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Morphine/ativan cocktail

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OK.. i have wondered this since i was an aide... i totally agree that euthanization is wrong.. but in a way we do it often.. in LTC.. especially those on hospice we give res so much morphine and ativan scheduled.. .25 to .5 roxanol q hour sometimes that they die much quicker... now i agree in quality over quantity but.. why do they schedule roxanol and stuff? why couldn't it be q 1 hr PRN for s/s pain or discomfort? I always am leery of giving so much roxanol to a dying patient any opinions?

Could be common knowledge that the pt is in constant pain...and the staff wants to keep on top of it so it doesn't get out of hand.

Z

yeah, i mean i'm not saying that it shouldnt be done ever.. it just seems kinda routine (where i work anyways)

OK.. i have wondered this since i was an aide... i totally agree that euthanization is wrong.. but in a way we do it often.. in LTC.. especially those on hospice we give res so much morphine and ativan scheduled.. .25 to .5 roxanol q hour sometimes that they die much quicker... now i agree in quality over quantity but.. why do they schedule roxanol and stuff? why couldn't it be q 1 hr PRN for s/s pain or discomfort? I always am leery of giving so much roxanol to a dying patient any opinions?

hi april,

first and foremost, we do NOT perform euthanasia-euthanasia's intent is to assist someone in dying.

in hospice, the intent of adminstering mso4 is to relieve pain or prevent it.

big, big difference.

most md's will set parameters for mso4, such as hold for rr

others will not even set parameters.

i've also encountered too many md's that order mso4 et al, prn only.

many times that is frustrating as there are many nurses that hesitate to give mso4, such as yourself.

if you think a pt. is getting too much where s/he is literally snowed, you can always withhold the med, circle it and write on the back why it was held. but you need to also let the md know that you held it.

in my experience as a hospice nurse, there have been more md's that prescribe a controlled substance only on a prn basis.

but i reiterate, in euthanasia, you are actively assisting in suicide.

in hospice/end of life care, you are controlling/preventing pain.

it all comes down to intent.

much luck to you.

leslie

Yeah I know. I saw a lot of that too where I did my clinicals.

They're dying though. I'm not saying drug em up and yeehaw.

But if I were dying and in pain, I wouldnt want to have to be bothered to ask for them ...but if I didn't want them I'd say so. If I could. Pretty delicate topic. When I was a newbie here I asked something similar. I think its great that you asked too.

I also had a thought. On psy wards the pts are all drugged up too. I find that strange sometimes. Its almost like its mandatory to have something every 4 hrs.

We'll learn right? :)

Z

meownsmile, BSN, RN

Specializes in Med/Surg, Ortho.

I think the side effects of end stage pain far outweigh the side effects of giving the pain medication. Even if something is scheduled, nurses still have the option of making a nursing judgement about withholding if the patient is showing signs of being over medicated. You can hold even a scheduled dose an hour or two if needed. But, the nurse needs to monitor frequently and give the dose with any s/s of pain. I dont think anyone would make a big deal about it.

I also had a thought. On psy wards the pts are all drugged up too. I find that strange sometimes. Its almost like its mandatory to have something every 4 hrs.

Z

ugh....don't even get me started on psyche wards. my dd initially went to an acute psyche facility, to medically stabilize her. they gave out prns like it was candy.

for instance, one time my dd said "f**k you" to the charge nurse.

the charge nurse just sat there and continued to eat her chips.

so i reprimanded dd and asked the nurse why she allowed that.

her response was "we'll deal w/it".

i left and a couple of hours later i called to speak w/dd. she was soooooo slurred and i asked her why. she told me the charge nurse gave her a pill right after i left.

i told dd i wanted to speak w/this nurse; the nurse got on the phone and i asked what she had given tiffany, she replied "ativan 2 mg for agitation" :angryfire

from that day on, i insisted on being consulted for every single med given to her and if they didn't, there would be a lawsuit waiting to happen. (there was a major incident that had preceded the ativan one that was extremely negligent on the nurses' parts.)

i was glad when she was transferred to the 2nd facility, where she received all the therapy- i loved it there and they did not give out prns casually at all.

sorry for the rant and going off topic-but i get all worked up thinking of this one psyche facility.

leslie

I always am leery of giving so much roxanol to a dying patient any opinions?

