ordered to give roxanol with resp. of 5

[wantsthebest]

I was recently ordered to give a dose of Roxanol to a patient with terminal Alzheimers. I withheld the dose due to the fact that his resp. was 5, there were no s/s of pain, no SOB, and no labored breathing. Pulse was slow and weak. No response from stimuli. The MD said I should give it and (I quote) "you can make it a humane death"

I have a problem with this, I always thought that we first do no harm, isnt giving some one something they dont need harm? No signs of distress, just someone busy dying and not having a problem with it.

[TrudyRN]

furthermore, the process of dying itself, is a relatively humane and comfortable process.

leslie

You must have seen something totally different than I have seen. There is nothing humane or comfortable about a slow death, especially death from starvation and dehydration.

[TrudyRN]

Unless I'm missing something or don't understand correctly, I am having a real hard time understanding why anyone would think that this whole situation is ok. From the way I understand it, this man was able to eat/drink on his own with some assistance and he was alert up until the decision was made to make him NPO without a medical reason, e.g. inability to swallow and his current mental state (basically unresponsive) is caused by the addition of a powerful narcotic Q 2 hours! I see serious ethical issues.

Once again, unless I'm misunderstanding something, I see serious ethical concerns with possible criminal elements.

These are excellent points and I missed them. I'm glad you brought this up, Kymmi. What were the man's medical conditions, other than Alzheimer's?

[Indy, LPN, LVN]

Sometime during the dying process, after the patient no longer speaks or acknowledges that people are there, I make a note in my documentation as to what I am going to interpret as signs and symptoms of pain, or of distress, and I'll stick to it. If the patient is suffering every time they are able to have morphine, I'll document how I know and give the med. If they are resting quietly, I'll document that I skipped a dose and why. The respiratory depression varies from one person to the next, so it's important to pay close attention to what it does for each person, so you don't get in a hurry and give too much, even if the patient did seem to need it.

Every person who is on morphine for comfort while dying, is going to get a last dose. They may die soon after their dose or a long time afterwards; but there will be a last dose. It was important for me to wrap my head around that and realize that I have to be aware, fully, of my intentions and document the pain assessments, such as they are, on each dying patient.

There will be families who are terrified of their loved one getting morphine, and they can be educated, but I'll make sure the patient gets what they need, as well as I can judge it. There will be overeager families who really want that morphine each and every time it can be given, and those people scare me because my judgement doesn't always match theirs; gotta document the crap out of it and be tactful and honest. "I have certain criteria that I have to use to give the morphine, and I will give it when the patient meets those criteria" is a good line. "I value my license and I'll do what is necessary, but I won't do too much" is another that I've used.

No amount of rationalization, and I mean none, will help me shake the feeling I have when I'm the one that administers that last dose. It hasn't been often, most of my dying patients live through my shifts, or go home. Sometimes I wonder if there is more value in handholding and music than in the morphine; singing to a patient as they go would certainly make me feel better, but it might not do much for the patient. Again, it's a whole world of uncertainty. Because of this, the only thing I think that will help the nurse is being honest with yourself, knowing your feelings and intentions where each patient is concerned, and documenting the heck out of what you do. Use your judgement and stick by it. The patient deserves to be pain free, but you have to be vividly aware of "the line" so that you don't cross it.

Sorry this is so long. I have worked with those who are very flip about morphine at the end of life, and though I don't know their hearts, it causes me to examine the issue very closely. I really, really like for both my license and my conscience to be in good order.

[Kymmi]

I am still amazed that everyone is focusing on the fact of whether or not to hold this drug....TrudyRN---I think that you understand what Im saying and I also agree with what you posted. From what I understand this man was NOT unresponsive until he was made NPO and has not had food or water for over 14 days AND he's receiving a powerful narcotic q 2 hours however prior to that he was alert with a diagnosis of Alzheimers. I understand he might also have pain but so do alot of people...alot of people live with chronic pain however we dont withhold food/water and oversedate them in order to ease their pain. I still stand by my thoughts that this quite possibly be criminal and I definitely would get a OMSBUDSMAN involved.

