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...

I actually had a patient once that was full code EXCEPT narcan. He had extensive cancer and wanted everything done. But he had gotten narcan once, and he said it was worse than dying would have been. He wanted to be coded, but he'd rather die than get narcan.

Please folks, if you cannot advocate for your patient get out of nursing (or at least bedside nursing). For those who might EVER give narcan when the family "changes their mind" you have utterly failed your nursing duties.

You are the patient's only true advocate for their wishes and needs. You must be willing to battle everyone- the family (when they freak out), the pharmacy (when they are slow to deliver necessary meds for comfort), the doctor (when he does not have the balls to stand up to the family for the patient's CLEAR DNR request). Yes you may lose but if you do it right, you can educate the family through their freak-out and you can stand by the doc and encourage him/her to remember the patient's wishes.

Please, please, please do not let your patient die in agony from pain or even worse (I think) writhing around trying to get air. Morphine and Ativan work great for that and you should be generous with it.

Whoever mentioned the PCA- I hope you are not expecting your end of life patients to be pushing the dang PCA button to get relief at end of life? PCAs are the devils own torture for any patient that want relief and sleep as they get neither having to wake up every 10 minutes of they want pain relief.

Do research on palliative and hospice end of life. Read the research articles.

Whoever mentioned the PCA- I hope you are not expecting your end of life patients to be pushing the dang PCA button to get relief at end of life? PCAs are the devils own torture for any patient that want relief and sleep as they get neither having to wake up every 10 minutes of they want pain relief.

They can be amazing if they're used on a basal rate. I'm assuming that's the way they'd be used. (Ok, maybe not "assuming" but "hoping.")

Specializes in Acute Care, Rehab, Palliative.
They can be amazing if they're used on a basal rate. I'm assuming that's the way they'd be used. (Ok, maybe not "assuming" but "hoping.")

Ours are usually both. Basal rate and bolus. We push the bolus button for them.

The policy for every facility that I have been at is that it is absolutely not acceptable (like a fireable offense) to push the PCA button for the patient. We can manually give boluses but we cannot push the PCA button (nor can the family).

Specializes in LTC.

A quote comes to mind in regards to hospice and pain control. It is our duty as nurses to "make the body comfortable so the spirit can leave"

concentrated morphine should never be diluted as it is made to be absorbed bucally/sublingual in patients not able to swallow and it works very well for end of life care along with the ativan.

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

When decision was made to call the code, the physician and the manager were both present....it is policy that those two people and the charge as well as the code team and primary nurse remain during the code. The ever growing fear of lawsuits is what I believe is the reason behind management caving in to the whims of customers.

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

As far as the DNR and/or POA, patients trust that their designee will honor their wishes when they cannot speak for themselves. But this does not always happen, as was the case that I witnessed last year with a 97 year old man. It was a sad case and the person was oriented to ALL faculties and was ready to die. But when s/he became incapacitated, his/her designee (who just happened to be married to an attorney), turned the status into a full code. That of course, left us co-workers expecting the ethics committee to chime in at any moment with the right-to-die speech. Well, they NEVER did and 3 months of hospital regimine (labs, bloodwork, vitals, intubation, extubation, 80mg of Lasix today, 20mg of Lasix tomorrow, X-rays.....you name it, it was done), the poor soul finally expired. 97 years old being put through the ringer, and the Ethics Committee did nothing simply because, I believe, an attorney was a member of the immediate family.

As far as the DNR and/or POA patients trust that their designee will honor their wishes when they cannot speak for themselves. But this does not always happen, as was the case that I witnessed last year with a 97 year old man. It was a sad case and the person was oriented to ALL faculties and was ready to die. But when s/he became incapacitated, his/her designee (who just happened to be married to an attorney), turned the status into a full code. That of course, left us co-workers expecting the ethics committee to chime in at any moment with the right-to-die speech. Well, they NEVER did and 3 months of hospital regimine (labs, bloodwork, vitals, intubation, extubation, 80mg of Lasix today, 20mg of Lasix tomorrow, X-rays.....you name it, it was done), the poor soul finally expired. 97 years old being put through the ringer, and the Ethics Committee did nothing simply because, I believe, an attorney was a member of the immediate family.[/quote']

If we know what the person's wishes were, nobody has the right to go against them. If the ethics committee doesn't step up, ADVOCATE.

It's these kinds of stories that make me thankful I don't work in the US. Our system isn't perfect but at least we aren't constantly being threatened with ridiculous law suits.

Your posts about this "scenario" make me incredibly angry. Not *you*, but the whole situation. I'm not a new nurse, I'm not naive, but come on.

Specializes in Acute Care, Rehab, Palliative.
The policy for every facility that I have been at is that it is absolutely not acceptable (like a fireable offense) to push the PCA button for the patient. We can manually give boluses but we cannot push the PCA button (nor can the family).

Really? How come?

Really? How come?

The safety of a PCA comes in that oversedation is prevented by the patient having to be unsedated enough to push the button to get another dose. If someone else pushes the button, that overrides that safety.

I'd say in end-of-life care, that safety isn't necessary. But I think we all know that hospital policies are created to keep people alive, end-of-life care is an afterthought.

Specializes in PACU, pre/postoperative, ortho.

The safety of a PCA comes in that oversedation is prevented by the patient having to be unsedated enough to push the button to get another dose. If someone else pushes the button, that overrides that safety.

I'd say in end-of-life care, that safety isn't necessary. But I think we all know that hospital policies are created to keep people alive, end-of-life care is an afterthought.

And no matter how much teaching is given re PCA use, at least once every few weeks, we have to shut a pt's unit off completely because family doesn't "get it" & will continue dosing the pt while they sleep. (ortho cases, not hospice)

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