Right. I understand your concern. Regardless of what you do or don't do the patient is going to depart. In my practice I think it's a more humane and comfortable way for someone to depart this world. I have one caveat and I saw that someone alluded to this. I won't medicate a patient so much that it interferes with resp. function etc. That's a little over the top in my opinion.

ktwlpn, LPN, RN

Specializes in Med Surg, Homecare, Hospice.

OK.. i have wondered this since i was an aide... i totally agree that euthanization is wrong.. but in a way we do it often.. in LTC.. especially those on hospice we give res so much morphine and ativan scheduled.. .25 to .5 roxanol q hour sometimes that they die much quicker... now i agree in quality over quantity but.. why do they schedule roxanol and stuff? why couldn't it be q 1 hr PRN for s/s pain or discomfort? I always am leery of giving so much roxanol to a dying patient any opinions?
Those meds are not as effective when used PRN-routine use gives way better symptom control....

fluffwad

Specializes in MDS coordinator, hospice, ortho/ neuro.

we give res so much morphine and ativan scheduled.. .25 to .5 roxanol q hour sometimes that they die much quicker... now i agree in quality over quantity but.. why do they schedule roxanol and stuff? why couldn't it be q 1 hr PRN for s/s pain or discomfort? I always am leery of giving so much roxanol to a dying patient any opinions?

.5 mg of MSO4 is not a big dose.......depends on the patient's response to it...........I've given MUCH larger doses (40-100mg) than that to patients who remained alert and oriented. I've heard people say that they think the MSO4 makes them die quicker.....but I'd have to say that I think they die a lot faster when they're struggling to breathe and are being worn down by pain.

for most of their illness and have built up a tolerance for the meds. So the dosage needs to be increased to maintain their comfort. The patient is on hospice care, they are dying and in pain. Why should appropriate pain management be withheld? I am comfortable with liberal use of narcotics - most orders I've received in this situation is "titrate to comfort" or "titrate to a RR > 8". Like other's have said, if you see the person slipping into unconsciousness, you can give a lower dose or hold it until their vital signs are within limits for your comfort. Not giving a dying person pain medications if they are in pain is cruel IMO.

PRN's are good in theory, but then you run into nurses who are unwilling to give them because they are not comfortable with "snowing" someone. That's why I prefer them to be timed meds. The person is dying. Letting them go with as little pain and anxiety as possible is much different than euthanizing them.

Pain control is so important. Even if the patient isn't able to verbalize their pain, it doesn't mean that it isn't there.

J

I've heard people say that they think the MSO4 makes them die quicker.....but I'd have to say that I think they die a lot faster when they're struggling to breathe and are being worn down by pain.

hey fluffwad,

my experiences have been much different.

i have seen pts. linger way too long because they were undermedicated.

the physical pain accompanied by the anxiety and fear only perpetuates the stress hormones in your body, mainly adrenaline and cortisol.

once the pt. is properly medicated, pain-free w/absence of anxiety, then i see them pass much faster.

the only reason morphine will hasten death is because the body is finally in a relaxed state, enabling the disease process to take over, which is what takes the pt's life.

the ana acknowledges mso4 hastening death, but as long as the intent is to relieve suffering, then it's perfectly acceptable.

leslie

fluffwad

Specializes in MDS coordinator, hospice, ortho/ neuro.

hey fluffwad,

my experiences have been much different.

i have seen pts. linger way too long because they were undermedicated.

the physical pain accompanied by the anxiety and fear only perpetuates the stress hormones in your body, mainly adrenaline and cortisol.

once the pt. is properly medicated, pain-free w/absence of anxiety, then i see them pass much faster. the only reason morphine will hasten death is because the body is finally in a relaxed state, enabling the disease process to take over, which is what takes the pt's life. the ana acknowledges mso4 hastening death, but as long as the intent is to relieve suffering, then it's perfectly acceptable.

leslie

The ANA acknowledges that high doses of morphine might potentially decrease respirations enough to hasten someones death. ( but so can K+) This is not the same thing as saying morphine ( or K+) causes people to die faster. I'm not trying to split hairs, but one of the things I've noticed is that this is turning into one of those " medical legends" ( like urban legends)..........you know like the one about people dying in groups of 3...........and tying knots in the sheets to keep them from dying.......

