MORPHINE and Dying Patients

[constantlylearning]

Curious about the administration of pain medication (Morphine) and possibly speeding up a patient's death.

[EmmaG, RN]

One nurse told me that she's had a lot of patients deaths hastened after she had swiftly turned them to their left side.

Swiftly??

[MAISY, RN-ER, BSN, RN]

This has been a great thread to read! I'd hope for any of you to be my nurse if my end was near and I was in pain-you are all thoughtful and caring nurses.

Recently I had an 96 yo vented ICU patient that experienced a pneumo, went into a junctional then was coded. We regained a rhythm, but she was gone. Pupils were fixed and dilated...no reflexes. Family came back, and signed DNR. (Why this wasn't done earlier, who knows?) Orders were written for morphine boluses, for extubation, and then a titrated morphine drip. I felt terrible being the one....however....I was also reminded that she was called and we didn't let her go! She lasted approximately one hour-no family at her bedside...they were already gone. I was with her at last breath, I cleaned and performed post mortem care. I know it was the "right" thing, but it didn't feel right. Here was a woman who had been walking and talking 24 hours earlier....gone....and I had given her the meds to help her along. What I know and what I f eel are two different things. I truly believe in hospice and their goals with regards to patient end of life, but I can also understand why some are not so ready to be the one holding that last syringe. It's a weird feeling, but I'd do it again.

With regards to that gurgling, scopalamine patches are the way to go! They are placed behind the ear and dry up secretions-making the patient more comfortable and the family less edgy.

Maisy;)

[leslie :-D]

Swiftly??

sure.

you know.

just flip 'em into position.

you flip, they flop.

leslie;)

[EmmaG, RN]

sure.

you know.

just flip 'em into position.

you flip, they flop.

leslie;)

lol

Yeah, I know. I guess it was the "swiftly" that threw me there.

[cardiacRN2006, ADN, RN]

,and i wonder how you prove someone is in pain,when they are unconscious?

It's called 'non-verbal indicators of pain' and it should be part of your routine assessment. But also, it's obvious when a pt is in distress or needs titrating.

[TazziRN, RN]

as i said ,"not to a pt. who is in noooooooodistress whatsoever!no vs sign prob, no crying out, no dyspnea!!!!!!!!!!!!!!you become hospice,your talking ,you walking,your eating,your in moderate pain, you get ordered ms04,abhr& u become unconsious, getting ms04 round the clock,so the family can feel closure???]/B] when did i become god, (or the devil)?btw, i work in a christian home.

You never said anything about the pt becoming unresp. because of morphine, you said you don't medicate when the pt is in no distress.

Something to think about: CA pts have a great level of pain, levels that would knock the rest of us over like a feather. What you consider "not in distress but getting meds anyway" is probably maintenance for them......it's what they need just to be able to function. When they are at a functional level they appear to be in no distress: VS normal, no dyspnea, no crying out, etc.

[P_RN, ADN, RN]

Don't be upset that you brought such comfort to your patient. When we say actively dying we mean they have agonal,grunting, cheyne-stokes respirations, they gurgle, their tube feeding has residuals of 100, they are drowning in their own fluids; they neither look at you nor acknowledge your presence, Their extremities are cold and clammy. Their mind is there and they can hear I am sure, but I am not sure they understand. The doctor has recognised this, and morphine has been ordered.

Now that was my MIL. Her daughter who lived about 50 mi away wanted Mama conscious so they could chat. MIL hadn't been able to do that for nearly a month with NO meds. I asked if we could meet with the doctor and ask for MS and a total DNR. As it turns out my DH and I did most of the talking.

Every nurse that came in said "you know what this might do....?" And we said yes we do. About 6 hours later there was another beautiful soul at rest. And SIL finally agreed that it was the best.

Please be that compassionate nurse. Someone has to be first and someone has to be the last to soothe.

[leslie :-D]

lol

Yeah, I know. I guess it was the "swiftly" that threw me there.

i know, the visuals...

but.

knowing how many feel about death/dying, i can see a nurse "swiftly" repositioning a pt, getting in and out of there asap.

sigh....

you know i work inpt hospice.

well, recently, we got an admit, who up until yesterday (when she arrived), was receiving prn oxycodone for an inoperable fx.

then suddenly, she shows up at our facility, with minimal hx/documentation.

i did a thorough assessment, and in my report/notes, i noted absent bowel sounds w/distention, profound dehyrdration w/third spacing, lethargy and combative, bil 'junk' sounds...just acutely debilitated.

her skin had diffuse, stage 1's on heels, buttocks, coccyx.

