how comfortable I think the patient is. I do think the family has the right to request the medication be given. I'm sorry but I disagree with you
I also understand where you are coming from. If the family is in the home caring for the patient (family member) I instruct them on the meds and use then trust their judgement. I cared for a patient in a facility and the family wanted to give the med (oxyfast) every hour even though the pt resp were 18, no signs of pain were evident. They also stated they wanted him to just "go". I went back the next day and the patient had 28 doses then died. Whenever I give pain meds, there usually should be some documentation behind it for medicare to look at ( a reason). A patient should not be medicated because we "just don't know" if they are having pain. The non-verbal pain scale I use on every patient at every visit. If they have a pain rating even at a 2, I will give a dose of medicine, but if it is a 0, I stick with my rule to continue to assess the patient and give meds as indicated. I also think the family can request meds and the pt. be given the med~but not to "speed up the process"
thank you passion for your reply. would you be so kind to share written literature (web sites?) on how oxygen can produce an undesired
prolongation of life and suffering? i attempted to google the subject
but was unable to come up with anything specific.
thanks again!
i don;t have the exact book it came from but i can find out from one of my managers. she just went to a hospice district meeting. it is from a "therapeutic considerations" book on hospice. i will type you the written documentation now then will let you know the name of the book on tuesday.
oxygen
oxygen may be comparted to a phrmacologic agent or to fluid and nutrition, ie, it may supplement a deficit in a necessary resource. if it's use relieves symptoms ofdyspnea or a cognitive deficit, and causes no harm, it would fit well into any palliative care tx plan.
there are circumstances, however, in which the intuitive use of oxygen must be carefully sidered. if a pt is dyspneic, but for causes other than hypoxia, oxygen would not likely be of benefit and may actually be cumbersome to administer. even a simple fan or open window may be of more benefit, and the use of opioids or sedatives to reduce recptor sensitivity would likely be a more rational approach.
even in situations of poential or definite hypoxia, it may be appropriate to discuss with a pt and or his family the option of choosing to withhoold or withdraw oxygen supplementation if dyspnea and/or cognitive deficit would not truly be relieved by it's administration. this may be particularly true if a pt. is in an end-stage obtunded state either naturally from disease process and/or from meds by intention. in such situations, oxygen may actually produce an undesired prolongation of life and suffering, a consequence which may not be intended in consideration of the goals of care and the particular clinical situation at hand. pt and families deserve discussion of such situations and choices when appropriate.
well, that's the written paper i have with me but again, it doesn't give the name of the book. i will get back to you with the name of the book after memorial day.
Sabby_NC
983 Posts
You are so right Leslie.
We do the best we can for our patients but at the same time we do need to have a peace within us.
Well said my friend :)