Morphine neurotoxicity

[aphillipi]

I'm reading a lot about neurotoxicity seizures and hyperalgesia occurring due to morphine being administered around the clock even after a patients kidneys have stopped putting out urine and pt has been npo. So I've been telling PTs caregivers to lessen frequency (q 4 instead of 2) and watch for any signs of pain when pt gets to that point. If that occurred I'd imediaty say raise the frequency back and watch for myoclonus and if that occurs I'd call doc to switch to oxycodone, etc. however my administrator says to push morphine and don't even think about lowering it. If pt has any symptoms do Ativan and even more morphine. All the textbooks say this is exactly what not to do.. I'm new to hospice and just want to make sure I'm doing right by my patients. Has anyone seen morphine seizures? I saw myoclonus in a pt but it went away w Ativan and he passed shortly after.

[MomRN0913]

I have a patient right now who is in the active dying phase for end stage renal failure. She has been experiencing myoclonus and I remembered this thread, came back and read it and she indeed seems to have neuro toxicity. She is on a decent dose of roxonal, 20mg q2, for pain and dyspena. Also ativan and ABH Gel.

She is on a fentanyl patch also. Can't really swallow, using the meds SL, really.

Would it be appropriate to lessen the Morphine and increase the ativan (we also have sliding scale orders)?

The twitching is what really bothers her daughter, she hates seeing it. I want to make sure the patient is comfortable.

I thought she was dying a week ago. I can't believe she is holding on in her state. I want to make this as comfortable and peaceful as possible.

[tewdles, RN]

Yeah, talk it over with the doc...a decrease in the dose of morphine and a bit of a boost in the ativan may help.

[bargainsmarts]

At our inpatient hospice when we have a patient who begins to exhibit signs of neurotoxicity we often will start a ketamine infusion. This allows us to back off of the morphine and maintain pain control. The last thing you want is a patient ending their life with seizures, that is not comfort care. A very short but informative article: ketamine_use

[MomRN0913]

Very well said. The patient ended up dying Friday. Not the best most peaceful death. I do use what I can within our parameters. She was comfortable, yes, but there were so many other processes that were hard to handle for the family.

I'm not worried at all about thinking if I gave a med if it was killing the patient. I just want to make sure that med is providing comfort. What bothered me so much was that the patient was as comfortable as I hoped she would be.

I do actually love hospice but I will be leaving very soon. My company is no good, I also do a lot of home are and carry a 20+ patient load. I'm too scared to give hospice another shot elsewhere thinking I will be in the same situation.

But caring for these hospice patients have taught me so much and it's an experience I truly value.