TrudyRN....I also agree that after the fact no one will stand behind anyone if the family decides to sue and say their loved one was starved to death and no one can prove a medical reason as to why he was made NPO and given a narcotic q 2 hours and kept so sedated.

[XB9S, BSN, MSN, EdD, RN, APN]

I am still amazed that everyone is focusing on the fact of whether or not to hold this drug....TrudyRN---I think that you understand what Im saying and I also agree with what you posted. From what I understand this man was NOT unresponsive until he was made NPO and has not had food or water for over 14 days AND he's receiving a powerful narcotic q 2 hours however prior to that he was alert with a diagnosis of Alzheimers. I understand he might also have pain but so do alot of people...alot of people live with chronic pain however we dont withhold food/water and oversedate them in order to ease their pain. I still stand by my thoughts that this quite possibly be criminal and I definitely would get a OMSBUDSMAN involved.

TrudyRN....I also agree that after the fact no one will stand behind anyone if the family decides to sue and say their loved one was starved to death and no one can prove a medical reason as to why he was made NPO and given a narcotic q 2 hours and kept so sedated.

I have to agree with you, having read this thread the one thing concerns me is the withdrawl of diet and fluids on a patient without any clinical justification and the families request. I would question is this in the best interest of the patient of the family and even though I can empathise with the distress alzhiemers causes to a family, as a nurse it is the patients best interest that has to be a priority.

In the UK unless there is a surgical rationale or problems with swallow, this would be a nursing issue and not something the medics would order. Even with swallow difficulties our Speech and Language THerapy team would be involved to get a swallow assessment and they would recommend the NPO, these recommendations would be made to the nursing team who would act upon them

The fact this decision has been made at the request of the family without clinical justification would be something we would refer onto our protection of vunerable adults team and it would be classed as abuse, I am not critisising the family here.

Having cared for an elderly grandfather with alzhiemers I understand the distress, there were times that I wondered how much longer we as a family could cope with the anxiety and stress and yes there may have been times that I wished that I would get to the house and it would all be over. BUT we had good nurses to support us and they advocated for my grandfather when our mental and anxiety state meant that we were not i the best frame of mind to do so.

[Jo Dirt]

the patient in question has end stage alzheimers, his wife stopped letting us take him to the dining room, insisted on trays in his room, said she would feed him. he began losing weight. under orders, we began to feed him after she left, his weight stabalized. she then got an order to make him NPO and ate and drank in front of him. after 10 days she got the order for Roxanol, Q2, routine at family request.

The wife sounds like a real nut case,especially since you said in a later post that he was eating in the dining room.This whole thing would have me worried

You know what? There may be other issues going on here. Call me a horrible calloused person, but nursing home care is not cheap. It is possible that every month that goes by sees more and more of this couple's resources drained, everything they have being drained. The man is clearly dying, though it seems odd that he is able to go to the dining room and sit up and eat with a respiation of 5 and in end stage Alzheimer's.

There is a news article on this site about the boom in Alzheimer's cases and the devastating effects it will have on the economy and families, which gives me the impression that it will become more and more acceptable to euthanize. People who have not dealt with the financial devastation of losing the shirts off their backs to fight a losing battle like Alzheimer's generally don't understand how a family member could even think such a thing as giving a lethal dose of medication. But it isn't always about the patient and it shouldn't be. The family is the one who has to carry on, and it is a burden. Even if it is a burden of love it is still a burden. I will absolutely give my consent for my family to see this is done when I'm in such a state. Not many people want to be a burden to their families, most definitely not me.

I do believe, though, that nurses shouldn't be in a position to do the "dirty" work. If the doctor doesn't want to do it the wife should take this responsibility.

[leslie :-D]

You must have seen something totally different than I have seen. There is nothing humane or comfortable about a slow death, especially death from starvation and dehydration.

as a hospice nurse, i've seen hundreds, if not thousands of deaths.

when someone dies of 'natural causes' only, the dying process is flowing and rather non-invasive.

meds as well as sev'l other interventions are given to ensure a painless transition.

it is when comfort care is introduced prematurely that the pt struggles.

if this pt still has a gag and swallowing reflex intact, npo would not be indicated.

when the body is not ready to die, then all interventions to prepare for death, is euthanasia. period.

this pt is now unresponsive r/t all the mso4 he's received.

not only is this unethical, it is illegal.

but when someone's time has come to die, dehydration/starvation are not considered invasive occurences.

the body really does respond w/compensatory mechanisms that allow us to focus on other bumps that occur down the road.

most of my pts have cancers or aids.

dehydration/starvation are the least of their problems.

leslie

[Focker, CRNA]

I hope you live in Oregon. Or look good in jail stripes in the other 49.

