Question about morphine

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Specializes in ER, ICU, Medsurg.

I'm going to post this in here as well as in Hospice because I don't know where I would get the best response. Thank you all in advance.

I am currently an ER nurse (new grad May 2010). We had a patient come into the ER Friday and Saturday night in end-stage metastatic bone cancer. After much ado all weekend, the family had decided to involve Hospice (I will spare you the details). The doctor ordered 2mg of Morphine to be admin q5 minutes until pain management is achieved. The nurse who was supposed to have this patient was having a hard time with this and I offered to take over the patient for them (also for continuity of care, since I had had him the previous night). Pt respirations were 8- 10 with periods of apnea. BP was ranging between 62/46 and the highest I saw was 99/54. The patient was undeniably in pain. This raised a lot of question about the appropriateness of the morphine between our ER supervisor and the nurse I took over from. I myself, believed (and confirmed by the family) that this patient did not want to be in pain. Personally, I also believe that when pain is relieved, the disease process can take over. The ER physician and I shared the same viewpoint.

Was I wrong in following this order? Are my co-workers in the "save life" mode from being in ER so long? Not saying either opinion is right or wrong, just trying to figure this all out

Thanks in advance for your input and advice!!

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Specializes in hospice, corrections.

Morphine is a wonderful drug for pallative pain control. I've not seen orders like this, and would be interested in what the orders were once pain control was achieved. Our hospice standing orders are up to 15 mg per hour subcutaneous morphine. We titrate for non-verbal signs of pain. If that isn't enough to achieve pain control the doctors can order a CADD pump that can continuously give subcutaneous morphine with a patient operated bolus amount. Thank you for taking care of that patient. Pain control is a huge issue for end of life care and I do not think there is enough educaction about it.

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Well, I believe she knew morphine would affect the R/R, which were already compromised. The goal of the intervention with morphine was to relieve the serious pain in this case, which was very important. It could be a number of things that were factors in the nurse's emotional response. I doubt seriously "the save life" concept was at the most of her concerns. You might want to have a discussion with her, and just see what her views were with this case.

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Specializes in Emergency, Trauma, Critical Care.

I"m just curious as to why an ER nurse would have a hospice patient? It seems to me they would try to get the patient to a medical floor where hospice patients usually reside? Not every nurse is comfortable with giving a lot of morphine, some feel that they are "encouraging" the patient to go and they got into the business to save lives. This is more of a moral/ethical perspective that is variable among all medical professionals. Good of you to take over the patient.

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Specializes in ICU, PICC Nurse, Nursing Supervisor.

i am a inpatient hospice rn...morphine has no ceiling so the dosage can go high. many times i have titrated morphine up for the patients comfort . it is not uncommon at all especially in ltc and hospice to see a q5 min order for morphine. to be honest with you 2 mg of morphine isnt nothing and when i hear nurses refusing to give this it makes me sad that people just dont understand morphine and death and dying. there have been patients we have had to give 20-30 mg ivp to just to stabilize their pain then they go on a pump..in my opinion you did the right thing but sounds like he needed more like 5 or 10 mg every 5 minutes until he was comfortable....i hate to see people in pain

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Specializes in Oncology; medical specialty website.

You did a great job.

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You did the right thing pharmgirl!

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Specializes in PACU, OR.

Completely off-topic, but may I congratulate txspadequeen on that hilarious avatar? Brilliant, just what I needed after a very trying day. Thanks for the laugh! :lol2:

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Specializes in Critical Care/Coronary Care Unit,.

Well you have to remember that almost all of us non-hospice nurses are in "save lives" mode, especially ER nurses. Of course, the end-stage cancer patient has a right to be pain free and giving the morphine wasn't a problem...b/c they probably needed more. As far as your co-worker not wanting to give it..she was probably just uncomfortable and perhaps just needs some more education regarding palliative care. I'm not an ER nurse, but I'm guessing it's not something you guys probably comes across that often. :)

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Specializes in ER, ICU, Medsurg.
I"m just curious as to why an ER nurse would have a hospice patient? It seems to me they would try to get the patient to a medical floor where hospice patients usually reside? Not every nurse is comfortable with giving a lot of morphine, some feel that they are "encouraging" the patient to go and they got into the business to save lives. This is more of a moral/ethical perspective that is variable among all medical professionals. Good of you to take over the patient.

The called EMS to bring the patient to the ER on Friday because "he was having trouble swallowing". Well, yes, he was definately having a trouble and therefore, unable to take his pain medication and therefore, had zero pain control. Personally, I believe that the family was unwilling to admit to themselves that we were pretty close to the end. They were not with hospice at the time. We tried to hook them up with hospice Friday night and had a mixed reaction (one family member had a syncopal episode and the other 15 members began crying....loudly). Saturday when they returned, I believe they had had some time to digest things and were willing to try hospice. So we were successful in getting them admitted to hospice and get them ALL the support they needed. However, at the onset of things Saturday night, they were there just to have him admitted to medsurg. Once we explained to them that he would be able to go home, they were more than happy.

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Specializes in ER, ICU, Medsurg.
Well you have to remember that almost all of us non-hospice nurses are in "save lives" mode, especially ER nurses. Of course, the end-stage cancer patient has a right to be pain free and giving the morphine wasn't a problem...b/c they probably needed more. As far as your co-worker not wanting to give it..she was probably just uncomfortable and perhaps just needs some more education regarding palliative care. I'm not an ER nurse, but I'm guessing it's not something you guys probably comes across that often. :)

It definately is not something we come across a lot in the ER. And you are right, we are in the save lives mode. I think it is totally a moral/ethical issue, I did have a talk with the other nurse and he stated that the ermd's intention was to suppress respirations. I said no, the ermd's intention was to suppress the pain. The nurse said "same difference". Don't get me wrong, there is no animosity about this at work. I am just trying to get a grip on it all.

I actually took great pleasure in taking care of this patient. I've learned a little about myself in this process and am researching Hospice more. I think I really might enjoy this type of nursing

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Specializes in ER, ICU, Medsurg.
i am a inpatient hospice rn...morphine has no ceiling so the dosage can go high. many times i have titrated morphine up for the patients comfort . it is not uncommon at all especially in ltc and hospice to see a q5 min order for morphine. to be honest with you 2 mg of morphine isnt nothing and when i hear nurses refusing to give this it makes me sad that people just dont understand morphine and death and dying. there have been patients we have had to give 20-30 mg ivp to just to stabilize their pain then they go on a pump..in my opinion you did the right thing but sounds like he needed more like 5 or 10 mg every 5 minutes until he was comfortable....i hate to see people in pain

i agree txspadequeen, 2mg was nothing. this patient was used to a lot more! in total we ended up giving him 15mg, which he still prolly could have used more.

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