Some advice on morphine admin

[pharmgirl]

I'm going to post this in here as well as in ER because I don't know where I would get the best response. Thank you all in advance.

I am currently an ER nurse (new grad May 2010). We had a patient come into the ER Friday and Saturday night in end-stage metastatic bone cancer. After much ado all weekend, the family had decided to involve Hospice (I will spare you the details). The doctor ordered 2mg of Morphine to be admin q5 minutes until pain management is achieved. The nurse who was supposed to have this patient was having a hard time with this and I offered to take over the patient for them (also for continuity of care, since I had had him the previous night). Pt respirations were 8- 10 with periods of apnea. BP was ranging between 62/46 and the highest I saw was 99/54. The patient was undeniably in pain. This raised a lot of question about the appropriateness of the morphine between our ER supervisor and the nurse I took over from. I myself, believed (and confirmed by the family) that this patient did not want to be in pain. Personally, I also believe that when pain is relieved, the disease process can take over. The ER physician and I shared the same viewpoint.

Was I wrong in following this order? Are my co-workers in the "save life" mode from being in ER so long? Not saying either opinion is right or wrong, just trying to figure this all out

Thanks in advance for your input and advice!!

[leslie :-D]

as far as i'm concerned, it's a perfectly appropriate order.

(i'm hoping these folks know there is no ceiling on mso4.)

from a moral viewpoint, your intent was to relieve pain and suffering.

from a legal viewpoint, even if he bottomed out and died, you'd still be covered, because of your intent.

whether an er nurse or any other type of nurse, i've known too many who are reluctant in giving mso4.

and i heartily applaud the doc who prescribed the order...

as there are still (too) many that prescribe it sparingly.

thankfully your pt is receiving hospice now.

and thank you for taking over.

leslie

[pharmgirl]

He is (as far as I last heard) receiving Hospice. I am so thankful for that. Thank you for the advice, made me feel a lot better about it. I thought by the reaction of the other nurses that I may have done something inappropriate following that order but I really didn't see it.

One thing about having this patient, I've peaked an interest in Hospice. It was always on my radar, but now am doing a little more research. I really enjoyed taking care of him.

[catlvr]

Metastatic bone cancer = pain pain pain. Thank you for caring out the order, and relieving this poor gentleman, since that was his wish.

I, too, have been considering hospice, and am so grateful for Leslie's good advice.

e

[tencat]

Totally appropriate orders, and thank heavens you were there to make him comfortable. So many medical people desperately need training about what hospice is and what hospice does.....you did the right thing.

[sclpn]

i agree!!! bone cancer can be one of the most painful cancers there is. you sound like a hospice nurse in the making. thank you for being there for this man. appropriate orders totally. and yes, in my experience, when pain is relieved the disease process can take over. I wouldn't say you coworkers are in the "save the life" mode b/c of working in the ER....in nursing school we are taught interventions to save lives and fix problems. this is very hard to "let go" of.....by that i mean, understand that there isn't always a solution to fix the problem and now we need to make this person comfortable and just treat the symptoms that arise from the disease process. i have been working with hospice for a little over a year now and love every minute of it. wouldn't want to be doing any other kinda nursing

[ErinS, BSN, RN]

I had an amazing medical director once that explained it like this. If a patient has a symptom that is uncontrolled (ie. pain), it triggers the sympathetic nervous system (fight or flight) which triggers adrenaline release, hence prolonging life. So your supposition that the morphine allows the natural disease process to take over is correct. The morphine relieves the suffering, allowing the pt to relax and stopping that adrenaline release. This is why people think their grandma went on hospice and the morphine killed her! This explanation has helped me cope with some of the moral issues. It sounds like you did a great thing.

[vapn]

I had an amazing medical director once that explained it like this. If a patient has a symptom that is uncontrolled (ie. pain), it triggers the sympathetic nervous system (fight or flight) which triggers adrenaline release, hence prolonging life. So your supposition that the morphine allows the natural disease process to take over is correct. The morphine relieves the suffering, allowing the pt to relax and stopping that adrenaline release. .

That is a great explanation! I'm stealing it. I know this thread is a month old, but the order is completely appropiate. Another thing to keep in mind is that with bone mets, lots of times pain can go from 0-60 in a short amount of time and it is very challenging to get it under control at "60" when there was really no noticeable progression of pain. Also, this was in the ER, which means the patient was likely at home with subtherapeutic pain control for who knows how long, also making it a challenge to get that pain under control. Kudos to you for following that order.