morphine drip for "comfort"

[melisgood]

What is your view or experience with taking care of a patient on comfort care when you know the family and doctors are trying to assist the patient in dying? I took care of a patient who was on a morphine drip. He was a young trauma patient and the ventilator had already been removed and he was a DNR. The order was to increase the morphine every hour as needed by 2mg/hr. The family was requesting we increase it every hour or two (while they were at the bedside) and he did not have any obvious signs of increased pain. At the end of my shift he was up to 74mg/hr! The doctor did put a max dose of 80mg/hr.

On one hand I understand the family wanting to end their pain of seeing their loved one like this, but on the other, I felt like I was assisting in killing this patient. What would you do?

[Fiona59]

No matter what way I look at the situation I would feel I was assisting a patient to their death. We all know what morphine decreases respiration in a situation like that I would pray and as the Holy Spirit for His help.

Then I would have to turn you away from caring from me or mine. Religious beliefs have no place in the workplace particularly if the patient doesn't share your viewpoint.

I've seen the results of religious nurses with holding morphine because they felt that the patient wasn't in pain and that god would do what was right. The patient is now vegetative, the family destroyed, it's a mess.

[Gabby-RN]

Was the patient struggling to breathe or having increased respirations? My guess is that they were, especially if they were terminally weened from the vent. Morphine helps open the airway and allow for less labored breathing. It helps the person whose lungs are filling up with fluid as their body shuts down, the person whose whole body is shutting down, die peacefully and comfortably. Most dying patients can't tell you they are uncomfortable when death is near. It is your job as the nurse to notice the subtle signs and medicate appropriately. If my loved one were dying I would not want my last image of them to be gasping for air as they drown in their own secretions.

The doctor who wrote the order to titrate up the morphine accordingly was doing so to ensure the patient was comfortable when they died not because they wanted to hurry death along. If at the time the family requested the morphine increases the heart rate was 50, the respirations were 10, and the patient lay their listless then it would be appropriate to educate the family that an increase is not appropriate but I am guessing that was not the case.

[anon456, BSN, RN]

Aside from the end of life issue here . . . I am still trying to wrap my head around morphine not causing someone's death. I had a young patient recently who was post-op and had had a rough day with pain and agitation. They put them on clonidine patch, IV ativan, IV benedryl, IV ketoralac, IV tylenol, and a morphine drip. When I took report I went in and the patient was shallow breathing at a rate of 5! And mind you this is a young pediatric patient. Sats were okay, HR a bit high but not horrible, the start of circumoral cyanosis and not the least bit arousable. I turned off the morphine and MD was called to bedside immediately. Was worried about retained C02 among other things. Narcan was started, patient started to wake up and breathe at a rate of 12-15 and deeper, and then morphine drip was turned back on with a concurrent narcan drip. It was such a small dose of morphine for the patient's size. Obviously things could not continue like that or the patient would crump.

[ktwlpn, LPN]

No matter what way I look at the situation I would feel I was assisting a patient to their death. We all know what morphine decreases respiration in a situation like that I would pray and as the Holy Spirit for His help.

Instead os assiting a patient "to their death" we are really assisting them "through their death"

[MunoRN, RN]

I'm not opposed to it, although I know I've most likely hastened death in the past with morphine.

Prescription opiates kill 16,000 people per year (that doesn't even count those who die in the hospital from over sedation). So what supposed magical power do those on comfort care have that makes the immune to the relatively narrow therapeutic index of opiates? Why don't we give that immunity to the lethal effects of opiates to everyone?

[heron, ASN, RN]

The lethal dose of any opioid, including morphine, rises with the tolerance to the drug. This is why many people treated long-term with opioids require such large doses to get any effect at all, and tend to need faster escalation to maintain effect. People on comfort measures are not immune to lethal doses ... it's just that the lethal dose, for them, is higher than for someone who is opioid-naive.

Safely titrating morphine involves the same nursing process we all learned in school - assessment > intervention > re-assessment, including pain indicators and rate/quality of respirations (resps often become shallower before the rate drops) > further intervention if needed. It's the re-assessment part that seems to get people confused. It's especially important with opioids, since individual responses and lethal doses vary so widely that a dose that would kill one person, barely touches the person in the next bed.

The highest rates I've seen in "walkie-talkies" was 750+ mg/hr of morphine and 90mg/hr of dilaudid (and still uncontrolled - probably opioid-induced hyperalgesia).

[OCNRN63, RN]

No matter what way I look at the situation I would feel I was assisting a patient to their death. We all know what morphine decreases respiration in a situation like that I would pray and as the Holy Spirit for His help.

You have no business working in any area of nursing where you could potentially deal with patients who are dying or have complex pain management issues. Honestly, if someone like you were assigned to take care of me or mine, I wouldn't hesitate to report you to the BON.

You should not be forcing your religious beliefs onto your patients or their families. I shudder to think how many patients may have died in needless pain because you were uncomfortable with their medication orders.

It's about the patient...it's not about you.

[KelRN215, BSN, RN]

Aside from the end of life issue here . . . I am still trying to wrap my head around morphine not causing someone's death. I had a young patient recently who was post-op and had had a rough day with pain and agitation. They put them on clonidine patch, IV ativan, IV benedryl, IV ketoralac, IV tylenol, and a morphine drip. When I took report I went in and the patient was shallow breathing at a rate of 5! And mind you this is a young pediatric patient. Sats were okay, HR a bit high but not horrible, the start of circumoral cyanosis and not the least bit arousable. I turned off the morphine and MD was called to bedside immediately. Was worried about retained C02 among other things. Narcan was started, patient started to wake up and breathe at a rate of 12-15 and deeper, and then morphine drip was turned back on with a concurrent narcan drip. It was such a small dose of morphine for the patient's size. Obviously things could not continue like that or the patient would crump.

Sounds like your patient was opioid naive. If you titrate the morphine to effect, it won't kill the patient. If you go in and push 100 mg of morphine on an opioid naive patient, they will of course stop breathing. For my patient, we started him on 1 mg/hr and his dose was escalated over several days per hospital protocol and his final dose was 100 mg/hr with 10 mg boluses available. He lived for DAYS on that dose and when he finally died, it was brainstem herniation from a rapidly progressing tumor- not the morphine- that did him in. This child weighed something like 24 kg. With the typical dose of morphine for a child being 0.05-0.1 mg/kg q 2-4 hrs PRN, he was getting 40x his recommended dose with no harm done.