You make some good points but your post would be easier to read if you used periods and capitals. Thanks.

I am entitled to my opinion, this is a discussion board. Save your grammar corrections and admonitions for someplace else.

[TrudyRN]

I am entitled to my opinion, this is a discussion board. Save your grammar corrections and admonitions for someplace else.

If it's a discussion board and if you are free to say what's on your mind, then I guess I also am free to discuss, opine, and let someone know that their posts would be easier to read if they would use caps and punctuation, Focker. What's the big deal?

What's good for the goose is good for the gander.

[TrudyRN]

You know what? There may be other issues going on here. Call me a horrible calloused person, but nursing home care is not cheap. It is possible that every month that goes by sees more and more of this couple's resources drained, everything they have being drained. The man is clearly dying, though it seems odd that he is able to go to the dining room and sit up and eat with a respiation of 5 and in end stage Alzheimer's.

There is a news article on this site about the boom in Alzheimer's cases and the devastating effects it will have on the economy and families, which gives me the impression that it will become more and more acceptable to euthanize. People who have not dealt with the financial devastation of losing the shirts off their backs to fight a losing battle like Alzheimer's generally don't understand how a family member could even think such a thing as giving a lethal dose of medication. But it isn't always about the patient and it shouldn't be. The family is the one who has to carry on, and it is a burden. Even if it is a burden of love it is still a burden. I will absolutely give my consent for my family to see this is done when I'm in such a state. Not many people want to be a burden to their families, most definitely not me.

I do believe, though, that nurses shouldn't be in a position to do the "dirty" work. If the doctor doesn't want to do it the wife should take this responsibility.

The patient was able to eat and sit in the dining room BEFORE the wife got him on NPO status and BEFORE she got him on the morphine.

I think the financial devastation is a factor that Americans need to come to grips with. Life here on planet Earth is supposed to be temporary but we Yanks haven't accepted that yet in a meaningful, practical way, in this area. Lawmakers don't care for terminally ill people, they don't spend hour after weary hour, day in and day out with the terminally ill, the chronically ill, such as those on dialysis, the paralyzed, those with horrible neuromuscular wasting diseases, those dying of cancer by inches despite all the slash, burn, and poison "care" we foist upon them, those with dementia, those who can't feed, turn, bathe, or toilet themselves, etc., etc.). They are in their chambers, far from the sights and smells. No Code Browns for them, just legal briefs and 3 piece suits. They mean well. Euthanasia cannot be taken lightly, God knows. But we as a nation have simply not come to grips with the economic realities of extended illnesses and extended dying times. We feel guilty about letting a person go on into eternity. Certainly we must be very cautious, we must involve Ethics committees, rabbis, priests, ministers, imams, families, etc. Certainly we must preserve life when there is life to preserve. So maybe our problem is defining "life".

At any rate, I agree that financial devastation should not be forced upon a family by a hopelessly ill relative. But how and where do we draw the line? When do we decide, and who does this deciding, that we will no longer treat? That we must now starve and dehydrate the patient? I for one must leave that to others to decide. At the very least, I must keep my patient clean and comfortable, to the best of my ability.

Just recently, I watched helplessly as the relatives of my friend listened to the docs tell them she was hopelessly terminal and they decided to starve her, dehydrate her, and snow her with morphine and Fentanyl. As a friend, not family, I had no right to make decisions about her care and she had no Adv. Dir. I watched her relax when morphine was given and watched how she struggled for breath when it wore off. All I could do was tell the nurse she was struggling again. And who would tell her when I wasn't there? No one. No family ever visited her. They were out of town and came only after she died. Not to judge them but it hurt terribly to know she was so alone. I know people are busy and have their own lives, jobs, kids, etc. but it hurt a lot to see how alone she was.

