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 Critical Care.
Meetings with case managers and the interdisciplinary team were very frustrating, as they repeatedly said, "our hands are tied; this is what the family wants so we have to honor the 'family's' wishes until the patient can say otherwise". Really????? Yeah, I know...s/he DID say so. Everything was in 'review' clear up until the patient expired.

Although poorly enforced by Hospitals, it's not legal in any state for family or other POA's to change a DNR order that was made when the patient was able to make decisions. The legal obligation of family and the POA is to make decisions on behalf of the patient only when the patient has not already expressed their wishes, if the patient has expressed their wishes then the family is legally bound to abide by them. In terms of lawsuits there's really not much if any risk to telling the family they cannot override the patient's wishes as the precedent is clearly in favor of denying family the ability to override the patient's wishes.

The problem usually comes down to having someone who will actually enforce it. Unfortunately the squeaky wheel gets the grease, even if they're in the wrong, this is where having a palliative care team is very useful, since in my experience they are the only ones to consistently enforce this sort of thing, even ethics committees typically are too weak, or just plain don't understand the laws.

Sort of a generic source, but worth bringing up if this happens again:Do not resuscitate orders: MedlinePlus Medical Encyclopedia

Specializes in Critical Care.

As for the PCA, it's not an absolute rule that Nurses cannot assist a patient with their PCA button, ISMP actually has a position on this:

"PCA by proxy (someone other than the patient pushing the button) may be legitimately used by Nurses in certain situations, but it is probably more appropriate to call this practice nurse-assisted analgesic dosing. Nurse-assisted analgesic dosing can be used safely when the healthcare professionals involved are authorized, properly educated on pain assessment and opioid toxicity, and required to follow a protocol."

We often use PCA's to deliver continuous morphine drips on comfort care patients only because we can lock the bag and the keypad locks more securely, we've had at least two instances where family up-titrated or bolused patients with the intention of hurrying the process along.

We once had a pt on 1000mg/hr.

Specializes in LTC, Sub-Acute, Hopsice.

The PCA pumps that we use have a basal rate and a prn amount (the "button"). We teach the patient and family when the button is needed to use it. It can be pushed only so often (q __ minutes) for the prn dose on top of the basal rate then is "locked out" until the prescribed time limit is up. If the patient is not able to push it, for whatever reason, we teach the family what pain looks like and to use the button. There is no reason I can think of NOT to teach the family how to use the button. If the patient is unable, but in pain, or SOB, the family should provide the prn dose. We teach the families to use the liquid morphine if the patient cannot do it themselves, why would we not teach the same for the IV? The pump is actually safer in regards to "giving too much" as there is a strict schedule that cannot be overridden by the patient or family. In fact, the nurse cannot change the dosing frequency or the amount given (prn or basal) without calling the pharmacy and having a code to put into the pump. And that code changes with every order to change the dose.

Specializes in Pedi.
The PCA pumps that we use have a basal rate and a prn amount (the "button"). We teach the patient and family when the button is needed to use it. It can be pushed only so often (q __ minutes) for the prn dose on top of the basal rate then is "locked out" until the prescribed time limit is up. If the patient is not able to push it, for whatever reason, we teach the family what pain looks like and to use the button. There is no reason I can think of NOT to teach the family how to use the button. If the patient is unable, but in pain, or SOB, the family should provide the prn dose. We teach the families to use the liquid morphine if the patient cannot do it themselves, why would we not teach the same for the IV? The pump is actually safer in regards to "giving too much" as there is a strict schedule that cannot be overridden by the patient or family. In fact, the nurse cannot change the dosing frequency or the amount given (prn or basal) without calling the pharmacy and having a code to put into the pump. And that code changes with every order to change the dose.

Our PCAs had no codes but you did need a key to get into it to change any settings. Officially, it was against policy for family members to push the demand button when I worked in the hospital. If a patient was too young or too cognitively impaired (pediatrics) to push it himself, he was ordered for "NCA"- Nurse Controlled Analgesia. This didn't mean that parents didn't push the button, of course, but they weren't supposed to. For end of life patients they were allowed to.

We use CADD Pumps which are sub-q. We have a continuous dose and a bolus dose. There are safeguards built in regarding time between bolus dose and how many an hour. No one but the nurse can change anything and we have a code and a key.

Using Morphine Sulfate Liquid and Lorazepam is useful in end-of-life pain or breathing difficulties. The morphine is concentrated so you only give a tiny amount between cheek and gum. The Lorazepam is tiny and goes under the tongue to dissolve. No issues here with swallowing. And yes, do not dilute!

There is no real ceiling on the amount of morphine or dilaudid with hospice patients - they slowly get used to high doses and we have people on pumps getting quite a bit and still walking around, A/O x3. ;)

Truly horrific....that poor soul

Specializes in Hospice.
What is the max dose of morphine?

The amount it takes to make them stop breathing.

There is no max dose. The lethal dose that would stop breathing increases along with tolerance. This is why the dance of dose > assess > dose > assess is so important. If you are worried that you're getting close to a what would be a lethal dose to that patient, check resp quality. Typically resps will become shallower before the rate drops or stops.

Roxanol or liquid morphine is administered buccaly, between the cheek and gum. It is absorbed so the patient doesn't need to be able to swallow. Sub q requires a injection why would any nurse prefer to cause pain in order to relieve it when there are other less invasive ways to administer?

Specializes in Acute Care, Rehab, Palliative.
Roxanol or liquid morphine is administered buccaly, between the cheek and gum. It is absorbed so the patient doesn't need to be able to swallow. Sub q requires a injection why would any nurse prefer to cause pain in order to relieve it when there are other less invasive ways to administer?

If you put in a sc port then you aren't poking them over and over.

If you put in a sc port then you aren't poking them over and over.
Good point. We aren't allowed/equipped to do a port so it would be either separate injections or liquid Roxanol. No IVs or ports for us.
Specializes in HH, Peds, Rehab, Clinical.

I work in LTC, on the rehab/short term side of the facility, which means we have hospice clients. I've yet to see one come to us with a sc port and there is no way that an invasive procedure such as this one would be done for someone on hospice status.

If you put in a sc port then you aren't poking them over and over.
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