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?
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.
to absolutely ensure/guarantee death, the doctor would have prescribed at least, quadruple the amt of mso4 and anxiolytic.
and elvish, it honestly doesn't matter what he dies of.
if the INTENT is to relieve suffering, we are legally covered.
leslie
eta: ok, the op states the DON stated it was to immediately end his life.
if the intent is to kill, then yes, 100% illegal.
if the intent is to palliate and the result is death, 100% legal.
i'm wondering if the DON stated the pt will die, versus 'to die'.
Specializes in Oncology; medical specialty website.
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.
(((HUGS)))
How horrible for you. I'm so sorry that was something you had to witness.
Specializes in Trauma Surgery, Nursing Management.
(((HUGS)))
How horrible for you. I'm so sorry that was something you had to witness.
Thanks OCRN63. My mom was a cancer researcher, which makes her death all the more Twilight Zone-ish. But my experience with caring for her and handling the fallout of her death is what made me go into nursing. I am MUCH more compassionate for those who are terminally ill, and will go to the ends of the earth to make sure that my patients are comfortable BECAUSE of Mom.
I agree that hospice nurses have a very heavy responsibility to care for those in end-stage illnesses. I am not a hospice nurse, and do not claim to know what y'all go through regarding the care of your patients. I can only raise my glass to you in a toast...YOU ARE MY HEROES!
It was the pall care nurse reassuring us that the order would be enough to kill him that had us go looking for information. A toxicology text at work said morphine has an LD50 of 120mg oral.
We convert by dividing by 3 so that would be a 40mg parenteral dose. Even dividing by 2 it would be 60mg. The order was for 60mg parenteral morphine and 20mg midazolam. This man is so emaciated he only weighs about 40kg (88 pound) and he is 6'2".
We are actually concerned that we might not get there to assist him in time as his door is always closed so if he is unable to push his buzzer, it might be all over before anyone checks on him.
We'd have no problem with an order that would completely sedate him, render him unconscious. We'd have no problem with an order for large doses of morphine administered at one minute intervals to make it a more legal order. We have a problem with one large dose when it is clear the intent is to kill him. All of our med charts are being audited and the pharmacist said he knew the auditor from an external authority would immediately report that order and the consequences would be dire for everyone involved.
Years ago two new grads administered a fatal dose to a patient, ordered by the same doctor. They had just started. The doctor wrote the stat order and instructed a new grad to administer it immediately. The new grad went looking for someone else to witness it and found another new grad at lunch. She came out, got the morphine out of the safe, and witnessed it being given. Twenty minutes later the pt was dead. The seniors arrived back from a meeting and asked what had happened to him. The new grads were in tears. They didn't know the order could be lethal. That man wasn't on narcotics either. Problem was, he wasn't suffering when it was given. He was nowhere near to dying and was asymptomatic. He had a large fungating tumour of the face and throat too.
No-one has ever forgotten that. The new grads were protected, but both of them left soon after. It had scared them so much they left nursing.
We average two deaths a week on our ward. We have young doctors who are still training and only spend short periods here. They have no pall care experience when they arrive. It is a constant rerun of getting them to make a decision to palliate a pt and then having to tell them what to order. Every time we list the drugs we need we feel like we are putting our registration at risk, but if we didn't do it our patients would suffer. We've tried introducing pathways but the medical director won't approve them, he doesn't believe in them.
We have a population with terrible health problems. Our chronic disease rate, suicide rate, cancer rate etc is the highest in the country. Many of our patients are diagnosed with advanced Ca when with us, and then die. They all present way too late for anything to be done to help them. We have no specialists available to us. We are generalist nurses who spend a lot of time at home researching patients symptoms and conditions so we can guide our young doctors in their treatments.
Because our doctors aren't familiar with pall care and the drugs used they are scared about ordering them so sometimes we get ridiculous orders like 1mg subcut morphine six hourly. So we have to yet again print out information and convince them that a patient in severe pain needs much more.
