Morphine/ativan cocktail

fluffwad · Jun 4, 2005

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

leslie :-D · Jun 4, 2005

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 · Jun 4, 2005

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.

:)

leslie :-D · Jun 4, 2005

you're right- there are no absolutes.

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

leslie

hollyster · Jun 5, 2005

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.

aprilleverett · Jun 6, 2005

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..

txspadequeenRN, BSN, RN · Jun 7, 2005

agree 100% I have even sat by the bed and gave Roxanol every 15 min.

.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.

txspadequeenRN, BSN, RN · Jun 7, 2005

People do not because of to much morphine (in the hospice situation), People die because of their disease process. Very often the reason for the decrease in respirations after Roxanol admin is the somple fact they had increased SOB D/T extreme pain ,which is now relieved. I will always combo Roxanol/ Ativan intensol it evens out the respirations and lessens the pain . I make the PRN dose routine if the pain is out of control then revert back to PRN status when the pain subsides. IMHO Roxanol and Ativan are a God send for anyone on hospice and for anyone who is actively dying.

Antikigirl, ASN, RN · Jun 7, 2005

IN certain higer doses MS actually helps not only in the pain aspect but to increase circulation and increase the tidal volume of respirations (by increasing circulation, opening airways, and allowing more O2/CO2 exchange). So it is a benifit for comfort in two ways!

It also decreases cardiac demand (of course as a bonus decreasing oxygen demand from the lungs) because it increases contractions of the heart. IE the reason why we do it in heart attacks..remember MONA.

So when I see .25-0.5 q hour I see that as a small amount! HOWEVER, I don't even try higher dose levels for resp/cardiac if the resps are under 10! I then get to sit by and help.

Atavan also does a similar action with cardiac/resp...mainly by calming a scared or painful patient which decreases the resp/cardiac load which is being caused by anxiety!

Ask any hospice nurse, they will tell you MS is a interesting drug we should all really know about. A higher dose is actually more benificial then a smaller one at times...very tricky stuff!

I would say that all nurses should take a course on narcotic meds at end of life so we all can understand the effects of these medications (and the doses for certain effects) clearly so we don't have our patients suffer from us simply not knowing but assuming.

I was so flustered by other nurses I talked with hospice teams and with paramedics and with MD's to find this stuff out. Then, a little spark flew through my head...duhhhh I did learn this in nursing school...I had just forgotten over the fear of decreased resps!

ktwlpn, LPN · Jun 7, 2005

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)
QUOTE] THat probably happens as often as people wake up from a 20 yr "coma" and sit up and start talking....It's the kind of thing that perpetuates alot of misconceptions about terminal care...

aprilleverett · Jun 7, 2005

wow, i must say that i am glad i started this post.. i didnt even think about the benefits of ms with the heart and oxygenating the pt. DUH lol i feel stupid now.. ok i feel much better about giving it now and kinda stupid for questioning it.. but i guess that's how we learn :) thanks everyone!

webblarsk · Oct 11, 2005

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

Because alot of nurses have a hard time assessing someone's pain and in most cases I have seen would just rather not tx the pain. So if it is made routine atleast the patient's pain is being controlled.