I recently had a pt admitted with an large fungating SCC of the face. When he was handed over to us via the community pall care CNC we were told that the pt would die within two days. This would be either to his palate collapsing and occluding his airway, or to drowning in his own blood. She handed us a med chart with an order for a huge dose of parenteral morphine and gave us the instruction to administer that and the dose of midazolam immediately that happened to him. The dose of morphine was greater than 50mg. The pt had never taken narcotics, hadn't even had acetaminophen. We were uncomfortable with this Stat order. As she made it clear the intent of giving the dose was to immediately end the patient's life it made us even more uncomfortable.
We are used to caring for terminal patients. We average two deaths a week. We have no problem administering meds when required to alleviate suffering, when the orders are legal. All the research we did indicated this was an illegal order. We asked the physician if he could change the order to smaller doses, administered at frequent intervals for the alleviation of suffering. Even an order for sedation. He refused.
Our NUM said she'd have no trouble giving the dose and would do it herself. The juniors on our staff, aware of legal and ethical obligations, were fearful about losing their registration if they were coerced into being a witness to the administration of the dose.
I asked our pharmacist for help and he consulted many specialists who all said it was an illegal order and amounted to euthanasia. He discussed it with the physician and the response was for the order to be rewritten and underlined.
I believed I had an ethical and legal obligation to act so documented all of this in the patient's notes.
I was called to see the DON. She said she had no problem with the orders and if she lost her registration for administering the dose, so be it. She told me she was giving me the first warning for documenting inappropriately in the patient's notes about 'political issues.' If I do it again I will be terminated. She said the concerns about the dose had nothing to do with the patient's care.
Please...........can I have some feedback about this?
Specializes in Trauma Surgery, Nursing Management.
Onaclearday-yes, I have. It was my mother. She aspirated to death. She had end stage renal small cell carcinoma. She died at home, under the care of a wonderful and giving hospice care team. I tried to make her as comfortable as possible, I gave enough meds for her to be sedated, but did not go over the prescribed dose written by her hospice care doctor. I watched her turn blue and then die. It was the most horrible memory of my life. I still have nightmares about it.
I think that there is something to be said about making someone as comfortable as possible in their last days. But to purposefully mainline a syringe with a lethal dose of medication is clearly unethical, illegal, and amounts to being an executioner. I am all for palliative care...within our scope of practice, and within the confines of the law. As hard as it is to witness, this is the realm that we must live with, and practice within.
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I'm in Aust and yes euthanasia is illegal. I've also worked in palliative care & oncology with professors & directors (Drs) of pall care, & CNCs, and have NEVER seen a dose like this written up, or seen a NUM/NM say they will give it. Doing this is illegal and isn't right. You can't just dose someone to kill them off, despite what ur religious or other beliefs are. We are supposed to ease suffering in the last minutes, not just kill people.
It's hard 2 say what u charted exactly when we don't have it in front of us (I know u can't transcribe it on here), but I would have just written what was ordered and that I refused to give it on the grounds of such & such illegalities, & who I had informed re this.
Then I would be speaking to the Director of Palliative Care & getting advice from the nursing council about this (or call AHPRA). You don't want to put ur registration at risk.
Your NUM & DON should be ashamed of themselves, & so should the Dr who ordered this - underlining indeed! Just because it's underlined does he arrogantly think that nurses will just follow blindly?
Ur patients sounds so brave & wonderful. It's great ur standing up to these older, bullying, know it alls, & many older nurses just need to retire - they've lost the plot as to why they are actually there. I've done it as well & been sacked from some jobs too for advocating for patients/procedure changes, so know how hard it is.
I'd also be contacting the media anonymously about this - Today Tonight would love this story, and I'd be explaining to the family this is illegal & to contact a lawyer. I'd also tell medical administration re this too (anonymously if scared for ur job).
Make sure you keep your own written record of all this, because I know nurses who were in similar situations, wrote everything down (and I mean times, dates, conversations, etc), then later on everyone got called into court when the situation blew up.
I hope ur patient passes away knowing all his options and peacefully as well.
I am going to say something here... get ready for it.
Something makes me see mercy in this, albeit hard to wrap my brain around in practice. Have any of you seen someone die emergently in this way. It's an awful horror. Makes me want to cry, this situation, it really does.
OP is tracking right though, we all agree that this is some heavy ****. One of those times when you must keep your head. And one in which you must be ready to work fast.
OP, sending you calm and peace.
I used to work with plastic & reconstructive surgeons & we had a patient like this. He had THE most massive facial, fungating, oozing, disgusting SCC I've ever seen (he left it for years, too scared to get treatment, had mental health issues). Anyway they did a huge excision & graft - 16 hours or more for the op I think, he had the chemo/rad therapy etc - they hit it with everything, then I think the graft failed (or part of it failed). Well, it continued to metastasize & we had to care for him. This SCC was the most disugsting & smelly, awful thing I've ever had to deal with - even seasoned nurses were appalled by it. We'd never seen anything as huge as this.
