Morphine doses while dying?

Dolce, RN · Oct 12, 2008

exactly.
it is euthanasia.
as for the dying process itself, it's truly non-invasive, painless and peaceful.
how one (physically) dies is all going to depend on the pathophysiology presented.
and, there are definitive ways to assess for pain/distress/anxiety.
if a pt is demonstrating air hunger, we aggressively treat w/meds.
furthermore, we aggressively treat and maintain regimens until we are 100% satisfied that pt is dying w/o pain.
it's all about intent.
when you administer morphine to abate suffering (aeb specific s/s), then it is ethically and legally acceptable.
but when you start administering a drug to appease the family's anxieties, then intent is misplaced and therefore, inappropriate.
we are there to support the pt's dying process first and foremost...
and always.
once we start giving outrageous dosages with frequencies that would kill an elephant, then there are definte legal and ethical boundaries to consider.
with that said, yes, i know of many nurses that still administer unnecessary dosages per md orders...per family requests.
i don't and won't.
if i know my pts are comfortable, then i educate the families as to how distress presents itself, and empathize with their fears, anxieties.
i explain the dying process, give permission to leave or whatever they need to do.
but as a longtime hospice nurse, i have never, nor ever will administer meds to placate the family or anyone other than the pt.
pts are my first priority, and i will care for them passionately yet legally and ethically.
it's the only way i could sleep at noc.
leslie

Thanks for your post Leslie. I was hoping you would respond to this post. I'm all for comfort care and treating pain and anxiety during the death process but I would never given MS until "respirations cease." That is not the point of giving morphine. It is not my job to dictate when a patient dies for the convenience of the doc and family.

morte, LPN, LVN · Oct 12, 2008

exactly.
it is euthanasia.
as for the dying process itself, it's truly non-invasive, painless and peaceful.
how one (physically) dies is all going to depend on the pathophysiology presented.
and, there are definitive ways to assess for pain/distress/anxiety.
if a pt is demonstrating air hunger, we aggressively treat w/meds.
furthermore, we aggressively treat and maintain regimens until we are 100% satisfied that pt is dying w/o pain.
it's all about intent.
when you administer morphine to abate suffering (aeb specific s/s), then it is ethically and legally acceptable.
but when you start administering a drug to appease the family's anxieties, then intent is misplaced and therefore, inappropriate.
we are there to support the pt's dying process first and foremost...
and always.
once we start giving outrageous dosages with frequencies that would kill an elephant, then there are definte legal and ethical boundaries to consider.
with that said, yes, i know of many nurses that still administer unnecessary dosages per md orders...per family requests.
i don't and won't.
if i know my pts are comfortable, then i educate the families as to how distress presents itself, and empathize with their fears, anxieties.
i explain the dying process, give permission to leave or whatever they need to do.
but as a longtime hospice nurse, i have never, nor ever will administer meds to placate the family or anyone other than the pt.
pts are my first priority, and i will care for them passionately yet legally and ethically.
it's the only way i could sleep at noc.
leslie

thanks leslie, i thought i had that about right, but back up is nice...

mizlittlevoice · Oct 12, 2008

hi, i'm a hospice nurse and i deal with my patients in their homes as well as in snf's and alf's. so, anyway, i saw the title of the thread and had to peek in here. i deal with high doses/frequencies quite a bit... but the way the doctor worded his order gives one pause, imo. just a thought. why did the family feel the need to go above the nurse's head and call the doctor themselves? i'm not saying there was anything wrong with the nurse's care, i'm just saying that when someone is dying, the family often goes into overdrive. they need a lot of care, too. there is no guarantee that their loved one was completely pain-free and they apparently wanted the assurance that she would die without pain. the doctor's wording disturbs me, however.

mizlittlevoice · Oct 12, 2008

Originally Posted by earle58

exactly.

it is euthanasia.

as for the dying process itself, it's truly non-invasive, painless and peaceful.

how one (physically) dies is all going to depend on the pathophysiology presented.

and, there are definitive ways to assess for pain/distress/anxiety.

if a pt is demonstrating air hunger, we aggressively treat w/meds.

furthermore, we aggressively treat and maintain regimens until we are 100% satisfied that pt is dying w/o pain.

it's all about intent.

