Hurrying death?

mappers · Dec 27, 2012

At the LTC facility where I teach, they frequently place a subQ line. They give ativan and morphine through that Q1-2 hours. Is that not common in other palliative situations?

tinks599 · Jan 6, 2013

This could be an infinite discussion. Several of you have already brought up good points and good strategies for dealing with these situations. Here's my thoughts:

Despite our current culture, death is as much a part of life as being born and living life.

Having (or helping to provide) a "good death" is a perfectly acceptable and admirable goal.

There is a difference between prolonging life and prolonging death. I'm all for prolonging life, I am not at all for prolonging death.

There are fates worse than death. Death can be a real gift for the patient and the family.

I am not advocating going against orders. I'd also be lying if I didn't say I wish assisted suicide were legal in all 50 states. I also feel equally strong that we (as a country) can do so much better in educating people about end of life and advanced directives so there is no question what the patient would want and how they want to go. Of course, that is part of my utopia...dignity to the end.

tinks599 · Jan 6, 2013

At the LTC facility where I teach they frequently place a subQ line. They give ativan and morphine through that Q1-2 hours. Is that not common in other palliative situations?[/quote']
I have seen records from multiple states. I see some areas where Q1-2 hour orders is more common, others the orders are PRN. I think both are likely equally as common if you average them but it tends to go with the comfort level of the directing physician.

johnys · Jan 24, 2014

"Yes, when I worked in hospice we did use highly concentrated liquid forms of morphine and sublingual ativan on our patients who were actively dying. Most of them did not have veins that could support IV access. Besides, why cause a dying patient more pain with repeated sticks (IV, IM or SC)? Absorption/circulation of the drug may not be as efficient as oral mucosal route. [quote)

I know this is a mildly older thread, but I have seen discussion about the absorption of SL/PO morphine and more importantly, WHERE it is absorbed. Much (but probably not enough) research has been done (with healthy subjects - not dying people) on the bio-availibility of nebulaize, PO, SL, IV, SC, PR equianelgesic doses of morphine.

Pharmacology: Sublingual administration of morphine is often used to treat breakthrough pain in an attempt to hasten analgesic onset and peak; however, available data do not support more rapid absorption of morphine through the sublingual mucosa when compared with the oral route (1-3). Indeed, a number of clinical studies have found no substantial advantage to the use of SL morphine over oral morphine (4-6).

•Mean time to maximum concentration has been shown to be shorter following PO morphine (0.8 + 0.35hr) compared with SL (1.75 + 1.30 hr), indicating that SL morphine is likely swallowed and absorbed gastrointestinally rather than through the oral mucosa. From www.eperc.mcw.edu. (Fast Facts from the EPERC).

Morphine placed in the mouth is not well absorbed through the oral mucosa - something about its lipid insolubility and the pH of the mouth....it IS absorbed via the GI tract, but is subject to 1st pass hepatic metabolism. I have not had much sucess with clients who are not able to swallow AND in pain - will go to PR, IV or SC route (preferably not PR but it can be effective) anytime I can.

Just my .01 cent. BTW, hospice nurses rock!