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Morphine/ativan cocktail


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txspadequeenRN, BSN, RN

Specializes in ICU, PICC Nurse, Nursing Supervisor. Has 20 years experience.

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

Specializes in ICU, PICC Nurse, Nursing Supervisor. Has 20 years experience.

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

Specializes in Education, Acute, Med/Surg, Tele, etc. Has 13 years experience.

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, RN

Specializes in Med Surg, Homecare, Hospice.

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...

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!

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.

I hope this message goes to Leslie :-D.

Do you work for hospice? I have some questions regarding meds, family dynamics and such. I just sent you a friend request. If you allow me to, I would like to pick your brain every now and then. I seem to always have questions re: my brand new LVN in hospice career.

Thanks in advance,



I work for hospice. I am no stranger to the MSO4 and Ativan Cocktail. It seems to be prescribed to all of my termanilly ill pts. Usually it is 0.5mg to 1.0mg q4h to q1h and always PRN.

Here is my question after reading your posts: Once I go to work at bedside, I notice in the MAR that all the nurses before me gave these PRN meds regularly and consistently. Many times, after several hours with my patient, I do not see signs or symptoms of pain, SOB, agitation, anxiety, etc. so I hold the PRN pain and anxiety drugs. Am I being overly conservative with these meds? Am I setting these patients (and their other caregivers/family/nurses) up for a horrible breakthrough pain comeback? I have experienced positive results by holding these meds before. I do not want to "dope" my patients but I also need them to be pain free.

What says you?

RNBearColumbus, ADN

Specializes in Hospice. Has 16 years experience.

Am I being overly conservative with these meds? Am I setting these patients (and their other caregivers/family/nurses) up for a horrible breakthrough pain comeback? I have experienced positive results by holding these meds before. I do not want to "dope" my patients but I also need them to be pain free.

What says you?

Are you being overly conservative? Yes, but you are right to be. You are doing your job and performing a proper assessment of the patient and his/her pain level and respiration status. I've also held PRN doses of roxanol and ativan for the same reason: The patient was comfortable, sleeping peacefully , and not in any acute distress. I once had a visiting hospice nurse DEMAND that I give a patient ativan AND roxanol simply because she had "twitched funny" in her sleep. (Needless to say, the hospice nurse didn't like the answer I gave her, or the fact that my DON and our CNP told her that they trusted my judgement more than hers. )

CapeCodMermaid, RN

Specializes in Gerontology, Med surg, Home Health. Has 30 years experience.

I've seen too many people undermedicated at the end of life because family members think they are too lethargic or because doctors don't have a clue how to prescribe morphine and ativan. We have many hospice patients. The latest drug for pain at least here is Methadone. It doesn't depress respirations as much as Morphine does and seems to be an excellent med for pain relief. Pity the docs don't know how to properly dose it. And thank goodness for Hospice nurses who do!

Hello everyone!

I am not a nurse, but am a Caregiver to my Mom. She is home with Hospice care with end stage COPD and Heart Failure. In the last week or so her appetite and taking in fluids have decreased. The Nurses that come out all say that she is rapidly declining. Her meds they prescribe are normal from what I have been reading in this blog. Actually this morning is the first time in a couple of days she is communicating her to me - very groggy, but I can manage some of what she is saying. I was worried about the over medicating, etc because she has been in a state of sleeping 24/7, not communicating, eating, or drinking (which I know at this state is not feasible). I worry about her being hungry and dehydrated, but have slowly given her ice chips (as prescribed from Hospice).

I am not sure if I am allowed to even post a comment, but I wanted to thank you all for clarifying some concerns I have had recently regarding the morphine/ativan and the state she is in. I am still trying to understand the "end stage" signs, etc., and hope I am doing everything for her. But these posts have helped me a lot.

Again, thank you!

Sincerly, Jennifer

i try to alternate the morphine with the ativan-for example, if both are ordered q2h prn, then i would give morphine at 1300, ativan at 1400 and morphine again at 1500. This has seemed to work the best. What do you more experienced hospice nurses think?

NamasteNurse, BSN, RN

Specializes in Pediatrics, Geriatrics, LTC. Has 8 years experience.

I felt the same way at first. Until I had been a nurse in LTC for awhile and gotten attached to the residents. Dying is a process, sometimes a very long one. Usually in LTC, and I've seen it many times, there are stages. They stop talking. They stop eating. They stop drinking. They don't get up anymore. So sad. How do we know what they feel? Are they in pain?

One indication for morphine (roxanol) is increased respiration's. They can't get enough oxygen so they breathe faster. Even so, the mouth becomes white with effort and mottling may begin. So we use the drug to lower the respirations so they become deeper and slower, more efficient. Otherwise the poor soul feels like they are drowning.

Yes, morphine can hasten death. But at this point, we don't want them to suffer any more. If it were your loved one, you'd want them out of their misery. It's very hard, I question it every time. But I do it. Then I sit with the resident and talk quietly to them. I love them. I help the family get through it. It's what we do. That's the reason. IMHO.


Specializes in Med-Surg/Neuro/Oncology floor nursing.. Has 10 years experience.

This is why we kept my dad at home to die. He had end stage pancreatic cancer and my mom had a terrible experience with her mother in a hospice facility(she was dying of ovarian cancer and her pain wasn't in control at all)....and please this is not to offend ALL hospice facilities but this one was a dog and pony show. There are MANY hospice facilities with amazing doctors and nurses and keep the patients pain under control and make sure they die with dignity. So we kept my dad home and had some home health care workers come to the house. However, my dad's doctor from the start was in charge of his comfort medication. My dad was on FTD amongst other things since morphine never seemed to work for him from the start of his treatment. It was so long ago I believe he was on 75mcg FTD and also a liquid benzo(can't remember what). But my dad died with minimal pain and with dignity. Like I said...some facilities are a crap shoot.


Specializes in Long Term Care. Has 2 years experience.

I once asked our hospice nurse who visited our facility why she wanted routine roxanol and ativan orders for her residents that were end stage. She simply stated if they were not ordered routine, chances were they wouldn't be given. It was on that same day I was giving report to the oncoming nurse and told her I had medicated a resident for pain and the nurse responded that she has never had to medicate them before. she said it as though it was like a pat on her back or feather in her cap and she should get kudos as just because she was their nurse that day they refrained from having any pain.. lol.. At that moment I realized the hospice nurse had a point.

I have had the pleasure of working with a fantastic hospice nurse who I have learned so much from. She laid to rest any fears I had regarding roxanol and ativan. I would suggest for those uneducated or uneasy about giving these meds to ask your staff development to have hospice come in and do an inservice regarding end of life care and medications.

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