I'm supposed to what now?

[jojo489]

Long story short, it was suggested to me that I administer sublingual morphine to a sleeping patient. I see several problems with this.

1. In my view, this takes away the patients right to know what medication they're receiving and also their right to refuse.

2. All I can see is aspiration pneumonia on the horizon.

3. Is that even flipping ethical?

I will not do this. Absolutely not. Not when the patient is alert and with it enough to ask what medications they are taking. My morals don't allow this.

So, what route do I take if I catch flack from management? And I'd love to hear your thoughts on this.

[Karou]

Why are you being asked to do this, and who is asking you? How is this medication specifically ordered (PRN or scheduled)?

If the patient is alert and able to state when they are in pain and ask for medication then I see no reason why you should have to give it to them while they are sleeping. That is really strange to me. Is pain an issue for this patient, is this something they asked for? I have had patients tell me, "Oh just give me that morpheme through my IV in two hours when it's due while I'm sleeping. I don't want to wake up hurting". I then have to explain that PRN means as needed and that they have to ask for it.

I am imagining trying to open a sleeping patients mouth to slip them a sublingual med and everything in me is just screaming "no".

[heron, ASN, RN]

You don't include enough information about the situation for me to have an opinion.

If someone has severe chronic or acute pain that needs atc dosing, then withholding pain meds would allow that pain to get out of control. Trust me, when that happens it's a nightmare for the pt. and that's against my morals.

Pain management requires a critical thinking process - the classic nursing process of assess, plan, intervene, reassess, change plan if needed, lather, rinse, repeat.

Give us a little more data.

[loriangel14, RN]

It would depend on the circumstances. I have had patients on morphine and give it regularly without waiting for the pain to build up. If it's that bad you don't want it to get ahead of you. I have given PRN morphine without waiting for the patient to ask.

Why is this patient taking morphine?

[caliotter3]

When I was visiting my daughter in the PACU when she was post-op, her nurse told me it was ok for me to push the pump for her because she was having trouble getting rest. She explained to me the signs of pain, restlessness, etc., and said there was no problem because of the lock-out. I don't see anything wrong with providing the morphine if, under the circumstances, you think the person is in pain, and would benefit from the med at that time without waking them. You have to use your discretion.

[HappyWife77, BSN, RN]

We give it SL round the clock to cancer patients as hospice nurses. While they are resting we administer it. I don't think it would be enough to cause aspiration pna.

We need more info on your situation.

[AmyRN303, BSN, RN]

We give it SL round the clock to cancer patients as hospice nurses. While they are resting we administer it. I don't think it would be enough to cause aspiration pna.

We need more info on your situation.

I've given it SL for an NPO pt on aspiration precautions. He wasn't yet on hospice, but was awaiting a meeting with them. There isn't a lot of fluid there and with good oral hygiene the risk for aspiration would be low.

[jojo489]

I have not been directly ordered to do this, but it was passed on in report that I give it at night as PRN. This Pt receives it regularly during the day but not at night. At one point they did have meds overnight and told me that if they wanted the med I have that they would ask for it. This pt is on hospice, but the morphine isn't primarily for pain (if they were in overt amounts of pain, or had ever reported pain at all, I would have less of a problem with this)

The morphine is moreso to control respirations which increase due to copd but also are related to the pts anxiety. At night, they tend to sleep through with even and unlabored respirations usually between 18-22 and a pox WNL.

I don't feel that it's necessary for this pt to get this overnight, but if I walked in and they were awake, I would absolutely offer it.

And as far as aspiration pneumonia goes, I tend to be a worry wort and thought maybe that was a bit overboard, but these are the things that cross my mind.

[jojo489]

I am imagining trying to open a sleeping patients mouth to slip them a sublingual med and everything in me is just screaming "no".

This is exactly how I feel.

[heron, ASN, RN]

Given those facts, then it makes sense to question that advice, especially since the patient has already told you how he wants it given.

I'd still keep a weather eye on the work of respiration - accessory muscles and all that. If I saw increased work, then I'd either give it or wake the pt up and ask - depending on what I knew about opt preference.

Respiratory distress in an end stage lunger never goes away on its own. Best to head it off at the pass. As with pain, you use less drug if you catch things early.

Why was the suggestion made in the first place? Does the pt tend to be in more distress in the morning after going all night without meds? More distress = more anxiety = more demands, more behaviors, more time-suck for the day nurse.

If that's the case, perhaps an early am dose of ativan would help relieve the am crazies and be more acceptable to the pt than overnite dosing with morphine.

Or maybe he just needs a fan.

[heron, ASN, RN]

Morphine isn't used just for pain relief. FWIW, in hospice, morphine is the gold standard for relieving resp. distress. Its euphoric effect helps the anxiety and its physiological effects ease the work of breathing. In fact, it used to be a first line treatment for pulmonary edema.

End stage COPD generally ends with some form of suffocation ... A truly horrendous way to go. Luckily, most of their distress is readily relieved with simple tools: morphine, benzos, a fan ... You get the idea.

[CapeCodMermaid, RN]

Here's a thought....ASK THE PATIENT. Ask them while they are awake if they want you to administer the morphine SL if they are sleeping.