Thank god, a lot of the docs in home care know what they're doing when it comes to pain meds for terminal patients. Had a 92 yr. old with gangrene in both legs, plus multiple health problems, and the family had decided that at her age, amputation was not an option. She was not eating or drinking, and on my morning visit was only semi-conscious. She was getting morphine sub-q by butterfly needle, with boluses q 15 minutes if needed (don't really remember the rate).
I came in again that evening, at the end of a VERY long day, and she was awake, alert, and obviously suffering. Her lungs were filling up due to her heart beginning to fail, and she was fighting for breath. I called the doctor on call, and when he FINALLY got back to me, he said: "I know nothing at all about morphine pumps. Her primary doctor said I would have to come and sign the death certificate, and that was it. Sorry!"
Well her doctor had been smart enough to leave a titration order for the morphine, so I bumped it up and kept bolusing her until she was comfortable and somewhat drowsy. (Do you think I even bothered counting respirations??? Are you kidding??) I told the doc. that usually end-stage patients were given Ativan or Valium to calm them down if they were in respiratory distress. He agreed to the Ativan, but only ONE milligram!! We got a scopolamine patch for her, too, and I told her daughter to not be afraid to give 2 Ativan.
She died peacefully several hours later. The last thing I did before leaving her was pray for her. The daughter was so touched by everything I'd done that she called both my boss and the CCAC office to make sure they knew what terrific nursing care her mom had had.