Morphine and Hospice Patients that are dying

[suzi0612]

Hello, I am a new nurse and I recently graduated with my RN and taking RN boards soon but working as a LPN at a long-term care facility. I got to take care of a patient that is dying and is hospice. We have a morphine order that reads like this in our mar: 10-20mg morphine sulfate sublingual every hour as needed for pain/dyspnea. I was doing some research online and I see a lot of orders every 4 hours not every hour. What are normal morphine orders in dying patients, is this dose to high? Any input would be greatly appreciated. I was just curious! Thank you.

[Hospice Nurse LPN, BSN, RN]

It all depends on the pt. I've had some pts that get doses of morphine that are higher than that. Doc will order whatever it takes to make the pt comfortable. If the pt is narcotic naive, then doc will usually start them @ 5 to 10 Q 2 hrs. Of course, if they were on a boat load of narc before, then the dose will start higher.

I'm wondering about the parameters in your order. In the LTC I visit, they are not allowed to accept orders w/ parameters. Which means, I'm getting n/o frequently. But that's not a big deal.

Is your pt comfortable? That's the real question.

[suzi0612]

Yes, and the patient isn't getting it every hour. Just like six-seven (20mg) doses in a 24 hour period prn. I was reading blogs about that too about how in a facility we should not have to judge with parameters like 10-20mg prn for pain. I know that hospice was the ones to get this order for the patient and had it signed by the physician. I know the patient was on routine oxycontin and oxycodone when not in the dying phase and taking PO medications. I was just curious because it was my first time working with a hospice patient and made me nervous.

[Hospice Nurse LPN, BSN, RN]

suzi0612 said:

Yes, and the patient isn't getting it every hour. Just like six-seven (20mg) doses in a 24 hour period prn. I was reading blogs about that too about how in a facility we should not have to judge with parameters like 10-20mg prn for pain. I know that hospice was the ones to get this order for the patient and had it signed by the physician. I know the patient was on routine oxycontin and oxycodone when not in the dying phase and taking PO medications. I was just curious because it was my first time working with a hospice patient and made me nervous.

Check w/ your DON about that order and if needed, call the hospice nurse to have it changed. In our home pts, doc will write the order for 5 to 20 Q 2 hrs PRN. That way, the nurse can up the dosage (up to 20) w/o calling him.

Since your pt was on oxycontin and oxycodone before, it doesn't sound like an unreasonable amount to me. You do realize that the dosage may have to be upped when the pt becomes tolerant? In the meantime, I'd def check on that order.

[czyja, MSN, RN]

suzi0612 said:

What are normal morphine orders in dying patients, is this dose to high? Any input would be greatly appreciated. I was just curious! Thank you.

I would have found this to be a usefully written order.

The proper opioid dose is the one that relieves pain/Dyspnea without causing undo side effects or harm to the patient. As noted by above posters, if the pt is opioid tolerant, than a dose in this range is to be expected. If the pt is opioid naive, than a dose of this size could quickly lead to death. If the pt is highly opioid tolerant, then it might not be sufficient. Remember, the maximum opioid dose is different for every pt.

I like that it was written every hour. If the patient does not get relief in an hour, and then it is time to consider then they need a higher dose. Of course, you have to use yer brain and the nursing process....lest you cause harm to your pt. Potential Harm, especially in the case of the actively dying pt, must, however, be balanced with the need for symptom management.

[vwevans, ASN, RN]

In our agency we write orders for Morphine Sulfate Solution 20mg/ml, give 0.5 to 1mL every 2 hrs prn pain, which is esentially the same order as you have but 2 hours instead of one hour. I prefer the 1 hr because an hours is a lifetime if you are hurting.

[leslie :-D]

the reality from my time in ltc is, whether the dosage is for 5-10 or 10-20mgs, many of the nurses do not give the prn's whether the pt needs it or not.

i am not trying to offend, but this was my reality, and it made me furious.

i begged the dr. to write a scheduled order, appropriate for each pt.

regardless of degree, training, eduction, inservices, there are still way too many nurses who fear giving mso4.

of course there are nurses (obviously including ltc) who are solely concerned for pt's well-being, and give freely and w/o hesitation.

one long-time nurse had the (bad) judgment to write in her nsg notes (not verbatim) to the effect of, 'pt received 5mg sl roxanol x 2 this shift. moaning and crying out continued. will continue to monitor.'

i mean dammit, nurse COULD have given more, but outright refused to.

ok, off my soapbox.

i wasn't aware that ltc regs allowed ranges...

that they had to be x amt only...none of this 5-20 for mild, mod, severe pain.

that's my only question about the order.

i sure hope this pt is getting the relief she needs.

