Morphine and End Of Life

[loriangel14, RN]

I would have held it too.I deal with a lot of palliative pts and our standard morphine orders are 2-10mg q15 min.We will give it to ease pain and treat respiratory distress.I would think with 7-8 breaths/min and long periods of apnea that more morphine would not be appropriate.I would have been upset too if another nurse indicated she was going to give morphine to hasten death. I would not give morphine if in my professional judgement it was not warranted.

[glutton4punishment]

I'm not a hospice nurse, and I understand where you are coming from......in my opinion, when someone is on hospice, they are dying. At this stage, and I assume you have never been at this stage, it is our responsibility to provide "comfort measures." You are not "killing" the pt. or assisting suicide. Furthermore, you are judging by YOUR OWN morals, not what the patients morals.

[OldNurseEducator]

MelissaLPN said:

Hey guys, I have a question, or a scenario rather that I have recently come across.

Recently at work I had a hospice patient who was unresponsive with resp. between 7-8 bpm with long periods of apnea. Resident was thought to be in the "active" dying processes and had a order from hospice was to give morphine every two hours. I held the morphine due to hypo-ventilation and decreased LOC and notified the MD. MD asked if he was in pain and I said there was nothing to suggest he was and that I was going to hold the medication. Fast forward several hours and the hospice nurse came to check the patient. I notified her that the morphine was held. She told me I need to give it anyways. When I said that I was withholding it due to the risk of resp arrest. She said " that's kinda the point. He wants to die." And insisted that I must give the medication. She said that hospice could write an order to cover giving the medication regardless of resp rate. Is this ethical? If a nurse follows an order that is intended to kill a patient, how can she possibly be covered legally?

Hospice is not assisted suicide and if it is not explicitly for pain control, I will not give a lethal dose of morphine to hasten the dying processes. My question to you guys is, don't I have rights? I should not be forced to do something illegal and immoral against my will. She took down my name and I think she is going to complain but I am stunned that she really thinks it is our job to medicate these patients into the grave. I am not in the habit of assisting suicide or causing the death of another person. Am I too emotional about this situation or does this seem reasonable to you guys??

I have done hospice nursing and would have held the medication. Hospice nurses do not hasten a patient death. I truly question the integrity of the hospice nurse that made that comment to you...it was very inappropriate. You did nothing wrong.

[JB2007, ASN, RN]

She is a nurse if she felt the resident needed the meds she should have given it herself. I have given morphine when resps are that low if there is fluid in the lungs or if the resident has of pain or even if they are alittle restless (could be a sign of pain). However, I am with you, I will not give it just to speed up the dieing process.

[Isabelle49]

Was this patient normally non-responsive?

Am not a hospice nurse, but I do believe you did the right thing.

[tothepointeLVN, LVN]

In studying for my Hospice certification last night on of the passage of one of the many texts I am digging through suggested that for superior symptom control once Morphine has been started for pain management and to reduce respiratory distress ( which I think is what the nurse is referring to when she is talking about the point of the morphine is to reduce the respiratory rate ) that it should be given ATC to ensure symptoms remain manageable.

As a hospice nurse I would have questioned your holding the morphine as well. In this case it does not see to necessarily be in the best interest of the patient. ATC orders in hospice are common.

[MelissaLPN, ASN, LPN, RN]

the patient is not normally non-responsive and he was not in any distress, resp or otherwise. Keep in mind he maintained a resp of 7 after missing two doses, imagine had I plowed along and kept piling on the medication. Isn't the point of a nurse to evaluate the patient, not just blinding follow orders regardless of the patients current condition?

[tothepointeLVN, LVN]

Was he no responsive because of the morphine or non responsive because he was nearing the end of his life?

With hospice there are some many things to assess. When a patient is non responsive do we assume they have no pain/distress?

[heron, ASN, RN]

I'm certified in hospice, too, and agree with the OP. The ethics of morphine administration hinge on intent ... and the intent can never be to hasten death. If the pt showed no indication of distress ... including restlessness, muscle tension, facial grimacing or visible resp distress, there's no indication for morphine. I have had pts on atc morphine when death was imminent, but they had a history of severe distress and atc meds prior to becoming active.

[Asystole RN]

A common misconception is that giving morphine during the actively dying stage will hasten death.

Morphine is not given to only reduce pain, interestingly enough. Morphine reduces the amount of catecholamines that circulate, the anxiety fight or flight hormones that the body produces in times of severe stress such as in the dying process. Morphine also relaxes cardiac tissue which lowers the cardiac cell's demand for oxygen, remember the term MONA for MIs? The overall decrease in the patient's stress may account for the increased duration of the actively dying process in patients receiving proper analgesia.

During the active dying process you cannot accurately assess pain in a patient through visual, sometimes even physical assessments. As the brain starts shutting down typical responses to pain such as grimacing or anxious movement may no longer be present. I see this a lot in my current practice, we have a large population of persistive vegetative patients who elicit non typical symptoms to pain. A cardinal sign of pain in the actively dying person is labored OR irregular breathing patterns.

After a patient has been receiving morphine for several days the risks of respiration depression significantly lessen, especially in the dying patient. The stress of the dying process will actually activate the respiration drive, countering any respiration depression by the morphine. Morphine has no ceiling dosage of maximum effect, in theory the more you give the more pain is controlled, unlike other analgesics which work only so much. This is one of the reasons why morphine is considered the gold standard. I have seen patients literally on hundreds of mg of morphine per hour and still keep-on-a-ticking.

Your goal is to assist the patient to die in a dignified manner, peacefully and without pain. I am sorry that the hospice nurse misinformed you that the idea was to terminate life, obviously there was a lack of education and training. Sometimes we must do things that place the patient at significant risk of life in order to fulfill their health related goals. The nurse's intention is what primarily drives the ethical dilemma. If a patient with an illness wishes to undergo a radical surgical procedure with a 98% chance of death on the operating table there would be no ethical wrongdoing in helping the patient, it would be considered helping the patient keep hope alive. In fact this is what we are doing for the terminally ill, helping the patient die in a dignified manner is keeping their hope alive.

Always ask yourself, is this what the patient wanted? Your ethics, morals, religion, and values should have no bearing whatsoever on the patient, you are their advocate, not your own. This is the burden we bear as nurses we when were privileged with a license to serve our patients.

Things to consider on the ethics of the situation - ANA Code of Ethics

Provision 2

2.1 Primacy of the Patient's Interests

The nurse's primary commitment is to the recipient of health care services...When the patient's wishes are in conflict with others, the nurse seeks to help resolve the conflict. Where conflict persists, the nurse's commitment remains to the identified patient.

Provision 1

1.3 The nurse should provide provide interventions to relieve pain and other symptoms in the dying patient even when those interventions entail substantial risks of hastening death.

P.S. There is much research out there on the actively dying process, analgesic use during the end of life process etc. This seems like an excellent time to research the topic. The Hospice and Palliative Care Nursing Association (HPNA) and the American Nurses Association (ANA) have excellent resources on the subject.

[Heidi the nurse, BSN, RN]

Wonderful post asystole, and lots of info I had no idea of. As I like to say, you learn something new every day.

But on the other hand, I think it is wise for all of us to not blindly follow anyone else's "orders" - be they a trained in the field nurse, MD, etc etc. Always be willing to learn another POV, but not follow blindly. Given what the OP (and many of us not as informed in end of life issues) believed, I would have done the same. Especially if I felt the only reason was to hasten death.