Pain Medicine for a dying patient ...

kc ccurn · Jan 7, 2004

Originally posted by janfrn

A few weeks ago, I held an infant in my arms as he died. He had come into this world with scrambled anatomy and had undergone two open-heart procedures, a prolonged arrest, ECMO, numerous ischemic events, perforated his bowel and bled into his brain. In the pediatric world, DNR is often very difficult to sell to the docs. This boy had been deemed "no escalation of treament" but still got the occasional epi bolus when his BP drifted too far for the doc's comfort. All of us nurses were torn by this poor wee lad's struggles. Finally, his very young parents decided enough was enough and asked for a withdrawal of treatment. They took turns holding him, then left before the final acts were performed. I came on only minutes after he had been extubated. He had been given Ativan and fentanyl to ease his suffering. He lay in my arms, warm and heavy, eyes open and gazing up at me. We rocked and cuddled for half an hour before he sighed and passed. That half hour was likely the most comfortable and peaceful of his tumultuous brief life. I feel very privileged to have been there with him at the end.

janfrn, I have tears in my eyes. What a honor and privilege it was indeed! It's in those special moments as a nurse that makes all the ugly of the job go away. It is never easy when a patient dies, especially a little one, but to be able to ease the pain and hold him as he passed is a feeling that not many people know or understand. Thank you for taking such loving care of him, and all your patients!

Home Health Columnist / Guide · Jan 7, 2004

From ANA Position paper, published 1991:

Promotion of Comfort and Relief of Pain in Dying Patients

Summary: Nurses should not hesitate to use full and effective doses of pain medication for the proper management of pain in the dying patient. The increasing titration of medication to achieve adequate symptom control, even at the expense of life, thus hastening death secondarily, is ethically justified.

Nursing has been defined as the diagnosis and treatment of human responses to actual or potential health problems (American Nurses Association, 1980). When the patient is in the terminal stage of life when cure or prolongation of life in individuals with serious health problems is no longer possible, the focus of nursing is on the individual's response to dying. Diagnosis and treatment then focuses on the promotion of comfort which becomes the primary goal of nursing care. One of the major concerns of dying patients and their families is the fear of intractable pain during the dying process. Indeed, overwhelming pain can cause sleeplessness, loss of morale, fatigue, irritability, restlessness, withdrawal, and other serious problems for the dying patient (Spross, 1985, Amenta, 1988, Melzack, 1990). Nurses play an extremely important role in the assessment of symptoms and the control of pain in dying patients because they often have the most frequent and continuous patient contact. In planning nursing care of dying patients, "the patient has a right to have pain recognized as a problem, and pain relief perceived by the health care team as a need." (Spross, McGuire, Schmitt, 1990).

More info:

http://nursingworld.org/readroom/position/ethics/etpain.htm

webblarsk · Dec 6, 2004

A few weeks ago, I held an infant in my arms as he died. He had come into this world with scrambled anatomy and had undergone two open-heart procedures, a prolonged arrest, ECMO, numerous ischemic events, perforated his bowel and bled into his brain. In the pediatric world, DNR is often very difficult to sell to the docs. This boy had been deemed "no escalation of treament" but still got the occasional epi bolus when his BP drifted too far for the doc's comfort. All of us nurses were torn by this poor wee lad's struggles. Finally, his very young parents decided enough was enough and asked for a withdrawal of treatment. They took turns holding him, then left before the final acts were performed. I came on only minutes after he had been extubated. He had been given Ativan and fentanyl to ease his suffering. He lay in my arms, warm and heavy, eyes open and gazing up at me. We rocked and cuddled for half an hour before he sighed and passed. That half hour was likely the most comfortable and peaceful of his tumultuous brief life. I feel very privileged to have been there with him at the end.
Give the meds. Please.

Although a year later...................what a awesome story! Brought tears to my eyes. So nice to know there are still compassionate people out there!

AFWife · Dec 7, 2004

This is how my DH's grandpa went. He was end-stage, terminal cancer....had refused any treatments from the time he found out he had lung cancer. They just kept upping the pain meds, knowing the outcome. It's what he wanted. But he was unconscious at the end.

Hellllllo Nurse, BSN, RN · Dec 7, 2004

With the scenero stated, I would provide the pain medicine without hesitation.

Agree.

Hellllllo Nurse, BSN, RN · Dec 7, 2004

Wonderful, janfrn.

stbernardclub · Dec 7, 2004

.... pt is near death and is a dnr, i would give the pain medication to ease the pt's discomfort. Its one of the few things at this point that you can do for the patient...when the time comes for death, as a nurse,i would not even think about the why's??? I would be feeling good in knowing the person did not suffer.

with unstable vital signs. The patient is very near death and is a DNR.
A scenero such as a patient that is actively dying, vitals signs are poor, bp low, heart rate low, respirs low. The patient is moaning. The family says give him something, and you have doctors orders. You know the pain medicine may slow the respirations down too low and you're nervous it may even stop the respirations, but you know the patient is in some kind of distress, perhaps pain (say in a terminal cancer patient who prior to this has been in a lot of pain for months). You may even call the doctor to clarify orders, who says give it now. Do you give the pain medicine?
This is not a question about euthanasia, it's about pain and comfort measures. Is it going too far?

