Morphine doses while dying?

classicdame, MSN, EdD · Oct 13, 2008

In my state this type of order is only permitted when the patient already has an order for palliative care AND is suffering from pain. Otherwise it is euthanasia and not allowed in my state. I would not have delivered the medication but would have gone up the chain of command. Regardless of the outcome it is better to lose a job but keep your license.

nerdtonurse?, BSN, RN · Oct 13, 2008

Oops, made an echo.

nerdtonurse?, BSN, RN · Oct 13, 2008

When I saw that order, I would have gently pulled the doc aside and told him I couldn't "C" off the order as written, wording my request in such a way as to tell him I was concerned about HIM getting sued by some overzealous family member who might get ahold of the chart, so therefore I could not follow it. What I'd be thinking is: "Angel of Death" is not in my job description.

Having said that...

I've went into Anaphalactic shock from a drug allergy. Until you try to breathe in like you've done every day of your life and NOTHING HAPPENS, you have no idea of the terror that feeling can cause. When I've had people dying from COPD or lung CA, you bet I keep them medicated and pain free. I don't want anyone's last moments on earth to be anything like my experience, because they'd die in complete panic and terror. So even if it shortens their time here but makes those last moments comfortable, I'm going to keep the pt as pain and fear free as I can.

Ex130Load · Oct 13, 2008

My post doesn’t address the OP’s question, but addresses high morphine doses. A sister-in-law (SIS) elected to receive hospice care in a local hospital due to family convenience. Staff nurses engaged in, for them, non-routine care by tending to a terminal cancer PT. The non-routine aspect regarded the “out of the ballpark” morphine doses that became routine over the final 14 days.

New nurses to the case often initially balked at bumping up dosing when they first noticed infusion rates on the pump and consulted the MD or charge nurse for confirmation. One PM nurse refused to bump doses because she hadn’t personally observed symptoms warranting an increase. She stuck to her guns despite me destroying her logic, “…and a PT won’t have pain or express it in your absence?” I understood her reluctance, but her approach wasn’t providing the most effective possible. Sometimes, ya gotta trust PT’s family and in this case, I wasn’t “just a family member”off the street, but a BSN RN graduate. I called in the charge nurse with whom I’d developed a relationship and who bumped the dosage. In the AM, I related the situation to the MD who was POed and in turn further clarified his orders to help prevent further repeats. Again, I can understand reluctance regarding previously never seen before morphine dosing.

So, what constitutes a high morphine dose? I think for many or most floor RNs in most hospital practices, a high dose might constitute 10-40 mg. In the hospice environment, over 400mg isn’t unheard. In my SIS’s case, when she expired, she was at 244 mg and passed quietly and comfortably to all the family’s knowledge.

Prior to really getting into heavy morphine dosing, I led a tearful family discussion on what the SIS wanted, that to control pain, morphine would need boosting which eventually would cause a decreasing level of awareness. She wanted to be comfortable. That meant, whatever family wanted to say in way of final words had to be done sooner rather than later as the SIS would become progressively quieter with less responsiveness. The family learned to read pain from grimacing, flinching, increased resp and BP, muted groans, etc. Family input was vital to pain control as nurses couldn’t possibly sit bedside for the level of time we did. I think we, family and nursing, did a good job of giving the SIS what she wanted.

Back to high morphine doses, one of RNs said she’d seen higher dosing in a cancer ward elsewhere. A 14 YO teenager played Nintendo and beat siblings in scores…

morte, LPN, LVN · Oct 13, 2008

not any where as high, but as an example....had a person sent back to NH to be on a CAD pump with MS...big to do, they had the educator set it up they had a meeting.....well i am agency and no one mentioned this meeting so i show up on time but not early....so missed that meeting.....and much to my regret, relied upon them to have done it correctly.....the patient was in a fourbed alone, checked every time i went by, up till about 8P (3-11 shift) the aids came to me around 930-45 and said she was getting restless, seemed to be in pain (thank you ,goo aides)...went and checked the cad pump.....it had been set for 0.9 mg instead of 9 mg......i dont think that they had ever seen anything that high and assumed an error.....well i tell ya, i wasnt happy being the agency nurse calling the doc after ten pm with this info.....argh:cool:

TraumaQueenBScN · Oct 13, 2008

Just because a pt is not exhibiting s&s of pain does not mean that they are not experiencing it. However, this sounds like it's crossing the line of palliative care into euthanasia.

