How much is too much morphine?

Specialties Hospice

Published

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...

Specializes in BNAT instructor, ICU, Hospice,triage.
Are you a CNA? Why did you have to call the nurse? Or are you an LPN?

The way my brain was thinking was that it might be a facility nurse taking care of a patient in long term care faciity, who was calling hospice for orders for comfort.

It is concentrated on purpose, why would you dilute? is she actually getting the med, or is she drooling some of it out? + NO, NO, narcan!

The way my brain was thinking was that it might be a facility nurse taking care of a patient in long term care faciity, who was calling hospice for orders for comfort.

Oh I see.

Specializes in Going to Peds!.

Your patient is dying. Please use your palliative care orders to keep them comfortable & ease their passing. Don't dilute the po morphine syrup. Your patient will drool out a good bit of it, lessening how much is absorbed & actually relieving their pain. It's just cruel and heartless to make them suffer needlessly.

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Specializes in Pedi.

I once had a patient (an 8 year old who weighed about 25 kg) receiving 100 mg of IV Morphine PER HOUR with 10 mg boluses available at the end of his life. He was also on continuous Ketamine and high dose Ativan q 4hr. The typical dose of Morphine for a child is 0.1 mg/kg q 2-4hrs. This child was getting more in one hour than a child of his size would typically receive in a week. He lived for days on these doses. If the doses are escalated per protocol, there shouldn't be an issue. With my patient, when we started the continuous morphine he was only on 1 mg. Over a period of days, his doses were escalated to keep him comfortable. With a dying patient you can give more than you would otherwise. And giving Narcan to a dying patient is cruel and barbaric.

Specializes in Med/Surg, LTACH, LTC, Home Health.

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:

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 of what we do......the families.

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.

Specializes in Med/Surg, LTACH, LTC, Home Health.
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 agree with you. Just that when the families change their minds at THE LAST MINUTE, in an attempt to bring the patient back around, Narcan was the first order of business as a way to offset a code. I viewed the entire scenario as cruel and unusual punishment from the time they changed their minds. But as you said, Press Gainey says that either the patient or his/her representative must be satisfied.

When I cared for my first hospice patient as a nurse in an LTC facility, I was worried that I'd killed the patient with morphine. The hospice nurse who came to do the paperwork after death reassured me that no, I did not kill the patient, life did. It's a common misconception that giving morphine and ativan every hour makes the patients go faster. But the fact is many patients just happen to need more morphine the closer they get to the end of life. It's a coincidence.

And dear God, why would you give Narcan to "save the life" of a hospice patient who is there to die?

Specializes in Emergency/Cath Lab.

What is the max dose of morphine?

The amount it takes to make them stop breathing.

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

Specializes in Adult Internal Medicine.
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 use subQ pumps when appropriate here too.

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