I recently had a patient who was near death. His peripheries were cold and white. He had cheyne-stokes resps. Blood was pooling in all the dependent areas. When he seemed near to taking his last breathe he suddenly sat bolt upright. What followed was four hours of hell. If it is possible for a person to fight death then that is what this man did. It was the worst case of terminal agitation I've ever seen. I had to fight for every order because the doctors were scared. I approached doctors who didn't have that patient for orders too. The amount I'd given him would kill an elephant but he was still thrashing around. I was the only senior on the ward but my wonderful colleagues covered my work load for me so I could stay with him. I talked to him constantly and touched him to reassure him that he wasn't on his own, that I wasn't going anywhere. At times I was there with tears running down my cheeks. I was counting the seconds until I could administer more doses. I was also concerned that his family might arrive and see him like that. Then they did. They instantly burst into tears and left the room. So I had to work with them too, to help them through it. I knew they were traumatised, because I know I was. When my manager was checking out a dose with me she asked me what was wrong. I nearly cried and just said 'the useless ******* doctors. How are we supposed to help our patients when we can't get what we need from them because they are too scared?'
It changed when I sent a junior to ask for yet another stat dose and the doctors refused. I went up to them, sitting at the nurses station and said, 'you go down there and look at the patient, then tell me I can't have the orders I need.' They did. They were shocked and quietly asked me for what I needed. I finally got the doses I needed and only had to administer them once to settle him. I stayed with him until he did.
I was convinced that family would think we were the most incompetent nurses on the planet, and I wouldn't have blamed them for thinking that. I expected them to complain to our DON and I was ready to go and be disciplined for my inability to settle that patient. I was shocked when a few days later my manager said she had a card for me from them. They told her they thought I was a beautiful nurse and couldn't believe how I could care so much about a stranger. I've not forgotten that.
I don't know what to say. You are in your heart "Hospice" (one of us :heartbeat :hug:) But you just don't have the support. Not having support makes what you are faced with something almost too difficult. You know what should be, what needs be, but you are the only one. I hate educating MDs. So I understand the disbelief when they just seem too stupid to "get it", sorry lurking MDs but it must be said. I think you are at a crossroad. Take care of YOU. If you want to take the torch, there are algorithm books and much published on Palliative Care/Hospice referencing control of many of the events that come, including Terminal Delerium. If the MDs have you feeling you might at any time lose your license, the stress of this would be too much for me. With your patient acuity, you need MDs and good ones. You need to work elsewhere.
Specializes in Oncology; medical specialty website.
It was the pall care nurse reassuring us that the order would be enough to kill him that had us go looking for information. A toxicology text at work said morphine has an LD50 of 120mg oral.
We convert by dividing by 3 so that would be a 40mg parenteral dose. Even dividing by 2 it would be 60mg. The order was for 60mg parenteral morphine and 20mg midazolam. This man is so emaciated he only weighs about 40kg (88 pound) and he is 6'2".
We are actually concerned that we might not get there to assist him in time as his door is always closed so if he is unable to push his buzzer, it might be all over before anyone checks on him.
We'd have no problem with an order that would completely sedate him, render him unconscious. We'd have no problem with an order for large doses of morphine administered at one minute intervals to make it a more legal order. We have a problem with one large dose when it is clear the intent is to kill him. All of our med charts are being audited and the pharmacist said he knew the auditor from an external authority would immediately report that order and the consequences would be dire for everyone involved.
Years ago two new grads administered a fatal dose to a patient, ordered by the same doctor. They had just started. The doctor wrote the stat order and instructed a new grad to administer it immediately. The new grad went looking for someone else to witness it and found another new grad at lunch. She came out, got the morphine out of the safe, and witnessed it being given. Twenty minutes later the pt was dead. The seniors arrived back from a meeting and asked what had happened to him. The new grads were in tears. They didn't know the order could be lethal. That man wasn't on narcotics either. Problem was, he wasn't suffering when it was given. He was nowhere near to dying and was asymptomatic. He had a large fungating tumour of the face and throat too.
No-one has ever forgotten that. The new grads were protected, but both of them left soon after. It had scared them so much they left nursing.
