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?

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,

squeekymc

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Question:

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?

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Specializes in Hospice.
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. )

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Specializes in Gerontology, Med surg, Home Health.

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!

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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

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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?

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Specializes in Pediatrics, Geriatrics, LTC.

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.

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Specializes in Med-Surg/Neuro/Oncology floor nursing..

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.

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Specializes in Long Term Care.

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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