NativePapillon · Oct 13, 2008

In the last few minutes or hours of someone's life? Why is it such a big deal? Does someone really need to be exhibiting "signs and symptoms" of pain (as they are dying) to be in pain?? Do you want them to wake up and tell you? Are you afraid you might kill the patient? I'm having a really hard time understanding questions and attitudes like this. Some critical thinking is in order.
Morphine has other benefits and uses besides pain relief. One of the biggies is relieving "air hunger" that occurs due to inadequate respiration and low O2 sats during the dying process. Air hunger is the feeling of suffocation that you may feel while you're under water too long. Is that how you want to spend your last few hours?
What a great way to increase the discomfort of the family and possibly the patient as well as make the death of a loved-one even more difficult and infused with negativity than it already may be.

Well said Pricklypear.

nuangel1, BSN, RN · Oct 13, 2008

i simply must respond in this thread. and i have read all of it.i too agree that i would not have excepted that verbal order as given ie till no resp.because thats to close to euthenasia for me.however the rest i see alittle differently.as long as pt is dnr cmo it doesnot matter what the dose or freq is .its not upto the individual nurse to judge the pt or family request .pts who are dying have the right to die comfortably .we have that ability with drugs.leslie while i highly respect your opinions and experience i don't agree that the dying process is painfree in and of its self .it really depends on the reasons a pt is dying.and unless you have experience dying how do you know its painless.air hunger does occur.i too have never been close to death.but as a serious asthmatic i have had very bad asthma attacks that have landed me in the er .thankfully never intubated.and it is scary to not be able to get a breath.i have also been the family having to make my mom who had uti pneumonia cva and sepsis a dnr cmo.it was the hardest decision i have ever made.yes i wanted her to die comfortably and with dignity .yes i had her put on a morphine drip .as per my wishes the pcp ordered titrated for comfort and no set dosage or freq.the nurses followed orders and inc it accordingly .yes my mom appeared to have air hunger .it did not matter what her vs were they weren't taken .she was upto 10 mg /hr at her death.and i believe she died comfortably .so be careful as nurses not to judge the family when they ask for more med .you are not the pt or the family member .i would prefer to air on the side of maybe more drug then needed and have my family member myself or my pt in pain.because we really don't know wether they are in pain or not.

leslie :-D · Oct 14, 2008

i simply must respond in this thread. and i have read all of it.i too agree that i would not have excepted that verbal order as given ie till no resp.because thats to close to euthenasia for me.however the rest i see alittle differently.as long as pt is dnr cmo it doesnot matter what the dose or freq is .its not upto the individual nurse to judge the pt or family request .pts who are dying have the right to die comfortably .we have that ability with drugs.leslie while i highly respect your opinions and experience i don't agree that the dying process is painfree in and of its self .it really depends on the reasons a pt is dying.and unless you have experience dying how do you know its painless.air hunger does occur.i too have never been close to death.but as a serious asthmatic i have had very bad asthma attacks that have landed me in the er .thankfully never intubated.and it is scary to not be able to get a breath.i have also been the family having to make my mom who had uti pneumonia cva and sepsis a dnr cmo.it was the hardest decision i have ever made.yes i wanted her to die comfortably and with dignity .yes i had her put on a morphine drip .as per my wishes the pcp ordered titrated for comfort and no set dosage or freq.the nurses followed orders and inc it accordingly .yes my mom appeared to have air hunger .it did not matter what her vs were they weren't taken .she was upto 10 mg /hr at her death.and i believe she died comfortably .so be careful as nurses not to judge the family when they ask for more medyou are not the pt or the family member don't..i would prefer to air on the side of maybe more drug then needed and have my family member myself or my pt in pain.because we really don't know wheter they are in pain or not.

(((nuange))), i so understand about your mom and cmo.

i did the same w/my mom.

there are a couple of points that need to be addressed.

first, from working hospice for sev'l yrs, yes, it is my firm belief that death is truly a peaceful, gradual process.

however, and i did say, that one's quality of dying will depend on the pt's disease process.

i have often given sev'l hundred mgs of morphine/hr to control intractible s/s.

no one has ever died of air hunger on my watch.

we have a med'l dir who has yrs of experience in palliative/hospice care, as well as a highly experienced, talented pharmacist.

i do understand those who express fears of air hunger...

esp when we think of our lungs shutting down.

but i can assure you, when properly medicated, combined w/the natural shutting down of the organs, pts are not aware of distress...

i promise you that.

which brings me to my next point...

about being properly medicated.

there are too many doctors and nurses who are reluctant to prescribe/administer certain dosages of opioids. (i'll use morphine as the prototype)

so if there's a prn order for mso4 50mg q 10 min, excellent chance that pt will not get these doses, even when presenting with pain/distress.