We average two deaths a week on our ward. We have young doctors who are still training and only spend short periods here. They have no pall care experience when they arrive. It is a constant rerun of getting them to make a decision to palliate a pt and then having to tell them what to order. Every time we list the drugs we need we feel like we are putting our registration at risk, but if we didn't do it our patients would suffer. We've tried introducing pathways but the medical director won't approve them, he doesn't believe in them.
We have a population with terrible health problems. Our chronic disease rate, suicide rate, cancer rate etc is the highest in the country. Many of our patients are diagnosed with advanced Ca when with us, and then die. They all present way too late for anything to be done to help them. We have no specialists available to us. We are generalist nurses who spend a lot of time at home researching patients symptoms and conditions so we can guide our young doctors in their treatments.
Because our doctors aren't familiar with pall care and the drugs used they are scared about ordering them so sometimes we get ridiculous orders like 1mg subcut morphine six hourly. So we have to yet again print out information and convince them that a patient in severe pain needs much more.
I recently had a patient who was near death. His peripheries were cold and white. He had cheyne-stokes resps. Blood was pooling in all the dependent areas. When he seemed near to taking his last breathe he suddenly sat bolt upright. What followed was four hours of hell. If it is possible for a person to fight death then that is what this man did. It was the worst case of terminal agitation I've ever seen. I had to fight for every order because the doctors were scared. I approached doctors who didn't have that patient for orders too. The amount I'd given him would kill an elephant but he was still thrashing around. I was the only senior on the ward but my wonderful colleagues covered my work load for me so I could stay with him. I talked to him constantly and touched him to reassure him that he wasn't on his own, that I wasn't going anywhere. At times I was there with tears running down my cheeks. I was counting the seconds until I could administer more doses. I was also concerned that his family might arrive and see him like that. Then they did. They instantly burst into tears and left the room. So I had to work with them too, to help them through it. I knew they were traumatised, because I know I was. When my manager was checking out a dose with me she asked me what was wrong. I nearly cried and just said 'the useless ******* doctors. How are we supposed to help our patients when we can't get what we need from them because they are too scared?'
It changed when I sent a junior to ask for yet another stat dose and the doctors refused. I went up to them, sitting at the nurses station and said, 'you go down there and look at the patient, then tell me I can't have the orders I need.' They did. They were shocked and quietly asked me for what I needed. I finally got the doses I needed and only had to administer them once to settle him. I stayed with him until he did.
I was convinced that family would think we were the most incompetent nurses on the planet, and I wouldn't have blamed them for thinking that. I expected them to complain to our DON and I was ready to go and be disciplined for my inability to settle that patient. I was shocked when a few days later my manager said she had a card for me from them. They told her they thought I was a beautiful nurse and couldn't believe how I could care so much about a stranger. I've not forgotten that.
Are your doctors not allowed to write "titrate to comfort" with the orders? That is one way you can give the med at your discretion, without having to have concrete intervals. When I worked in hospice nearly every doctor we worked with would order pain meds and sedation meds that way. I don't ever remember feeling like I euthanized anyone. I do remember feeling like I helped people who were suffering.
I'm sure you understand that just because this patient will lose consciousness at the end does not mean he will not be suffering.
I agree with the other posters that intent is everything here. Is your intent to relieve the patient's suffering? If you can defend that, you should have no problem.
I know. My partner and friends want me out of there too. I think someone should certify me as crazy, because I keep turning up there.
But I can't think of a place that has a greater need for nurses who will do what I and a couple of my colleagues do. We do look after ourselves and each other. Occasionally we have mini meltdowns in the tea room. We tell inappropriate jokes, the usual poo stories etc and laugh until the tears are running down our cheeks. Then we go back out and face it again.
Our patients are grateful for everything we do for them. I think we receive back more than we each could ever give. We get to know them all quite well. Being an extremely isolated community most of my colleagues are actually related to the patients and they know all of their histories, etc.
Imagine what it is like to have six patients with dementia whose behaviours are extremely difficult to manage on an acute ward. That happened recently. We have one long stay facility and they refuse to take anyone who is aggressive or violent, so we get them, for months sometimes. Knowing the person they were before they became so lost helps us to reach them, and completely respect them.