leslie

[czyja, MSN, RN]

leslie ? said:

the reality from my time in ltc is, whether the dosage is for 5-10 or 10-20mgs, many of the nurses do not give the prn's whether the pt needs it or not.

i am not trying to offend, but this was my reality, and it made me furious.

i begged the dr. to write a scheduled order, appropriate for each pt.

regardless of degree, training, eduction, inservices, there are still way too many nurses who fear giving mso4.

of course there are nurses (obviously including ltc) who are solely concerned for pt's well-being, and give freely and w/o hesitation.

one long-time nurse had the (bad) judgment to write in her nsg notes (not verbatim) to the effect of, 'pt received 5mg sl roxanol x 2 this shift. moaning and crying out continued. will continue to monitor.'

i mean dammit, nurse COULD have given more, but outright refused to.

I dont think you are on a soapbox at all Leslie. There is a substanstial body of evidence that shows acute pain is undertreated in all settings. Providers dont want to write for MSO4 and nurses dont want to give it. It is a sad situation that causes vast amounts of suffering.

Nursing curricula are deficient in teaching about pain and the proper administration of opioids.

I am glad the OP sought to have here questions answered.

With respect to the previous poster - an hour in pain is a lifetime. And the pharmokinetics of morphine are such that the peak plasma concentration is reached within one hour. Thus, if the pain is not relieved in the first hour, it will not be relieved in the second, unless more morphine is administered.

[suzi0612]

Thanks everyone for your comments. I am a new graduate and this was my first hospice patient experience. Basically I have learned there is no high limit with morphine with the dying because some people have different tolerances. Basically keep the patient comfortable as you can, I just was doing research on morphine and "safe dosages" and wasn't seeing a standard order that matched the order we received for this patient. I guess every patient is different and you treat the pain as "real" and listen to your patient and know what signs/symptoms your patient expresses if they can not tell you. Thanks everyone!!

[czyja, MSN, RN]

suzi0612 said:

Thanks everyone for your comments. I am a new graduate and this was my first hospice patient experience. Basically I have learned there is no high limit with morphine with the dying because some people have different tolerances. Basically keep the patient comfortable as you can, I just was doing research on morphine and "safe dosages" and wasn't seeing a standard order that matched the order we received for this patient. I guess every patient is different and you treat the pain as "real" and listen to your patient and know what signs/symptoms your patient expresses if they can not tell you. Thanks everyone!!

Well said!

I would only add the the "no high limit" rule does not only apply to the dying. In an acute care setting very high doses may be needed, especially in patients with cancer that are opioid tolerant.

[ErinS, BSN, RN]

We use 5-20 mg morphine q 1 hour prn. Most pt's do fine with it about every 4 hours, but we leave that frequency because if someone has sudden respiratory distress or pain, we want a big window to be able to manage it.

[Hospice Nurse LPN, BSN, RN]

I got a call last Friday morning that one of my LTC pts was aggitated. I was on my way to the facility already and when I got there, I heard this woman SCREAMING all the way down the hall. She was a new admit (about 4 days) and had never taken anything for pain....not even Tylenol. I saw her Wednesday and she was very comfortable and sleeping soundly. I called and got an order for Roxanal 5mg @ 2 hrs PRN and ativan gel Q 6 hrs PRN. Pharmacy was asked to deliver STAT.

Informed the facility nurse of new orders and asked her to give as soon as delivery was made. I wrote the order in the chart and made sure the nurse understood the instructions. I have 6 other pts in the same facility, so I was going to be in the bldg for a while.

About 1 hour later I go to check on this pt again. She's sleeping soundly. The nurse told me she gave the Roxanol and ativan gel together on the advise of her DON. GREAT! This DON really understands hospice and pain mgmt. Just before I leave the facility about 1400, I peek in on my pt again. I didn't speak to the nurse....MY BAD.

Saturday morning, our w/e nurse makes an extra visit to check on this pt since she was in a pain crisis the day before. Lo and behold! Pt is screaming out again. W/e nurse asked when last dose of pain meds were given and the nurse replied,"oh, she had some yesterday about noon." Our nurse tells her that the pt is screaming out in pain and needs morphine ASAP. The facility nurse said it was reported to her that the pt screamed all night and they finally shut her door to keep her from waking the other pts. AND YOU WILL ADMIT THIS!!!

I talked to the DON on Monday morning to discuss this issue. She is going to speak to all the nurses involved. She asked if we would be willing to do an inservice some evening or on a Saturday. YOU BET! Heck, we'll bring lunch.

This is a large facility w/ approx 250 beds. This is the first time we've had a pt on this particular hall. I've worked w/ several of the other nurses there and they are getting MUCH better about giving morphine. It's all about teaching and re-enforcing. I know some of the LTC nurses are overworked.....been there and done that so I really want to thank the OP for asking this really important question.