when you administer morphine to abate suffering (aeb specific s/s), then it is ethically and legally acceptable.

but when you start administering a drug to appease the family's anxieties, then intent is misplaced and therefore, inappropriate.

we are there to support the pt's dying process first and foremost...

and always.

once we start giving outrageous dosages with frequencies that would kill an elephant, then there are definte legal and ethical boundaries to consider.

with that said, yes, i know of many nurses that still administer unnecessary dosages per md orders...per family requests.

i don't and won't.

if i know my pts are comfortable, then i educate the families as to how distress presents itself, and empathize with their fears, anxieties.

i explain the dying process, give permission to leave or whatever they need to do.

but as a longtime hospice nurse, i have never, nor ever will administer meds to placate the family or anyone other than the pt.

pts are my first priority, and i will care for them passionately yet legally and ethically.

it's the only way i could sleep at noc.

leslie

I think I did this posting the whole quote thing wrong... I'm new here. lol. But this is a beautiful and well thought out post. I just wanted to say that. Very nice.

cherrybreeze, ADN, RN · Oct 13, 2008

I don't feel that the dosage was too much, I don't see any problem with medicating a patient to ensure their comfort, even if you can't "see" those particular signs of discomfort (either air hunger, or pain). I believe nurses must be extremely proactive with medicating patients at end-of-life.

The only problem here is the physician's wording. I hope that he didn't mean it the way it came across. BECAUSE of how he said it, I would not have followed what he said to the letter, either.

While I agree with medicating for the patient's comfort and not the family's, we can't obviously know at the *very end* how the patient feels, so if the family is worried that they may be in any pain or whatever, and say "can you give grandma some morphine?" I would....I guess that technically would be for the family's comfort, but I think you know what I mean.

Straydandelion · Oct 13, 2008

I have had similar orders only once. The patient was never awake and the doc wanted the nurse to give morphine when the family called or every 10 minutes no matter what the respirations or VS were. We all knew the ramifications of the order though nothing verbal was said. In this situation using my best "professional" judgement and following the laws of the country I couldn't in fair consciousness follow this order. Other nurses felt the same, yet others had a different perspective with the patient and the family. It was these nurses that were assigned from then on for the patient's care. The patient expired about 24 hours later. What I am trying to say is we each have to do what we think is "right" "best" "fair" for us and our patients and different thought processes can give us different answers.

SunnyAndrsn · Oct 13, 2008

opps, double post

wayunderpaid · Oct 13, 2008

Dosage is not too high, but every ten minutes??? It should have been a prn order, so that nurses can use their clinical judgment. Until patient dies?? This doctor is a little disturbed.

I think that a continuous dose through the pump with a prn bolus for either agonal breaths or pain control would have been more appropriate. In the ICU we have bottles of morphine in the pixis that can be taken out as fast as any other pain medication. Setting a line up should take less than 5 minutes...

Wayunderpaid

SunnyAndrsn · Oct 13, 2008

Had I taken this verbal order, I would have read it back to the MD as "4mg q10 min PRN for...." and prompted the MD this way. I have an issue with it being stated "until respiration stops".

Right now I have a hospice pt. who gets 20mg every hour PRN, and I ended up giving it, along with valium (5mg each time) only twice my last shift. She was also getting 5mg of methadone BID.

I would be comfortable with a PRN order q10min for pain or O2 hunger if needed.

I had a COPD pt. early in the summer who had a living will/advanced directive where he had stated "I want to be morphined up". His family asked us how often he could get the roxanol and ativan, and it was every hour. They asked us to give it to him that often, and quoted his request from the living will.

I had no problem giving it to him that often, as he had a hx of being anxious d/t O2 needs. His fear was that he would suffocate and be in pain.

He was getting 20mg of roxanol every hour and 2mg of ativan every hour for several days.

The ethical approach here teaches us that our intent is to help ease suffering, not to end life--which is why I have an issue with the way the original verbal order was given.