ICUnowOHN · Dec 7, 2004

I just did the very thing with my Mom. Terminal Brain Ca. MS04 2-20mg PRN

Hospice pt by the way. We had her at home. I gave her every bit of MS I could. And, I don't remember who said this earlier, but she was comfortable enough to go ahead and die. She was unresponsive except to painful stimula i.e. turning, and repositioning. I know that I did her the greastest favor I could have. I made her comfortable enough to die, in peace.

Did the same thing 3 weeks to the day later with my Grampa. Terminal rectal Ca. had duragesic patch, and PRN MS04. I had to strongly suggest to his nurse that she give it to him. once again, I had him suctioned so he wasn't struggling to breathe, and given his 3mg MS/hr PRN and, not 10 minutes later, he sighed and passed on.

In both cases, they deserved to die as peacefully as possible, and I'm proud to say that I was there, and made sure they got what they needed.

WE are the patient advocate, even if the pt is your mom, or grampa, or a total stranger. Give the meds !

UM Review RN, ASN, RN · Dec 7, 2004

I'll never forget one patient. Though in her 90s, the family was in quite a bit of denial about her terminal status. She was in obvious pain, yet the family didn't want her "overmedicated." After several go-arounds with them, explaining that the patient needed adequate pain control, the MSO4 was given, and the patient able to rest.

A family member then came out and said to me, "I'm so glad you gave that, it actually looks like her heart is beating better. Maybe she'll pull through..."

What is really needed is legislation that takes all that power away from the families when there is a Living Will or Advance Directive in place for the patient, because it is worthless as soon as the patient is no longer lucid.

jaimealmostRN · Dec 7, 2004

with unstable vital signs. The patient is very near death and is a DNR.
A scenero such as a patient that is actively dying, vitals signs are poor, bp low, heart rate low, respirs low. The patient is moaning. The family says give him something, and you have doctors orders. You know the pain medicine may slow the respirations down too low and you're nervous it may even stop the respirations, but you know the patient is in some kind of distress, perhaps pain (say in a terminal cancer patient who prior to this has been in a lot of pain for months). You may even call the doctor to clarify orders, who says give it now. Do you give the pain medicine?
This is not a question about euthanasia, it's about pain and comfort measures. Is it going too far?

This is the Principle of Double Effect. The good effect (easing pain and respiratory distress) outweighs the bad effect (possible death). This is considered OK (even good) by the Nursing association, whereas euthansia/assisted suicide is considered wrong (NPs shouldn't prescribe the drugs, RNs shouldn't assist in administering them) even in places like Oregon where it is legal...

aimeee, BSN, RN · Dec 11, 2004

There is a broad consensus that when used appropriately, respiratory depression from opioid analgesics is a rarely occurring side effect. The belief that palliative care hastens death is counter to the experience of physicians with the most experience in this area. No studies have shown that patients' lives have been shortened through the administration of appropriate pain medication.

From:

The Double Effect of Pain Medication:

Separating Myth from Reality

SUSAN ANDERSON FOHR, J.D., M.A.

http://www.hospicecare.com/Ethics/fohrdoc.htm

nursemary9, BSN, RN · Dec 11, 2004

I just did the very thing with my Mom. Terminal Brain Ca. MS04 2-20mg PRN
Hospice pt by the way. We had her at home. I gave her every bit of MS I could. And, I don't remember who said this earlier, but she was comfortable enough to go ahead and die. She was unresponsive except to painful stimula i.e. turning, and repositioning. I know that I did her the greastest favor I could have. I made her comfortable enough to die, in peace.
Did the same thing 3 weeks to the day later with my Grampa. Terminal rectal Ca. had duragesic patch, and PRN MS04. I had to strongly suggest to his nurse that she give it to him. once again, I had him suctioned so he wasn't struggling to breathe, and given his 3mg MS/hr PRN and, not 10 minutes later, he sighed and passed on.
In both cases, they deserved to die as peacefully as possible, and I'm proud to say that I was there, and made sure they got what they needed.
WE are the patient advocate, even if the pt is your mom, or grampa, or a total stranger. Give the meds !

Yes, the same with my Dad. He was a hospice patient also. I'm so glad he was allowed to pass on with the dignity he always had in life thanks to

duragesic and roxanal. My dad was also at home, with my Mom & I at his side.

Mary Ann