Palliative Care and Euthanasia

[bracken]

Hi everyone,

This is my first time posting on allnurses.com. I am a final year nursing student at Napier University, Edinburgh.

Part of my coursework involves selecting one of the World Health Organisation palliative care principles. I have chosen 'intends neither to hasten or postpone death.' My essay will provide a literature review and analyse wether euthanasia has any place within palliative care - What are your views on this?

How does the above discussion relate to clinical practice?

[Katillac, RN]

At the risk of being controversial, I do believe in euthenasia and wish there was more acceptance of this need and the appropriate legislation and protections for providers to support it. In 1974, For a nursing class, I wrote a paper on this subject and all heck broke loose.

Having had some experience in ther hospice setting, I think passive euthenasia, if you will, occurs. For example, in a case of end-stage COPD, MS in used in nebulizers extensively as well as oral administration PRN. We all know the respiratory impact of Morphine. Hospice physicians are really incredible. Their point of view about pain control, comfort, medication dosage and administration is unique to the profession.

You have indeed adopted a controversial stance. Your view must have presented a challenge for you if you did hospice work given that the ethics associated with the hospice philosophy prohibit intentionally hastening death. I don't doubt that there have been occasions when some clinicians in hospice have acted with disregard for the law, their license, and the ethics of their profession and their specialty. It's unfortunate, though, if your "some experience in ther hospice setting" gave you the impression that euthanasia of any kind is accepted or widespread in hospice.

Further, I think we need to be careful with statements like, "We all know the respiratory impact of Morphine," and equating morphine usage to euthanasia, passive or active. There is NO evidence that morphine when "started low and titrated slow" causes fatal respiratory depression. Even aside from the fact that the principle of acceptable double effect applies, it's all about the dosage. Morphine is a phenomenal tool when used in end of life care. Like a knife or a gun, it can be a dangerous tool if not used responsibly and carefully.

[leslie :-D]

very well stated katillac.

it is NEVER our intent to hasten death......NEVER.

but if morphine brings relief to a struggling respiratory pt, then our intent is to relieve the suffering, even if it does hasten death. it all revolves around intent. and most times, morphine is given with very specific parameters. i needn't go on-katillac said it all.

leslie

[jsteine1]

It would appear that earle58 chose to read into my entire message and misinterpret it entirely. This is not a debate forum.

[VickyRN, MSN, DNP, RN]

moderator's note:

please debate the issues and avoid personal attacks. thank you.

[hollyster]

It would appear that earle58 chose to read into my entire message and misinterpret it entirely. This is not a debate forum.

I agree with Earle58. It is not our place to play God. We are to do everything in our power and scope of practice to make patients as comfortable as possible. We are not ANGELS of death.

[jsteine1]

I agree with Earle58. It is not our place to play God. We are to do everything in our power and scope of practice to make patients as comfortable as possible. We are not ANGELS of death.

I agree totally with all of your comments regarding the purpose and correct approach to palliative care. I simply stated that my comments were seriously misinterpreted by one and the followers followed. Lets all try a new thread! The original issue was the concerns some experienced LTC nurses had with what appeared to them to be an acute care approach which again, appeared to some nurses to be overly agressive. Period, end ,finis.

Reading an entire thread before responding puts ALL responses in perspective to the original issue.

[leslie :-D]

It would appear that earle58 chose to read into my entire message and misinterpret it entirely. This is not a debate forum.

i reread your post and am unsure of what i misinterpreted. my response is similiar to katillac's. i was merely responding. actually there's nothing to debate. i'm confused re: your response to me but certainly won't dwell on it. if you care to elaborate, i'm all ears.

leslie

[Moishe Pupik]

In terminal illness patients are confronted with physical, emotional, and spiritual suffering, as well as loss of control and dignity. I believe it rational for a terminally ill, mentally competent adult to want to hasten their death. It should be the patients choice. We should not break the law, but nor should we impose our values on our patients.

[aimeee, BSN, RN]

i think passive euthenasia, if you will, occurs. for example, in a case of end-stage copd, ms in used in nebulizers extensively as well as oral administration prn. we all know the respiratory impact of morphine.

i absolutely disagree. i believe most nurses fear the respiratory impact of morphine without regard to the dosage of morphine being used due to the cautions we continually heard in nursing school. the morphine doses used in nebulizers and orally are small, effective and safe. this is the kind of misconception that we have to continually battle against.

i doubt any nurse here would consider giving a couple of vidodin to be "euthanasia" and yet they contain a higher equivalent dosage of narcotic than the standard dose of morphine used to relieve dyspnea in an end-stage copd patient. in our country an absolute mythology has grown up around morphine that has little to do with fact.

furthermore, chart reviews have shown that narcotics given during the dying process according to established protocol, for the purpose of relieving pain and suffering, have no statistical effect on the length of the dying process.

