How much is too much morphine?

Specialties Hospice

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I had a patient on hospice last night that was receiving 0.5 mg Lorazepam and 15 mg morphine. The patient began moaning between each breath so we gave her another dose of 0.5 mg Lorazepam and 15 mg of morphine an hour later, as well as repositioned her on her side as she is a bigger lady so the lungs could expand more.

About an hour into my shift this patient continued to moan between each breath, increasing in frequency, so I called Hospice. Hospice said to continue what I was doing every hour and that they would send out a nurse. The nurse came out, evaluated the patient, and decided to continue this 15 mg of morphine every hour and bump up lorazepam to 1 mg every hour (given together diluted in water and placed slowly in the cheek).

I asked the hospice nurse if there was a limit to how much morphine should be administered on my shift, however, the hospice nurse said that the resident needs it. In total I ended up probably giving 120 mg of morphine and approximately 6 mg of lorazepam (8 hour shift). The resident was on comfort cares and has been declining over the past few weeks, and especially has been declining over the past few days. The family was there and accepting of her passing away within the next day or so.

However, at the end of my shift we repositioned the patient went into this anoxic like state while moaning much louder than before. I'm guessing this is a sign of overdose and am concerned that hospice lead me down the wrong path.

Any comments would be great...

I'm always surpised that end of life medications are buccal in the USA, in the UK we give sub cut meds in hospital and could be given in nursing homes or at home.

buccal seems a poor choice in semi comatose patients as if they could swallow you would give oral meds.

15 mg buccal equals 7.5mg oral seems resonable to contorl pain in end of life equal

we use sub cut midazapam(versed) for anxiety

That's more in the nursing home/long term care situation than the hospital. Lots of laws governing who can do what in LTC and there's often not an RN on at notes. LVNs are pretty restricted in their scope in a lot of places. Is that an enrolled nurse in the UK?

Specializes in Acute Care, Rehab, Palliative.

We use PCA pumps on pretty much all of our palliative patients.

Specializes in Pedi.
I'm always surpised that end of life medications are buccal in the USA, in the UK we give sub cut meds in hospital and could be given in nursing homes or at home.

buccal seems a poor choice in semi comatose patients as if they could swallow you would give oral meds.

15 mg buccal equals 7.5mg oral seems resonable to contorl pain in end of life equal

we use sub cut midazapam(versed) for anxiety

In the hospital patients would likely be on IV medication. All the dying patients I've cared for in the hospital were on continuous morphine and usually something like versed or ketamine.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Are you quoting a drug guide? This doesn't at all apply to active end of life care. Giving narcan to a dying person is cruel and unnecessary.

he didn't notice that this was a hospice patient and deleted his comment.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I had a patient on hospice last night that was receiving 0.5 mg Lorazepam and 15 mg morphine. The patient began moaning between each breath so we gave her another dose of 0.5 mg Lorazepam and 15 mg of morphine an hour later, as well as repositioned her on her side as she is a bigger lady so the lungs could expand more.

About an hour into my shift this patient continued to moan between each breath, increasing in frequency, so I called Hospice. Hospice said to continue what I was doing every hour and that they would send out a nurse. The nurse came out, evaluated the patient, and decided to continue this 15 mg of morphine every hour and bump up lorazepam to 1 mg every hour (given together diluted in water and placed slowly in the cheek).

I asked the hospice nurse if there was a limit to how much morphine should be administered on my shift, however, the hospice nurse said that the resident needs it. In total I ended up probably giving 120 mg of morphine and approximately 6 mg of lorazepam (8 hour shift). The resident was on comfort cares and has been declining over the past few weeks, and especially has been declining over the past few days. The family was there and accepting of her passing away within the next day or so.

However, at the end of my shift we repositioned the patient went into this anoxic like state while moaning much louder than before. I'm guessing this is a sign of overdose and am concerned that hospice lead me down the wrong path.

Any comments would be great...

I don't think youa re overdosing her...it sounds like she has been pocketing the meds in her cheek and when you changed her position she had a choking episode.

Be sure all of the meds are swallowed when given ....this patient may benefit from SQ administration of the morphine....if she is developing trouble swallowing.

However, at the end of my shift we repositioned the patient went into this anoxic like state while moaning much louder than before. I'm guessing this is a sign of overdose and am concerned that hospice lead me down the wrong path.

Any comments would be great...

No, hospice was definitely not leading you "down a wrong path." This patient was dying and you were doing what you had to do to help her with pain and anxiety.

I don't know what an "anoxic like state" is.

Someone who has been accustomed to high doses of opioids (habituation) over time tolerates them; "overdose" isn't a concept that has much meaning in this setting.

Do not fear death so much. Ask the hospice person (nicely, not accusingly) to clarify this scenario for you.

