IV Push Ativan

[Nurse Nonnie RN]

Hoping to get some support for my story. Please be kind because this involves the death of my mom. My mom had metastatic breast cancer for 3 years and passed away Apr. 2021. She was in the ICU, then admitted to a med/surg floor that also had hospice patients.  I was so grateful the doctor agreed to admit her instead of sending her home because she was in a lot of pain.  She was receiving IV Morphine. Her Morphine dose started at a low infusion rate. When she started vomiting and having more pain, I asked her nurse if she could have IV Ativan. The nurse agreed and gave her the Ativan by slow push. Immediately my mom fell asleep and was not responding much. I have so many mixed feelings about this. I wanted my  mom to be comfortable but I did not expect the Ativan to make her fall asleep so quickly. But she needed the pain/anxiety relief.

So here is my issue. I worked in he NICU for 25 years and we pushed Ativan many times, slowly of course. I have never worked with adults, except with my mom and dad when they were very ill. The other day I was sharing my story about my mom to another nurse and she said "You don't push Ativan!!" She used to work in the ED. I was shocked and confused.  I told her I have pushed Ativan many times in the NICU and so did my coworkers. I go back and forth between blaming myself for asking for the Ativan, which at first made me feel like I helped to end my mom's life. I know the cancer is what ended her life, but mentally I keep telling myself if we would have held off on the Ativan we could have talked to her longer. But she suffered for many months before she passed. So I am also glad the Ativan helped her comfort level. To all the nurses out there who work with adults: is it WRONG to push IV Ativan?? I just want to get some clarity. Sometimes it feels like she died yesterday. I am tired of beating myself up about Ativan. She knew she was passing, and I made sure she was clear that our goal was to keep her comfortable. thanks for reading. 

[EveP]

Yes, you can push ativan slowly. The policy where I work is you take VITALS first 15mins and 30 min after.

[Tenebrae, BSN, RN]

OP I once gave a patient four drops of clonazepam and they died 10 minutes later. I know that the clonazepam was what relaxed her enough to let go., I was a bit nervous the next time. 

Working in hospice, I often gave ativan as a subq push or we had it in the syringe driver. This is your mum, and its understandable to think about all the "what ifs" and 'Should ofs". Sounds like the medication gave her enough to relax so that she could let go,. Sorry for your loss OP. 

[Enm89, BSN, RN]

Former ER nurse here, also floated and worked on a palliative unit for a few years. We push IV Ativan ALL THE TIME in ER, and give SC in palliative (only because most palliative patients don’t have/require IV access). The nurse who told you that was grossly misinformed. 
You were absolutely right to request IV Ativan for your mother in her last moments, and I’m sure she was honoured to have you by her side advocating for her best interests. Sounds like you did a great job supporting her and ensuring she was comfortable. I’m so sorry you have been second guessing this, stop being so hard on yourself! Don’t ever doubt your instincts! 
My condolences on the loss of your Mom?

[Nurse Nonnie RN]

Thank you so much for the support. I know I helped her die peacefully. It's just been bothering me because my sister and I were both surprised at how quickly the Ativan worked, especially my sister because she is not a nurse. So I felt a little guilty that we didn't have more time with her. My sister was in more shock than I was at how quickly Ativan made her fall sleep, and basically never respond again. But I told my mom we would keep her comfortable.  she chose to stop antibiotics for sepsis, and just have comfort care. she had been in the ICU and went through enough her last 6 months of life. Thanks to everyone here for all your support. I feel so much better having nunrses on my side. That nurse who made the dumb comment about Ativan is not my firend, she is a new co worker of mine.

[CeciBean, ASN, RN]

30 years in grade in all kinds of units, mainly critical care/stepdown, and I've pushed Ativan a zillion times. Slow push is recommended. You did the right thing, helped her relax enough to let go. So often anxiety about leaving us behind makes our dying parents and loved ones not want to let go, and drugs like Ativan can help. And the fact that the morphine was making her sick was aggravating things. (They better not give me any, I will immediately puke all over everyone and everything!) You did right by your mom and you can be at peace about it. PS: That other nurse didn't have a clue what she was talking about.

[Tirian1050]

Hospice nurse here:  sounds like your mom was experiencing terminal agitation.  It’s common at end of life for our patients to become restless and confused.  Sometimes it’s disease process-pain, nausea, hypoxia, hypercapnia, electrolyte imbalance, etc.  Some people believe terminal agitation has a spiritual aspect- patients have one foot in this world, one foot in the next.  It causes them to feel in between and unbalanced, stuck.  It could be a combination of both.  The way we treat terminal agitation is usually with opioids and benzos (and as you’re  probably aware, we also use Benzos for nausea).  Most commonly Morphine and Ativan are the meds of choice. In hospice we frequently give both, together.  And yes, even IV push. The goal is comfort, not preservation of function.  Bearing that in mind, in hospice we commonly use higher, and more frequent doses of these meds than some nurses are comfortable with.  I assure you it is entirely appropriate.  As far as how fast your mom fell asleep, many times when we get terminal agitation under control, the patient is able to relax (maybe for the first time in hours or even days).  The process of relaxing physically and spiritually allows them to finally make the transition to what is next.  What you did for your mom was a mercy.  You allowed her to make the inevitable transition in a peaceful, dignified manner.  Thank you for advocating for your mother.  You did the best thing a daughter and a nurse could do- you gave her a good death.

[Nurse Nonnie RN]

23 minutes ago, Tirian1050 said:

Hospice nurse here:  sounds like your mom was experiencing terminal agitation.  It’s common at end of life for our patients to become restless and confused.  Sometimes it’s disease process-pain, nausea, hypoxia, hypercapnia, electrolyte imbalance, etc.  Some people believe terminal agitation has a spiritual aspect- patients have one foot in this world, one foot in the next.  It causes them to feel in between and unbalanced, stuck.  It could be a combination of both.  The way we treat terminal agitation is usually with opioids and benzos (and as you’re  probably aware, we also use Benzos for nausea).  Most commonly Morphine and Ativan are the meds of choice. In hospice we frequently give both, together.  And yes, even IV push. The goal is comfort, not preservation of function.  Bearing that in mind, in hospice we commonly use higher, and more frequent doses of these meds than some nurses are comfortable with.  I assure you it is entirely appropriate.  As far as how fast your mom fell asleep, many times when we get terminal agitation under control, the patient is able to relax (maybe for the first time in hours or even days).  The process of relaxing physically and spiritually allows them to finally make the transition to what is next.  What you did for your mom was a mercy.  You allowed her to make the inevitable transition in a peaceful, dignified manner.  Thank you for advocating for your mother.  You did the best thing a daughter and a nurse could do- you gave her a good death.

Hi. Actually she wasn't experiencing terminal agitation. She was vomiting so I asked for Ativan. I don't think it was a high dose. I think it allowed her body to relax. Yes, I do believe the medication helped her transition with dignity and peace.

[Asdf]

Maybe she meant that you shouldn’t push it undiluted?  I work in the ED and we push Ativan all the time. You’re supposed to dilute it before giving it straight push (if you’re giving at the y-site with a NS bolus running it’s diluted already) point being, you can give Ativan IVP, don’t beat yourself up.  

[stepwintention]

It's a pretty standard med. I've used it in the ICU and the floors for Alcohol withdrawal around the clock CWA where we give a dose every four hours while a patient is going through DTs. Also helps to calm an agitated patient.