Help with understanding a pain management situation

[Runnergirl84]

I had a patient I had taken care of for a few nights. He was progressively getting weaker each shift. He was newly diagnosed with cancer after coming in for something else. But it was in his lungs, brain,

hip bone and a few other places. Anyway, each night I took care of him he always was alert and oriented and in fair spirits and watching movies on his laptop and reading the newspapers. He always denied pain which was very surprising to me. He was a DNR from the beginning. His actual wishes after learning of the cancer diagnosis was to have physician assisted suicide but that is a process that wasn't being actively pursued during this stay for reasons I'm not sure about. The plan was for him and his wife to discharge on hospice the next day after the last night I took care of him. The holdup in doing so was getting everything arranged at home. He had an awesome supportive family who truly wanted to help him to follow his end of life wishes.

The last shift I worked with him, he had had an MRI of his hip on day shift to see how much cancer there was in it and he had been too weak to get out of bed and so we helped him with a urinal/bedpan. I attributed a lot of this to being wiped out from the tests done during the day. Still no pain at bedtime. Said goodnight after getting him some hot tea he requested.

No pain or changes in his assessment noted until later in the shift he suddenly had pain in his right hip. He had nothing but Tylenol for pain. But this was 10/10 so I notified the hospitalist right away and she ordered a dose of morphine 2mg IV which I gave as soon as I could after checking his BP which was 90/60s. His Bp had been trending lower like 90s/60s. Which I mentioned to the doctor. I gave the morphine and he dropped real low like 70s/40s and his daughter/POA soon after was requesting additional morphine. Patient still alert and requesting pain meds also. I told the daughter that she want to call in her sister (it was 4am) because I sensed he was not going to last very long but figured it would be at least be hours from then before he passed. Notified the doc and told her the low Bp after the first dose and she ordered 0.5 mg morphine to give now. Patient not looking well. Charge nurse was aware of the situation and agreed to give the additional morphine. So she came with me and I did. Patient expired within minutes of that last dose.

His family thanked me profusely for giving him morphine so he didn't die in pain like he had wished. His wife had also been a patient next door on our med surg floor and also was newly diagnosed with cancer also. The other daughter had made it just in time to hold his hand as he took his last breath. I was so shocked that this all happened so fast... from alert and conversational to dying within 30 min. My charge nurse assured me I did the right thing in administering morphine per his request so he was comfortable but part of me feels it may have hastened his death. I was very comforted to know the family was extremely thankful but I still feel unease with this mainly because of how fast this all occurred and my second concern is that why were they pushing the further testing the day before the morning he passed if he was going home to discharge on hospice the next day. I think honestly that it just wore him out and his body was done. Also shocking to me was to go from zero pain to 10/10 so suddenly. Being a previous rehab nurse that didn't typically handle dying/cancer patients I want to know if that is common? What could I have done to handle this situation differently or did I do the right thing. It still weighs on me because there was really no debriefing after. Cleaned the room after doing post mortem cares for the room to be cleaned for a new admission:/ all before shift change at 7am.

[Ruby Vee, BSN]

When you work with cancer patients, you have to know that the morphine dose you're giving could be the one that pushes them over the edge. But not to give the pain medication -- allowing the patient to suffer needlessly -- isn't the right thing, either. It sounds like this man had made his peace with his upcoming death, and was just ready. He may have been denying his 10/10 pain for days so he could get his affairs in order and say goodbye to his family with a clear head. Once that work was done, he was ready to let go, admit to the pain and receive medication for it.

You didn't do anything wrong. You don't medicate pain if the patient tells you he isn't having any. When he does admit to having pain, you called the provider and got him some pain medication. You called the family and got his daughter there in time to say goodbye. You followed his wishes. You did the right thing. Yes, the morphine may have hastened his demise, but he died comfortably and not in 10/10 pain. The provider was aware of that possibility when she gave the order. Withholding the morphine wouldn't have prolonged his LIFE, it would have just extended the dying process. That's torture. You did good.

It sounds like you could use a little debriefing. Is there a nurse educator, a mentor, or someone you could talk to about this? An Employee Assistance Program where you work? If not, journalling helps a lot. Just put pen to paper or fingers to keyboard and write for 20 minutes. If you don't know what to write about, write that. Whenever I do that, I find that by the end of 20 minutes, I've written out the question that was bothering me, and if I don't have the answer yet, I'm always halfway there.

[Dodongo, APRN, NP]

Have you taken an ethics course? I'll risk explaining something you may already understand, but there is something called the "Principle of Double Effect". This idea helps explain the licitness of administering pain medication, although it may hasten a patients death, in order to also accomplish something good - which would be the relief of suffering. The patient was terminal. He was suffering. The pain medication may have ultimately caused or hastened his passing, but you eased his passing by administering the morphine. It's a tough spot to be in, but one that you will encounter frequently when working in ICU/hospice/oncology, etc.

I think the situation was appropriate. Focus on the good you did.

[annabanana2]

My vote is that you did the right thing, 100%. Very little I would've done differently other than maybe push to avoid unnecessary testing (like you mentioned) and I might not have done the BPs, but then, I work in hospice so it's a different setting. Honestly, the man was dying quickly as it was. Even if you did hasten his death (which, questionable at best) - what would have been worse, speed up his comfortable, peaceful death by an hour, or let him live an hour longer in agony?