I know in hospice that patients are able to receive quite a bit of morphine during the dying process, but what is the normal dose at the care facility where you work? My hospital had a recent pt that was dying d/t hem. stroke and was already passing quickly when the family went above the nurses head and called MD at home, who then came in and gave nurse verbal order for morphine 4mg q10 min for pain prn. Aside from the fact that this pt had NO s/s of pain whatsoever, the MD said to nurse (with other nurses present) "the family is tired, just give it every 10 minutes unitil respirations stop". Very thankful I was not the nurse but this has really bothered a lot of us, and I just wanted to know if anyone has had a similar order?

liebling5, MSN, RN · Oct 13, 2008

Wow, I just had a situation somewhat like this just yesterday. The patient had aspiration PNA and was septic. He was breathing okay with O2 at 2L. He vomited about 50 cc of tube feeding. While the aide and I were cleaning him up, he started vomiting heavily. Long story short, his sister came to visit and requested him to be a DNR. I explained that we would still treat him until his heart or breathing stopped. I gave 2mg morphine, then another 4 about an hour later for respiratory distress. His sister consulted with her other sibling (the guardian) and they finally decided to stop all interventions. The doc, nursing sup and I explained that another dose of morphine would be given and then we (meaning me) would remove his non-rebreather mask that was on by then. I gave him 6 mg morphine, removed his mask, and left the room for his sister to say her goodbye's. It was literally a matter of minutes before he stopped breathing. At first, I was struggling ethically and morally about what I had done (gave him enough morphine to stop breathing), but then reconciled that with the fact that he would have stopped breathing within a matter of hours. Plus, had it been me, I would have wanted a quick and pain-free death. The morphine helped him be pain-free at the end.

Like another poster, I simply have an issue with the doctor's wording of the order. It does sound like euthanasia.

Xbox Live Addict · Oct 13, 2008

exactly.
it is euthanasia.
as for the dying process itself, it's truly non-invasive, painless and peaceful.
how one (physically) dies is all going to depend on the pathophysiology presented.
and, there are definitive ways to assess for pain/distress/anxiety.
if a pt is demonstrating air hunger, we aggressively treat w/meds.
furthermore, we aggressively treat and maintain regimens until we are 100% satisfied that pt is dying w/o pain.
it's all about intent.
when you administer morphine to abate suffering (aeb specific s/s), then it is ethically and legally acceptable.
but when you start administering a drug to appease the family's anxieties, then intent is misplaced and therefore, inappropriate.
we are there to support the pt's dying process first and foremost...
and always.
once we start giving outrageous dosages with frequencies that would kill an elephant, then there are definte legal and ethical boundaries to consider.
with that said, yes, i know of many nurses that still administer unnecessary dosages per md orders...per family requests.
i don't and won't.
if i know my pts are comfortable, then i educate the families as to how distress presents itself, and empathize with their fears, anxieties.
i explain the dying process, give permission to leave or whatever they need to do.
but as a longtime hospice nurse, i have never, nor ever will administer meds to placate the family or anyone other than the pt.
pts are my first priority, and i will care for them passionately yet legally and ethically.
it's the only way i could sleep at noc.
leslie

Thank you very much for your insight on this subject as a hospice nurse.

I've no issue with ensuring a dying patient leaves this mortal coil as comfortably as possible myself, and aggressively treating discomfort.

But in the situation I described, much like the situation described by the O.P., I felt I was being pressured by the family and the physician to perform euthanasia, which is against my personal ethics as well as being against the law where I live. The hospice nurse was as uncomfortable with the situation as I was, but as I was a facility employee, it was I that was being pressured into pouring more morphine into a patient already drowning in it and showing severe respiratory depression, not the hospice, the physician, or the family.

I will _NOT_, under ANY circumstances, act as an angel of death or a Mafia button man.

ShayRN · Oct 13, 2008

As always, Leslie, you post is well thought out, wise and articulate. Thank you.

As another hospice nurse I agree with the wording of the order being the issue. My skin just crawled. I have told families time and time again that the Morphine I give is for comfort in the dying process NOT to speed up the dying process. I simply couldn't live with myself if I thought for two seconds that I killed someone.

I spent some time visiting with our pastor at work the other night. (Who just so happens to be an RN and married to a hospice nurse.) We spoke of the ethical issues his wife and I face at work every day. I thought he put it very nicely. He said just remember your INTENT. If your intent is to kill someone it is wrong and immoral. If your INTENT is to provide comfort, you are doing the right thing.

Ofcourse, he was much more elequant than that, lol.