One evening we were all talking & one nurse was annoyed because she said why don't they just quietly give him a big dose of morphine & he will just slip away? There was much heated discussion re this amongst the staff.
Although I do agree with euthanasia when all other options have been absolutely exhuasted, the patient knows his options re euthanasia & the family will help, and the actual euthanasia method won't hurt them more, it is not up to us to decide.
It is still illegal despite what we think or feel. I don't agree with keeping some people alive, especially when they're begging u to kill them, plus all the above, but then we'd all be taking the law into our own hands with all patients wouldn't we? I mean I personally don't agree with keeping some long, term dementias alive. I think they are robbed of their dignity & soul as a human being, & some families have told me they'd rather see their demented loved one dead than see them with dementia - and living with dementia is NOT living.
Sometimes we think patients won't make it, but they amazingly pull through, so we can't decide who lives or dies. That is why we have laws to follow. What this NUM/DON & Dr are planning to do is wrong and illegal, & health care practitioners have sworn to uphold the law as it is now.
We can't decide who lives or dies, unless the law is changed by the people, for the people.
Definitely a tough one. I have been in the position more then once where I have come on shift and a dying patient has an overdose going and both times I called the doc and reduced it only to come on the next day and someone pumped it back up and the patients were already gone. I am for mercy but it is illegal and if it's on my shift the morphine stays within reasonable parameters.
As for documenting on these cases only the facts and no pointing fingers or personal opinions. Both cases the people wanted to die and the docs were obliging; I was the only one who wouldn't because it was so blatant and obvious that if an investigation ever took place I didn't want my name on the list of nurses giving patients' exorbitant amounts of MS.
Specializes in Peds/outpatient FP,derm,allergy/private duty.
These are just the situations that increase my awe and respect of hospice nurses as they must deal with these things every day and I will guess there are a larger number of arrows in the quiver than just euthanizing the poor man or watching him endure the sensations of choking and drowning. How absolutely awful this situation is. Hope you're able to solve the dilemma in the best way for all concerned.
On the other hand, I need to look at the context of the order. I'm surprised that a hospice nurse would claim an intent to kill a patient. That's not what hospice does and I'd be interested in hearing a direct quote.
I'm afraid this post is going to come across a little harshly, but there's no way to candy-coat the reality of what this man is facing. My apologies to the poster who lost her mom to aspiration ... I hope the memory is easing a bit.
As a hospice nurse, I am bound to relieve suffering, even when it's happening within minutes of death. Whether this patient bleeds or collapses his palate, the manner of his death is still obstructive apnea, iow he's going to strangle.
Hold your breath for one minute ... then imagine that going on for several minutes while your heart gets the message that your brain already knows: that you're dying ... and feeling almost every minute of it.
That is the experience the order is intended to address. From the OP, it seems the order was fairly specific about the indications for the meds and that it is restricted to this one catastrophic event.
Morphine is given for dyspnea as well as pain ... and the patient would certainly be dyspneic and air hungry as he strangles to death.
Midazolam is a sedative and anti-anxiety agent given to suppress the panic associated with severe terminal dyspnea.
In the event of a catastrophic collapse of the patient's airway, there is no chance of averting or even postponing death long enough to let more cautious measures work.
IMHO, failure to follow these orders is malpractice, too. Failing to relieve distress in a pt known to be terminally ill and on palliative care and who has adequate medical orders to relieve that distress could set you and your facility up for big trouble. Not to mention the fact that you let this fine, courageous man suffer unbelievably.
I agree. My point too was that these people the OP works with most likely are not monsters. However the OP should be able to do as it seems h/she has done, request to be reassigned.
"In the event of a catastrophic collapse of the patient's airway, there is no chance of averting or even postponing death long enough to let more cautious measures work." --heron
Yes, and the infiltration/corruption of tissue including the major vessels adjoining, causing aspiration r/t massive local hemorrhage (drowning) is the other potential event.
Would he die anyway whether the morphine is administered or not? Is it going to be the morphine that kills this man, or will it be his collapsed airway?
I'm no hospice nurse, so this isn't my specialty, but considering that we give 10mg morphine for therapeutic rest for women in labor, 50mg really doesn't sound like a heck of a lot for a man dying of air hunger and dyspnea.
canesdukegirl, BSN, RN
1 Article; 2,543 Posts
Onaclearday-yes, I have. It was my mother. She aspirated to death. She had end stage renal small cell carcinoma. She died at home, under the care of a wonderful and giving hospice care team. I tried to make her as comfortable as possible, I gave enough meds for her to be sedated, but did not go over the prescribed dose written by her hospice care doctor. I watched her turn blue and then die. It was the most horrible memory of my life. I still have nightmares about it.
I think that there is something to be said about making someone as comfortable as possible in their last days. But to purposefully mainline a syringe with a lethal dose of medication is clearly unethical, illegal, and amounts to being an executioner. I am all for palliative care...within our scope of practice, and within the confines of the law. As hard as it is to witness, this is the realm that we must live with, and practice within.