through further investigation, she does have metastatic gastric ca.

and still....they're trying to feed her (remember, she's obstructed)

i wrote an order to monitor these stage 1's, q shift.

i placed an ng and rectal tube.

got her started on iv and sl meds.

when i returned the next day, she was still in the same position.

nurses are writing (+) bowel sounds x 4; that she took 250cc fluid po (i offered her 1 sm sip, w/a very delayed swallow noted).

after i was done w/a small hissy fit, i relayed my very strong concerns to the med'l director, and he wrote all sorts of orders.

i've worked w/some of these nurses for years...it just goes to show you, that even the experienced, truly mess up big time.

there are other factors that led to the poor judgment calls, but don't want to divulge too much.

but even on my day off, i think of that poor lady, and what she was subjected to, because some wouldn't grasp she was hospice appropriate.

WHAT WERE THEY THINKING???

even if she wasn't ha (hosp approp), she still presented with what i mentioned.

sometimes, people/nurses just act downright bizarre when it comes to death.

it's too bad it took me having a meltdown, before the appropriate orders were implemented.

and if i'm talking about the so-called experienced hospice nurses i work with, i can imagine the perceptions of those who don't work closely w/the dying.

so yeah, morphine is a major component of that.

doctors and nurses alike, need much more education about pain mgmt and eol issues.

much more.

much, MUCH more.

oops.

there goes my bp again.

leslie

[TazziRN, RN]

sure.

you know.

just flip 'em into position.

you flip, they flop.

leslie;)

*groan*

[JennaRN1006]

Ok I have read all of these posts, and I have to disagree with suespet and others who agree with her. Like many others have said before me, it is our job to assess pain. However, it is subjective. Therefore, VS, and pts may not verbally tell us what their pain really is. I am an oncology nurse -- I work on a Med Surg unit. I see post ops to the terminally ill. Many of my walkie talkies (post ops mostly) will under rate their pain, suck it up and deal because they dont want to take the medication for side effects, dont like how it makes them feel, or fear of becoming addicted. Education is key here. If they still refuse, I always let them know that it is available to them whenever they want it. And if I give it to them, I also tell my pts to let me know if it doesnt help them, because maybe it might not be the right drug for them. I will go as far to call a pt out when they are under rating their pain, if they are wincing, hunched over, grimacing, whatever. I will tell them you appear to me to be in pain. Why?!? Because I want them comfortable. It is a JCAHO (in the US) standard to maintain a level of comfort for our pts. For the terminally ill, pain control is even more important. For those who are unconscious, youre non verbal cues and assessments are what will tell you if your pt is in pain. I would give all the pain meds I could, if it made my pt comfortable and not suffering.

What bothers me the most is this idea of beliefs (religious or otherwise). I am christian as well, however, as nurses, we need to put those aside and do what is right for that pt. If we can not then it is our responsibility to advise our charge nurse. You can not with hold medication from a pt because you dont believe it is right. Im sorry. If the pt is snowed, by all means that is a different story. But if you believe it is wrong, then you are mistreating your pt. Think of the pt who is the Jevoah's witness. They do not receive blood products. In a child or adult who has a Hgb of 5 or 6, and all they need is a transfusion and it will help the immediate problem at hand, I may disagree with my pt's wishes, however, I must respect it and leave my own beliefs at the door. I need to treat my pt in other ways to help minimize bleeding, etc. I do not say, well i dont agree with them so Im not going to give this med at q3h, i will give it at q6h instead. As nurses, we cant do that. We need to treat and maintain a pt's pain and comfort level no matter what we believe.

Ok I am off the soap box...sorry for the long winded response

[Shantas]

The bottom line is that no matter what our beleifs are, what ever religion we follow, either christian, jewish, muslim, hindu, buddhist, what ever we are either homosexual or heterosexual, as a health care provider we need to stay nonjudgemental and neutral and we need to do what ever it is necessary for the best interest of our patients.

If I see my patient is suffering from pain and even if it is the last shot, I will give it.

[HM2VikingRN, RN]

american chronic pain association e-mail: [color=#004276][email protected]; web site: [color=#004276]www.theacpa.org. p.o. box 850, rocklin, calif., 95677-0850; [phone] or [phone].

american pain foundation [email protected]; [color=#004276]www.painfoundation.org. 201 north charles street, suite 710, baltimore, md., 21201-4111; [phone].

national foundation for the treatment of pain [email protected]; [color=#004276]www.paincare.org. p.o. box 70045, houston, tex., 77270; [phone].

http://www.nytimes.com/2007/11/20/health/20brod.html?ref=health accessed today.