I tried to do mouth care but she fought it. The Clin Spec kept telling me that fluids would be inappropriate, as they would flood her lungs, overwhelm her heart, etc. Maybe. How about TPN or a G tube - something to prevent dehydration and the horribly dry mouth she had from a week of intubation and then mouth breathing?

They literally dehydrated her to death, IMO. I thought there should be some middle ground between ICU all out efforts and comfort care. How about giving her appropriate heart meds and some nutrition and see how she might respond to these. Yes, there is a time to die but I thought they should have tried the middle ground before dehydrating, starving, and snowing her. No one can tell me, after seeing that, that she was comfortable. No way. If that's comfort, I sure don't want it. I know they tried their best and had, presumably, good intentions but it seemed just so barbaric to me.

But we do need to get laws that are more realistic, I agree.

[Focker, CRNA]

If it's a discussion board and if you are free to say what's on your mind, then I guess I also am free to discuss, opine, and let someone know that their posts would be easier to read if they would use caps and punctuation, Focker. What's the big deal?

What's good for the goose is good for the gander.

Theres a difference between being rude and having a discussion. Feel free to disagree with me and others and share your viewpoints, just try to have some tact.

[RNCRNA2BE]

I'll be damned if my patient is the family. And, while I might care about the family and their suffering, don't expect me to compromise my license so they can remember their loved one in a better light. :angryfire

My patient is the guy in the bed. And the family is already going to remember the suffering he has already done. There is no need for me to suspend all my training and education and experience for anyone else's benefit. If the doc wants it given, let him give it. If the family wants it given, get an order for them to give it and hand them the bottle.

But there will be nobody going to court with me if I practice euthanasia. In fact, it is a pretty safe bet to say that the family and doctor will all turn on you and swear up and down that they never gave any indication that they wanted you to do anything but use your nursing judgement to just keep the pt comfy, not end his life more quickly by OD'ing him on MS. Please wake up and protect yourself. How can you say that our viewpoint means nothing? We are the nurses, for God's sake. What can you possibly thinking? :uhoh21: Why are we on the scene if our judgement means nothing?

And don't assume that the family has the pt's best interest at heart all the time. Maybe they do and maybe they can't stand the old fart. Maybe he was a wife-beater and child abuser and an alcoholic and a total destroyer whom they can't wait to be rid of because he does have some money that will now be theirs. You must protect your license, not try to end all suffering of patients and their families. Yes, we try to do the very best we can but we do it within the law, not emotionally or based on presumptions. We follow the law and do the best it allows us to do, even as we work to get more realistic laws passed.

Anyway, if we hasten death intentionally, that person has less time to be dealt with by God on the spirit level. God determines length of life, not us. Maybe God is trying to bring that person to Jesus and to salvation in those final weeks, hours, days, and moments. He is speaking to that person in dreams and visions, on the spirit level, perhaps, about the person's eternal destination. We don't want to interrupt that. Pain here is horrible, suffering here is horrible. But an eternity of them will be even worse.

No one here has had the ability to assess this patient except for the op. Therefore we are interpreting the words of the op as we see them. Me, I see a patient who is dying. I have had a few patients who have been on comfort care and eventually pass away basically with the assistance of a morphine gtt. Is this euthanasia? Exactly how is it different? I never feel like I'm killing anyone. Is it ok because the person has said they don't want other interventions and are dnr/dni? Do the poster's here know what end stage alzheimers looks like? Does the op have the experience and assessment skills to properly assess the situation? We are all speculating here, which is not good nursing judgement. If it was my patient and I felt like the family or doctor didn't have the patients best interest at heart would I act differently and make different decisions? Absolutely. i am a nurse, and that is a huge part of my job. Patient advocate. People get on here with their :angryfire and:uhoh21: for absolutely nothing. I really hope that your bp didn't rise over a post on all nurses .com. If so, perhaps you have some soul searching to do. For none of us have enough information to make a really sound judgement about this patient either way. We don't have a good picture or the right data for this patient. I commented based on the mental picture that I got from reading previous posts.