Judgement Calls

[MedicalLPN, LPN]

Hi all. I've been an LPN for one year, I work on a medical floor where we take all the end of life care and inpatient hospice patients. We have a terrific MD takes care of these patients and we do a lot of IV and SQ infusion drips: Morphine, Dilaudid, Fentanyl, and occasionally Versed for these pts with orders to titrate to comfort, the patient often times recieves oral or rectal scheduled pain medication on top of the what they get IV or SQ. Since I started working here our caseload of palliative patients has increased quite a bit and I find myself second guessing myself when I got to titrate a drip. Even when the patient is grimacing or moaning, I don't want them to be in pain of course, but I also can't help but wondering, am I speeding up the dying process? I always get the Charge RN to assess the pt as well before I titrate, but I still can't get that nagging question out of my head.

I know it's silly to think I'm "killing" them, it's the disease process that is killing them, but are all the drugs they're recieving speeding up death's clock? I love taking care of the terminally ill, but I'm finding it challenging, how can I reasure the family that turning up a drip is the right thing to do when even with my charge nurse's approval I find myself wondering? Any advice would be greatly appreciated.

[leslie :-D]

yes, often these drugs do hasten the dying process, but a nurse's main concern should be to resolve the pain.

personally i have no problems if/when they die quicker since i know that if their pain is undertreated, they will linger longer...

all because of unrelieved suffering.

pain, agitation, restlessness, anxiety all prolong the inevitable.

why would that even be acceptable?

once suffering has abated, it allows the pt to relax, enabling them to die of the disease process itself.

please, don't give it a second thought.

let them die in peace.

afterall, it's about them and not us.

leslie

[MedicalLPN, LPN]

I appreciate your response, please do not get me wrong, I have never allowed a patient to lie there in pain, and yes the pt's comfort is obviously my main goal. I don't know why I've been second guessing myself lately I guess after you hear angry family members of either one of your pts or someone else's pt yelling that we're killing their beloved aunt, makes me wonder sometimes. I know better, hopefully I get out of this funk soon, anyone else ever went through this?

[aimeee, BSN, RN]

Would actual research showing that the use of pain medication does NOT actually hasten death make you feel better? Here is a quote taken from a research paper:

The implication

that opioid dose poses an extremely

small risk of hastened death in this population

was supported further by the relatively long intervals

between final dose change and death,

and the lack of higher opioid risk in subsamples

receiving high doses.

These findings resonate with clinical experience

and findings of other surveys.13,14 Although

experienced clinicians are aware that

serious toxicity, including risk of hastened

death, could be produced by rapid dose escalation,

the usual approach to opioid therapy

incorporates incremental dose changes that,

on balance, appear relatively safe even if

patients are near the end of life, require relatively

high doses, or need frequent dose

increases.

Quoted from: http://www.nhpco.org/files/public/JPSM/Dec06_Opioid_survival_JPSM.pdf