[elthia]

i absolutely disagree. i believe most nurses fear the respiratory impact of morphine without regard to the dosage of morphine being used due to the cautions we continually heard in nursing school. the morphine doses used in nebulizers and orally are small, effective and safe. this is the kind of misconception that we have to continually battle against.

i doubt any nurse here would consider giving a couple of vidodin to be "euthanasia" and yet they contain a higher equivalent dosage of narcotic than the standard dose of morphine used to relieve dyspnea in an end-stage copd patient. in our country an absolute mythology has grown up around morphine that has little to do with fact.

furthermore, chart reviews have shown that narcotics given during the dying process according to established protocol, for the purpose of relieving pain and suffering, have no statistical effect on the length of the dying process.

i totally agree. i once had a family member who was absent for the entire 2 month hospitalization until the last 3 days of the patients life. the family member then became very irate at the amount of morphine the patient was getting. the patient was dying of lung cancer, and was on a morphine drip titrate to comfort. i finally had to explain to the family that we were not "killing him" or keeping him "sedated". fatigue goes hand in hand with cancer, and when a patient is struggling to breathe, that is tiring also. i stated that "normal respirations run 12-20 breathes a minute", and i was going to keep titrating that drip until the patient's respers were down to 12-20. at the time the respers were 36-48!!! i also stated that the patient was going to die within a matter of hours to days, but on my shift i was going to do my best to make sure he died comfortably. the patient didn't always ask to have the drip titrated, but once he could breathe easier he did ask to speak to me, and some of his last words to me were "i just want to thank you for what you have done". sometimes nurses have to use alternative methods such as respiration rate and the flacc pain scale as guidelines in administering prn's, nurses need to remember that we speak for the patient when the patient is unable to speak for himself.

fortunately, at my facility most of the doctor's will write orders stating "pt is comfort care, do not hold meds for low bp, or low respers, only hold meds for excessive sedation, notify md when meds are held".

[dinkymouse]

I don't think you'll get much argument from anyone that it's poor nursing judgement to fail to take action with a patient who is "sweating and struggling for every agonizing breath (because they) could not verbalize pain". However, there is a huge difference between allowing that and presuming that you know, based on a patients' diagnosis, who has pain and who does not. My education and experience have taught me that all patients are different, that I need to assess carefully using both nonverbal and verbal signs and symptoms. If my serial assessments show that my patient has persistent pain, I often approach the MD for a routine order or a long acting med. Until I get it, I continue to treat the first sign of breakthrough pain.

By your logic, if I have a patient that gets a PRN order, I should start giving it then and give it to the max perameter routinely to eliminate the possibility that they might have pain. With opioids especially, the consequences of that can be dangerous, and I think it shows poor nursing judgement. You say that "pain is subjective" but then go on to say that you know based on diagnosis whether a patient has pain or not. So if someone with liver CA with bony mets says he has no pain, you give him the PRN anyway? Your education and experience have taught you that you know best, it seems.

This board is read by both laypeople and professionals. I'd like to assure those reading that few nurses take this "one size fits all" approach to pain management, and few allow pain to go untreated.

In a discussion with a doctor in my first year as a nurse he said, "It is better to put the cart before the horse, In other words it is better to prevent the pain before it gets there" I have followed these words throughout all my jobs. I have had many stoic patients who say they aren't in pain but their body is rigid with it and their vitals also emphasis the point.

[Katillac, RN]

In a discussion with a doctor in my first year as a nurse he said, "It is better to put the cart before the horse, In other words it is better to prevent the pain before it gets there" I have followed these words throughout all my jobs. I have had many stoic patients who say they aren't in pain but their body is rigid with it and their vitals also emphasis the point.

OK, I'm just back from a glorious vacation, so I'll bite again. How, exactly, do you "prevent the pain before it gets there"? I hope what you mean is that you give routine and/or long acting medication as ordered. That's just appropriate nursing practice.

As to the patient whose body is rigid and their vitals abnormal but they are denying pain, how do you respond?