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
I work in ICU, and we've got a strong dose of the "fix it" gene in play, just like ER....it's broke, let's fix it. But there are things we can't fix...the fix is, we send them home on hospice.
I've got no problem giving a dying patient pain meds to keep them comfortable, and yes, sometimes it may mean they live 30 minutes less than they would have otherwise. But we can't cure what's wrong, we can only try to keep them as comfortable as we can until nature takes its course. Thanks for thinking of your patient's comfort and well being.
you did the right thing - the family wanted him to have his pain controlled, and you noted he appeared to be in pain. Some might argue that this hastens his passing, but what else can you offer someone who is terminal, on comfort measures? Pain control, warmth.... = comfort. Those who have problems with this order should try to understand being in pain and dying and someone withholding pain medication based on their opinion it may hasten their death. Do you not help them with their pain? Do you just let them have some pain?? I believe the morphine order is appropriate. I believe nurses should be ok with medicating a person that is dying and in pain. I can't imagine not doing anything in your power to help minimize pain during such a time.
Thank you. You guys have really made me feel better about this. I couldn't imagine doing anything about his pain either. Yes, it might or may hasten death but to me a slow painful death is a scary scary thing!. Thanks again all, I appreciate your help and advice.
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.
all sorts of patients come into an ER - many of whom are dying and were hospice patients, brought to the ER because the family didn't want them dying in the home. I have seen Morphine orders like this. It is not unusual.
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
that nurse that told you that needs some education. Of course Morphine suppresses respiration, but eases pain. What is with that nurse??!?!!? We don't need that in our profession.
Specializes in PICU, NICU, L&D, Public Health, Hospice.
Thank you for stepping forward to provide the needed care for this guy...
Keep this in mind...even people who have NO opiates on board may have significant bradypnea at end of life...
Even those hospice patients fortunate enough to have no pain will still stop breathing...
All patients that I have cared for, in all age groups from birth to geriatrics, experience some change in their level of consciousness near time of death...regardless of opiate use. I don't recall ever having seen a human die without experiencing some change in their respiratory pattern, irrespective of age or opiates.
I am not suggesting that too much morphine can't kill someone...I worked with a young woman who presumably died from a morphine overdose during a hospitalization. I just think that we can more often observe painful patients become comfortable and then bradypneic when larger doses of analgesics are given. Now that we have benefit of portable pulse ox, we know that many people tolerate this just fine, especially if they have some additional oxygen (easy in many settings). Back in the day we just shocked them with Narcan...now we know that we don't necessarily have to be that extreme.
You did good...it was likely not anywhere close to enough to "hasten" his death.
That poor soul. I'm not going to debate on something so fresh, but to extend my thoughts and prayers for the family of said patient. Death is never easy, so if the patient passed on your shift, my condolences for you as well.
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".
Wow! Like MassED stated, that nurse needs some education. #1) I think he was guilty of not trying to alleviate the patient's suffering. Not a crime, but I don't see how anyone could ethically justify such an action. #2) he doesn't understand mso4, especially in a patient with bone mets. I don't work hospice or oncology but I've SLAMMED ~20 mg of morphine on patients who needed it (all terrible burns, I'm not speaking from personal experience, but I bet the pain is excruciating in both) and there wasn't even a dent in their respirations.
I hear you about no animosity in your workplace, but it is also concerning if the nurse actually thought the ER MD was trying to euthanize the patient (which is what it sounds like he was insinuating).
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.
This is the viewpoint I was taught in school by an instructor that worked as an oncology nurses for many years. I think you did the right thing by giving the med.
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!!
No, you are absolutely correct and I applaud you for putting this patient's comfort first and not being pressure by your co-worker.
I attended an ethics seminar once that was joint-taught by a Medical Director and the Hospital Attorney..whch I thought was a good combination, so if we had legal questions, they could be asked.
The Medical Director told our group is that it was his belief, it is unethical, to leave someone in pain. The definition may not be 100% pain free, but what the patient can COMFORTABLY tolerate and if they are conscious, the ramification of continuing dosages.
I am sure a Hospice nurse will chime in here...but if someone is terminal and there is no hope for recovery and is in pain that they cannot tolerate it, you treat the pain (with a physicians order) and if that leads to a terminal event (death or respiratory failure), then so be it.
Now, you will find that segment of the population that does not wish for that and are willing to tolerate a huge amount of pain because to them, being conscious while loved ones visit for that one last time is what is important....that is why it is important that the teaching is clear to what the end result may be.
It will vary with each patient.
Some nurses, have a problem with that, they don't want to be the person to give the "last dose"...I personally have no problem with it...if that is what they need to be comfortable, then that is what I am prepared to do.
I'm with the majority - you definitely did the right thing.
We're talking end stage CA here. The patient is dying. If someone questions the morality of administering enough medication to control their pain, my question would be this: Is it more moral to relieve their pain, even if death may come more quickly, or let them die in agony?
nerdtonurse?, BSN, RN
1 Article; 2,043 Posts
I work in ICU, and we've got a strong dose of the "fix it" gene in play, just like ER....it's broke, let's fix it. But there are things we can't fix...the fix is, we send them home on hospice.
I've got no problem giving a dying patient pain meds to keep them comfortable, and yes, sometimes it may mean they live 30 minutes less than they would have otherwise. But we can't cure what's wrong, we can only try to keep them as comfortable as we can until nature takes its course. Thanks for thinking of your patient's comfort and well being.