doctors and nurses need to be educated over and over and over, about appropriate uses and indications of morphine.

so yeah, many of our dying pts are indeed, undermedicated at the time of death.

and that's just downright sinful.

but once i see my pt with even, nonlabored respirations

maybe it will be q 20-30 min...depends on my assessment.

but you can be rest assured that i will be keeping ahead of any anticipated pain/distress.

and any good hospice nurse will do the same.

the biggie here, is ensuring that all nurses, regardless of specialty, understand and appreciate that there is no excuse to undermedicate.

there is no ceiling/max dose for morphine and the pt will tolerate as much as s/he needs.

it's just a matter of convincing some nurses/md's of this.

i appreciate your post, nuange.

and i very much understand your concerns.

leslie

nuangel1, BSN, RN · Oct 14, 2008

exactly.
it is euthanasia.
as for the dying process itself, it's truly non-invasive, painless and peaceful.100% satisfied that pt is dying w/o pain.
it's all about intent.
.
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.
but as a longtime hospice nurse, i have never, nor ever will administer meds to placate the family or anyone other than the pt.
leslie

while i agree with most of what you wrote.this above is where i have a very different opinion.you have no way of knowing that the dying process in itself is painless and peaceful.second as you must know pt's have much different med tol and responses to a drug .why do you get to decide for the pt or family what is an outrageous dose.as a longterm nurse i have seen pancreatitis pts and others who i had to administer large doses of narcotics and sedation for comfort.i have given as much as 25 mg/hr of morphine ,ativan as high as 8mg /hr etc .yes these pts were vented.my point being that yes we have recommended doses on these drugs but sometimes you need to give more.and i believe that a family feeling that there loved one was in pain requesting pain med for pt is not unreasonable .it is irrelevant whether you as the nurse agrees that the pt is in pain,(at end of life pt being dnr cmo) .it only matters that the family does .how does it hurt you to go head and give a dose of med to the pt.the family feels better and feels pt is comfortable .thats not an inappropriate nursing act . we are there for both the family and the pt .one is dying one isn't.when the pt dies the family can believe their loved one died peacefully and painfree.i just feel that its inappriate for the nurse to project her individual opionion into the situation.it is not your place to judge or decide that the pt is not in pain and refuse to med pt.because i have been there both as a nurse and the family member .in my practice i prefer to give that extra dose per request eventhough i personally may feel pt is not in pain .that does no harm family feels better and pt is already dying.i have a very clear conscience and sleep fine.just my 2 cents.

pricklypear · Oct 14, 2008

This is turning out to be a really, really, great thread. I truly hope that we all learn from this discussion. I'm sorry if my earlier post seemed pessimistic. But I have some extremely strong feelings when it comes the dying process.

I agree that the OP's situation with the wording of the order, or more specifically, the physician's "directions" are problematic, and, on the surface may appear to be euthanasia. I disagree, but that is beside the point. Nobody really knows exactly what he meant except him.

My issue is when I hear things like, "Oh, no way am I going to give that much morphine." "This patient showed no s/s of pain." "It's about the patient, not the family." "The family was pushy, and went over my head."

I think the first two have already been addressed by several posters.

It IS about the family. If we're doing our job well, the pt is as comfortable as possible, it's the end of their journey. The family, however may not OK. The family are the ones who must face every day of the rest of their own lives with the memories of this event. They need education, comfort, reassurance, guidance. Not "conscientious objector" attitude. Recently, I worked with pts dying of many different types of cancers. Some of them had suffered for YEARS through chemo and radiation and their side-effects. Failed bone-marrow transplants. Graft vs Host reactions. Horrific opportunistic infections. I can't even IMAGINE the courage it took to continue to get out of bed every day. They had mothers, fathers, siblings, children of all ages who attended them for months through this hell. Who smiled, and shared birthday cakes with staff even though the pt was unable to eat. In the end, all they want is for their loved-one to be comfortable. Whatever I have to do to achieve it, I'll do. I want the family to feel that I did everything, they did everything, and most of all, that they had some control.

Leslie, as much as I enjoy your posts, and respect your experience, I just cannot understand how you can so confidently state that the dying process is inherently painless and peaceful. I have never died, nor have I ever discussed the issue with someone who died. If it truly is painless and peaceful, giving large doses of medication isn't going to make is less so. If is IS painful for some, then those doses of medication have at least helped. I'll take my chances giving "too much".

I think I've probably rambled on long enough....

nuangel1, BSN, RN · Oct 14, 2008

Well said prickly.I can't agree more