Specializes in Med/Surg & Hospice & Dialysis.
There is no ceiling for morphine. You give as much as the pts needs. Sometimes no amount of meds will stop the moaning. Besides the moaning did the pt show any other signs of distress, pain, anxiety?? These are the questions you will ask yourself when medicating your pt.. End of life care is very different and morphine as many great qualities..[/quote']

This!

It is unethical to give Narcan in this situation. You know what the patient wants, which is as peaceful a death as possible. Your first duty is to the patient, and your second duty is to the family.

Have the guts and professionality to explain to the family that with opioid reversal the patient's pain will explode, he will suffer terribly in his last hours, it will not increase his life span, and you will not do that to a helpless dying person.

Specializes in HH, Peds, Rehab, Clinical.
I don't mean to go against the grain here. And I'm kinda not. But I would have Narcan very close at hand simply because I've witnessed on 3 separate occasions over the years where families of DNR and/or care-and-comfort patients made a VERY LAST MINUTE decision to want their loved ones saved. Of course, this happened in a hospital setting with circumstances (increasing number of arriving family members that added to opposing views of the situation) contributing to status quo.

This is not an ordinary or expected occurrence but it does happen and unfortunately,when the Narcan proved fruitless, a full code ensued with a positive outcome ONLY for a few days in one of the cases. After witnessing the actual 'gruesomeness' of the code, the family let their loved one go in peace.

I agree WHOLE-HEARTEDLY that Narcan should not be used on an actively dying patient but it is good to have it nearby for the same reasons we do a lot of what we do......the families. Let's face it, for our nonverbal patients who appear to be more comfortable than we are, we medicate the families via patients more than we would like to, and management supports and encourages it. I personally think it sucks but I'm just a med/surg nurse threatened with repercussions if my patient is asleep and his/her family isn't smiling.

My nickel's worth......:no:

Once a DNR order is in place, the family has no power to reverse it. At least not in my state!!

I will never, ever give narcan, which eliminates the ability to control pain AT ALL for hours, to one of my dying patients. And thank a merciful providence I am no longer in a hospital setting. Press Gainey this.

I love the use of P-G as an expletive. I find P-G a lot more offensive to my sensitive eyes/ears than the words the site will automatically asterisk out. :)

I don't mean to go against the grain here. And I'm kinda not. But I would have Narcan very close at hand simply because I've witnessed on 3 separate occasions over the years where families of DNR and/or care-and-comfort patients made a VERY LAST MINUTE decision to want their loved ones saved. Of course, this happened in a hospital setting with circumstances (increasing number of arriving family members that added to opposing views of the situation) contributing to status quo.

This is not an ordinary or expected occurrence but it does happen and unfortunately,when the Narcan proved fruitless, a full code ensued with a positive outcome ONLY for a few days in one of the cases. After witnessing the actual 'gruesomeness' of the code, the family let their loved one go in peace.

I agree WHOLE-HEARTEDLY that Narcan should not be used on an actively dying patient but it is good to have it nearby for the same reasons we do a lot of what we do......the families. Let's face it, for our nonverbal patients who appear to be more comfortable than we are, we medicate the families via patients more than we would like to, and management supports and encourages it. I personally think it sucks but I'm just a med/surg nurse threatened with repercussions if my patient is asleep and his/her family isn't smiling.

My nickel's worth......:no:

That is a horrendous thing. Honestly. Any physician worth anything is going to say, no way am I putting this person through that. If they are dying, it is NOT the morphine that is making them die. I would REFUSE to give narcan because the family change their minds out of guilt or false hope or a complete acceptance of reality.

If a person is not going to come back from whatever it is that brings them into my care, no. Sorry. Somebody else can do it. I will not knowingly give narcan, throw somebody into severe pain, and code them so the family can get their reality check.

If the physician agreed with those expectations, I would question them, and if they insisted, I would get pastoral care/ethics committee involved. I would tell my coordinator (manager) that I was refusing and why.

Yes we care for families but not to the detriment of the patient. They can be angry at me forever, but if the person dies in comfort I know I did my best for them and would have no regrets.

I'm always surpised that end of life medications are buccal in the USA, in the UK we give sub cut meds in hospital and could be given in nursing homes or at home.

buccal seems a poor choice in semi comatose patients as if they could swallow you would give oral meds.

15 mg buccal equals 7.5mg oral seems resonable to contorl pain in end of life equal

we use sub cut midazapam(versed) for anxiety

We give lots of subcut meds too (Canada) and they work much better, especially when people are not responsive enough to hold buccal meds. Actually, we give oral until it isn't holding them or they can't swallow, and go right to subcut. Really the only buccal med we give is sufentanil for incident pain (before a turn or procedure, like a dressing change) for people who require a short-acting top-up, but only if they are alert enough to hold it until it absorbs.

Incidentally, I took a palliative care course recently and in that they said the UK is number one in the world at effective end-of-life care! Go you!

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