Parameters for Morphine

[CapeCodMermaid, RN]

OKAY, here's the story. First let me say that I think Hospice is a wonderful benefit and have no problem calling them in for my residents who are appropriate.

That said...I have a resident who is 94 years old and at the end of her life. She was very agitated and having some respiratory distress so the Hospice nurse suggested Ativan and Roxanol as a standing dose and said the son wants her "well medicated". Yesterday, one of the nurses came to me and told me the woman's respiratory rate was 6. She was calm, and appeared to be in no pain and have no distress of any kind. She told me she wanted to hold the Roxanol and Ativan as the woman was barely responsive and in no apparent distress. I agreed with her and she held the meds. The woman continued in that state. The hospice nurse came in, looked at the records and started hollering about withholding pain medication from a patient who was going to die. I explained to her that we(who are there ALL the time, not 5 minutes out of the day) assessed the woman and found her to be neither agitated nor in pain or resp. distress. The hospice nurse started to tell me that the hospice philosophy is to medicate regardless with NO parameters and how dare we not give this woman her meds...so I said we would never give meds to someone who had a resp rate of 6 who was in no distress. She told me she was going to call the hospice medical director to see what he said.

The patient's nurse practitioner was there, assessed her and came to the same conclusion I did. The woman was in no distress. We have the med available and certainly if she needs it she'll get it.

Am I wrong? Do all y'all keep giving Morphine with a resp rate of 6 and no signs of distress? The last pain inservice I went to which, by the way, was given by a hospice nurse practitioner, said the standard of care would dictate that we write orders with parameters to hold morphine for a resp. rate of less than 8 unless the patient was exhibiting s/s of distress or pain.

Comments?

[CoffeeRTC, BSN, RN]

You totally did the right thing. We don't have paramaters, but looking at her comfort level I would not have given it. Not to bash anyone, but how experienced was that hospice nurse?

[Hellllllo Nurse, BSN, RN]

I would have continued the MS, but at a lower dose. I would have held the Ativan.

The woman's pain could come back and be much worse than it was to begin with. I have seen this happen.

I feel it is better to back off on pain meds rather than D/C them.

[sirI, MSN, APRN, NP]

I would have continued the MS, but at a lower dose. I would have held the Ativan.

The woman's pain could come back and be much worse than it was to begin with. I have seen this happen.

I feel it is better to back off on pain meds rather than D/C them.

I tend to agree here. You would need rather astute assessment skills to say with any degree of certainty the patient was pain-free. And, when the pain returned, you would be fighting an uphill battle to control it; all the while the patient would be in agony. My experience has been to taper the MS, not completely hold it.....JMHO.

[CoffeeRTC, BSN, RN]

Okay...I would agree with the above. Never DC it. I would hold and definateley keep assessing. Ditto on the rebound pain. Keeping a steady level of pain meds so that you don't have to fight to get it back under control.

[Laurell28]

I would hold the Ativan but I would give the MS to maintain the comfort level that she had. If someone is premorbid or actively dying you would expect to see less responsiveness and lowered respirations. The attitude of the hospice nurse concerns me. She should have listened to your concerns and discussed them with you in a professional manner. Taking care of any person, espescially a dying person, is a team effort and all members and their input are valuable.

[sjrn85]

While the hospice nurse shouldn't have yelled at the staff, the staff should have contacted hospice first, instead of just witholding the meds. The hospice nurse could have given advice as to how to proceed.

I used to work in hospice, and I can tell you that while I may not have yelled, I would definitely have been upset to find out that a patient's meds were held without hospice being notified. Keeping pain under control, especially in the dying pt., is very difficult. Why bother even having hospice involved if the ECF staff is just going to go ahead and do whatever they think is right?

I have had the misfortune of dealing with this very situation, and believe me, it is no treat to have to try and get someone's pain back under control when non-hospice staff decided that the pt. "didn't need the meds."

Next time, call the hospice nurse first.

[sjrn85]

Forgot to add that the objective is for the pt. to remain comfortable, not have to demonstrate pain in order to be medicated.

It sounds like you have some issues r/t working with hospice nurses (e.g. the somewhat snarky comment about the hospice nurses only being there for "five minutes.") I find it hard to believe that the hospice nurses spend only five minutes with their patients. And while you may be with that particular pt. all day, please realize that hospice nurses see nothing but hospice pts. all day long, so they really are the experts in care of terminally ill pts.

Certainly, if something doesn't seem right, you should ask questions. But it's really not appropriate to just go ahead and do your own thing. Also realize that you don't worry about resps. in a dying pt.; the primary objective is to maintain comfort. It's far different from a pt. who isn't dying, when you do need to be more attendant to parameters such as RR.

Perhaps your facility could have a local hospice come and give some inservices about pain mgmt. to the staff. That may help alleviate some of the concerns you and your co-workers have regarding medicating the dying pt.

[doodlemom]

As a hospice nurse, I would say that the hospice nurse in question acted inappropriately by yelling at you. Our role should be of support to the staff at your facility as well as being advocates for the patient and family. I would encourage you to call hospice before holding any meds and get their advice the next time this happens. In my humble opinion, if this patient was peaceful and with no respiratory distress, I would not have kept giving her her meds and then I would have watched her closely for any inkling of agitation or increased respirations...and given the med appropriately. If thisvpatient had been taking the meds for a great deal of time, then I probably would have wanted to continue the meds at a lower dose. If that was the case, then I would have just cut back on them. Did this patient start having respiratory distress again after the meds were held for a while? When the hospice nurse came in, was the patient comfortable - or was the nurse reacting to the patient being uncomfortable?

While hospice is generally regarded as pain and symptom management experts, not all hospice nurses are "old hat" at it. I've been doing this for a long time and have come across nurses who have (admittedly) never been trained well and have been practicing on what they've read in books. If they don't have good support, then a great deal of time they're on their own. Unfortunately, many hospices don't offer very good training and support to their staff. Just my 2 cents...

[CapeCodMermaid, RN]

Snarky???? Perhaps 5 minutes was a tad of an understatement, but I've known this patient on and off for YEARS. While we value the contribution some hospice nurses make to our patients care and comfort, they are still our patients and we must trust our assessment skills. We've had many pain inservices with the hospice nurses. Their own pain "expert" says to write parameters for morphine.

By the way, the woman has remained peaceful without any distress or pain. She has been assessed and has been given morphine when needed to maintain her comfort.

[Nurse_Pauline]

I find this issue very difficult for many nurses to deal with. No one wants to give the "last dose"of Morphine and hold the med because of a low resp. rate or because they "looked" comfortable. Personally, i would never hold Morphine, despite the rr,and i hope that when im the one that is close, a nurse will feel the same way i do and keep me comfortable. That being said, i would never force my opinion on another nurse. If they feel uncomfortablegiving the med, i would discuss the reasons why it could/should be given and if they felt the same way about it, id suggest holding the Ativan or give the morphine myself.The hospice nurse should not of responded that way, but now you can take the opportunity to open the lines of communication between the facilty and hospice staff.