So I stay, and try to think of ways I can help the place to change. Education is my target for next year. We don't have time for inservices (we're constantly short staffed because no-one wants to move to the middle of nowhere to do nursing) so I thought I could produce a regular magazine.
So you get stat orders or prn orders. They will only write small doses prn and always at four hourly intervals. Ranges and titration aren't allowed. We've done some wrong things in the past, realised the doctors haven't written in frequencies but still using the order and giving as needed. But when we do that we do wonder if this will be the time we'll lose our registration or be disciplined. I'm still going to work on the pathway. The Liverpool pathway used to be great. I could have put it in front of the doctor and said, 'look, this patient fits these criteria, it's time to palliate them.' And it tells them how to work out what to prescribe. I haven't looked at the latest version yet.
There are bad outcomes that I feel responsible for too. I always wonder if I was a better nurse would've I have been able to do better. I really feel like I failed a patient when things don't go well.
I remember a patient whose wife had just died. He stopped eating and said he wanted to die so he could be with her. He was assessed as mentally competent to make that decision. So we looked after him as he slowly faded away. When he became unconscious the doctors started trying to treat his lung infection, trying to start parenteral feeds......and we fought them. Every day I went through the same fight, with the same result. We did everything we could to delay administering what they wanted. They said he was no longer competent to make any decisions about his care as he was unconscious, therefore they were obliged to treat him.
One morning I had a new grad approach me about him. She had to administer three lots of antibiotics and other meds to stimulate his immune system. She said she didn't want to do it. I told her I'd take over his care, but I was so far behind I wouldn't get to him until much later. I was sure he'd die before I got to it.
I later walked past his room and heard gurgling. I realised what it was and ran in. Unfortunately the doctors saw me dash in and followed. A yellow creamy coloured fluid was pouring out of his nose and mouth and he was aspirating. I still don't know what it was or where it was from. Doctors and nurses filled the room while I held his head to one side so the fluid could pour out. They were trying to get cannulas into him and trying to get a set of obs. I ended up loudly saying 'will you all just stop and actually look at your patient. He is about to die. You won't get a set of obs because he has almost shut down. Now can you please just leave him alone and let him die.'
They all left. I spent the next ten minutes with him, until he died, so he wouldn't be alone. At the end he went for four minutes between breaths, but there was a region above his right breast that was obviously his pulse and I watched it. At the end there was rapid quivering of that area, then he died.
That was a bad death. He'd been moaning for three days. We did everything we could and still failed to get him the help he needed. It has us wonder whether 'real' nurses in the cities would do better. Those with more education and more experience.
Specializes in Oncology; medical specialty website.
I am so sorry for you. You obviously have your hands tied here. You're having to work at extremes; resuscitating people who are actively dying on one hand, and doling out small doses to dying patients in some circumstances, while in others being expected to give large doses that make you clearly uncomfortable.
I'm not sure how you manage to face this on a day to day basis. But you cannot keep shouldering the responsibility for this on your own. You are doing the best you can within the confines of your job. Please don't torture yourself with the "If I were a better nurse..." and "I really feel like I failed a patient..." You are doing your best.
Darknights....God bless you. I know what you're going through....I, too work in a very small, rural area where everyone knows everyone else and the physicians are clueless. I really have been wondering WHY I keep doing hospice, and I've been on the verge of tossing it all and finding a new job. However, your courage and your amazing strength have reminded me WHY I keep doing this, and that I have my own courage and strength to DO this, because it HAS to be done and it is my calling to do it, no matter how hard it is. Thank you so much for setting me straight :)
leslie :-D
11,191 Posts
to absolutely ensure/guarantee death, the doctor would have prescribed at least, quadruple the amt of mso4 and anxiolytic.
and elvish, it honestly doesn't matter what he dies of.
if the INTENT is to relieve suffering, we are legally covered.
leslie
eta: ok, the op states the DON stated it was to immediately end his life.
if the intent is to kill, then yes, 100% illegal.
if the intent is to palliate and the result is death, 100% legal.
i'm wondering if the DON stated the pt will die, versus 'to die'.
big difference in context.