Once had a patient transferred from the ICU to the hospice unit. We took her off all her meds except the narcotic, and well, she just perked right up and we eventually discharged her home ( turns out she been almost poisoned to death by all her prescription drugs)

I don't happen to agree 100% with the part about the relaxed state, but that doesn't matter......its letting people suffer needlessly that honks me off.:angryfire

:)

http://www.nursingcenter.com/library/JournalArticle.asp?Article_ID=481946

The ANA acknowledges that high doses of morphine might potentially decrease respirations enough to hasten someones death. ( but so can K+) This is not the same thing as saying morphine ( or K+) causes people to die faster.

:)

]

what is the difference? i really am confused now.

as for your pt who perked up once she was in a pain-free state, she was not terminal, was she? i am only referring to terminal, end stage pts that tend to die quicker when they are not struggling w/pain.

leslie

fluffwad

Specializes in MDS coordinator, hospice, ortho/ neuro.

what is the difference? i really am confused now.

as for your pt who perked up once she was in a pain-free state, she was not terminal, was she? i am only referring to terminal, end stage pts that tend to die quicker when they are not struggling w/pain.

leslie

The difference is that morphine is not a poison like cyanide, which will cause you to die. It might cause some one to die if the dose is too large. So will water and tylenol.

The patient I mentioned above had a terminal dx. What I'm trying to say is that sometimes these observations can be very subjective, (and since we are obviously not going to take a 1000 lung cancer patients and test to see how fast they die on what doses of morphine, with a control group on no morphine ) that it is best to avoid making the assumption that the morphine is speeding things up necessarily. It has seemed to me that a lot of my patients lasted longer when they weren't having resp of 40, being worn out from the pain, weren't drowning in their own secretions, etc....................BUT there are lots of unseen internal factors going on also ( like are they "relaxed" because they are bleeding out, is that tumor just about to completely block something really vital, did that patient just have a PE / stroke that you'll never know about?) Maybe they might last longer with out the narcotics, but I'm not going to test that theory out on anyone. There is no cut & dried answer to this...far too many variables for each patient.

If you had a patient with respirations of 4 /minute and gave them SL morphine, I'd say it might be a toss up on whether it was the drug or the patient was moments from dying anyway (I'd probably hold it).

Just don't get hung up on the idea that morphine makes people die faster just because people say it.......my opinion is that is like an old wives tale. Its like that old saw about not wanting to give terminal patients narcotics "because they'll get addicted......in the end it doesnt really matter as long as the patient isn't suffering.

:)

you're right- there are no absolutes.

i was only stating that morphine can hasten death and should never be compared to euthanasia.

leslie

OK.. i have wondered this since i was an aide... i totally agree that euthanization is wrong.. but in a way we do it often.. in LTC.. especially those on hospice we give res so much morphine and ativan scheduled.. .25 to .5 roxanol q hour sometimes that they die much quicker... now i agree in quality over quantity but.. why do they schedule roxanol and stuff? why couldn't it be q 1 hr PRN for s/s pain or discomfort? I always am leery of giving so much roxanol to a dying patient any opinions?

Some nurses are afraid of causing a pts' death and will let them suffer rather than give PRN doses. With the dose being a regularly scheduled med the md is making sure that the pts pain is addressed.

In the unit I worked at a nurse could state at report that they were uncomfortable taking a dying pt and they would not be assigned one without penalty. It worked out best for the pt and the nurse.

I just want to clarify that I am not against giving morphine to someone dying and in pain.. i'm not against using it on a scheduled basis either, i was just curious to see is it is as commonly scheduled everywhere else as it is in the facility where i work. When it is scheduled i give it.. unless RR is extremely slow (like 4/min) I don't want to see anyone dying in excruciating pain..

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