Hypothetical, yet sticky situation for a new grad

[defyinggravity2009]

Hi All,

This morning, I woke up to the awful news that a neighbor of mine passed away early this morning. He had been diagnosed with stage IV stomach cancer, and had begun hospice care earlier this week, and his standing orders included morphine prn (not exactly sure of the dosage information, but you get the idea).

When the news of his death was shared with me this morning, I was told that his wife almost called me last night because he needed another dose of morphine, and the hospice nurse was running late on top of traveling about an hour to his home. They had wanted to contact me (a newly graduated RN who was licensed this past week, and still unemployed) to administer the shot. On a side note, he died almost immediately after receiving the shot of morphine.

Had they called me, I just don't know if I could have done it - I think I'm too afraid of liability, or (in hindsight) that someone may have blamed his death on the fact that a new grad administered the medication, instead of being fully able to understand the effects of morphine. Thankfully, I was out of town and hence they didn't call me. But what would you have done?

[CNL2B]

I would have done it as long as I could have called the hospice agency and spoken with the nurse and it was OKed. Would have asked for a dosage that she wanted to use as well as I don't do hospice, narcotic dosages can range widely, and I didn't know this person as a patient.

I do think that there is a significant possibility that it would not be OKed based on the hospice agency's policies, applicable laws, etc. However, when faced with an actively dying patient and asked if there was something I could do to help, I would make an effort to, if I could ensure that things were going to be square all around.

[azhiker96, BSN, RN]

I have some experience with hospice but it's limited. Generally though when a pt is at home, morphine is given as a sub lingual liquid concentrate. Family members are able to give these meds so there would be no need for anyone else to administer them.

To answer your question though, it probably would have been safer to decline to administer the med. Without report, there is no nurse-patient relationship. Even if you wanted to give it, you'd need to see the written order, know that it's the current order, and have access to a MAR to ensure it's time to give the med. The chart and orders would probably not be available to you at the home.

If in weighing risk versus the depth of your friendship you decided to help, here's how I would have approached it. Do an assessment of the patient. Call the hospice nurse and find out what medication (dose, route, etc) should be given. Then give the med. IMO, the morphine did not kill the patient. Cancer killed him. The morphine just helped ease his pain during the process. A hospice nurse once told me, "We all have to die, we just don't have to die screaming."

[CNL2B]

Agreed with above in that the limited experience I have with hospice (with my dying grandmother at home) -- narcotics that I have seen in home hospice are kept in the fridge at home and they are sublingual. It seems really inefficient to have to call a hospice nurse out every time a dying patient needs a shot of morphine -- maybe if that was the kind of care that was expected, there should have been a nurse there staffing her around the clock? IDK.

[TwilightRNurse]

What a sad situation. I would have had to decline. My license is too precious to me I wouldn't risk it no matter what.

[SlightlyMental_RN]

I wouldn't have done it. You don't work for the agency, haven't gotten report, don't have access to the orders, nor do you have access to the chart. Was there morphine locked up at the patient's home? I'm sure it wasn't just laying around, so you wouldn't have had the code for accessing it. I would have explained that I'm so sorry and feel terrible for their suffering, but it would be like walking into another hospital that I didn't work in and assuming care for a patient.

[Hospice Nurse LPN, BSN, RN]

Why in the world would the hospice nurse need to make a visit to give morphine. At end of life, shots aren't given. We use morphine sulfate SL. The family is instructed how to give it. I always have the caregiver do a return demostration. If morphine isn't being used in the beginning, I refresh the teaching from time to time so that when the pt needs it, the caregiver has the knowledge. Poor little man! I'm sad that the hospice nurse didn't do enough teaching, but then it sounds like the pt wasn't on services long. I'm thinking teaching should have been accelerated if he was actively transitioning on admit.

I wouldn't have done it. You don't work for the agency, haven't gotten report, don't have access to the orders, nor do you have access to the chart. Was there morphine locked up at the patient's home? I'm sure it wasn't just laying around, so you wouldn't have had the code for accessing it. I would have explained that I'm so sorry and feel terrible for their suffering, but it would be like walking into another hospital that I didn't work in and assuming care for a patient.

Yes, the morphine would have been just lying around (probably in a kitchen cupboard) The only time we lock up narcs in the home is if there is a problem with diversion or confused pts having easy access.

This whole thing just really breaks my heart.

[Hospice Nurse LPN, BSN, RN]

If in weighing risk versus the depth of your friendship you decided to help, here's how I would have approached it. Do an assessment of the patient. Call the hospice nurse and find out what medication (dose, route, etc) should be given. Then give the med. IMO, the morphine did not kill the patient. Cancer killed him. The morphine just helped ease his pain during the process. A hospice nurse once told me, "We all have to die, we just don't have to die screaming."

Thank you!

[canoehead, BSN, RN]

I'd do it, though I'd have to have orders.

Even if I wasn't comfortable with giving morphine there's always repositioning, hygiene, and moral support for his wife while family waits on the hospice nurse. Reassuring them that they've done everything possible would mean a lot.

[Sayra]

So sorry for your loss. That would have been a sticky situation and, I'm glad the issue was brought up because you never know when you may find yourself in something like that. Thoughts and prayers sent your way.

[traumaRUs, MSN, APRN]

No, I wouldn't have done it. There is liability in caring for a non-family member and a situation you don't need,.

However, I would have gone over to their house if asked and and sat with him/gave moral support, but no meds.

In hospice, the families have SL MS and SL Ativan readily available and its easy to give. There is no reason to give shots.

[defyinggravity2009]

I had very limited information on the client, and unfortunately all was through a third party. Since he was only on hospice for a few days prior to his death, I couldn't say for certain how much teaching (if any) was done regarding administration of morphine, nor do I know if a nurse was scheduled to be there around the clock. I was told that a nurse who was there earlier had left, and they were waiting for another to come, but again, I am not certain of the details.

IMO, the morphine did not kill the patient. Cancer killed him. The morphine just helped ease his pain during the process. A hospice nurse once told me, "We all have to die, we just don't have to die screaming."

I totally agree with this, too... but not every lay person understands that the morphine is there to ease the pain, and blaming others for the death of a loved one is a very real part of the grieving process.

Had the question been posed to me yesterday, I probably would have declined to administer the med for a lot of the reasons mentioned, whether the issue was no chart, no nurse-patient relationship, unclear orders, or whatever. To be honest, even with the suggestions, I would probably have sought non-pharmacological pain relievers while awaiting the nurse. Nursing school has put the fear of God (or the Board of Nursing - whatever your higher power beliefs are) into me, and I worked too hard to lose my license privileges.

I can only hope that in the years to come, I develop the knowledge, wisdom, and nerve to be able to successfully navigate through life as a nurse by helping others and still making sure to CYA.