Syringe driver terror

ladyandthetiger · Aug 21, 2017

Consider this - a bad way to die in medical hands is an all in, full heroic measures advanced life support resuscitation attempt. The patient lives there while person after person punch them in the chest, while others stab them repeatedly with sharp objects (cannulation attempts, arterial blood has sampling, maybe even a couple of tries with a bone gun). We repeatedly administer electric shocks powerful enough to cause burns and their body to spasm painfully - especially if they have a few broken ribs.

Pain relief and sedation don't scare me - I'll take that over a resus any day.

KelRN215, BSN, RN · Aug 21, 2017

Yes, we don't call them that at our facility... if they are using a syringe full of morphine, fentanyl or some kind of "caine" we call it a PCA. Anesthesia uses them to keep giving a steady drip of propofol in the OR.
I had a patient once that was using a PCA and the amount of morphine he was getting per hour would have taken down baby elephant... but he had been on morphine so long and was in serious pain that he was still awake and talking. It's not the medication that killed him... it was the brain tumor. By keeping the morphine PCA continuously giving him morphine and then allowing him to bolus himself (and clinician boluses on top) we allowed him to spend some valuable time with his family, rather then writhing in pain.

I will always come back to my 8 year old, 24 kg patient who was on 100 mg of morphine AN HOUR with 10 mg boluses available q 10 min PRN at the end of his life when this topic comes up. The normal dose of morphine for a (non-palliative) child is 0.05-0.1 mg/kg q 2-4 hrs. In one hour, this child was getting approximately 4x what a child his size would normally receive in a day. He lived for DAYS on this dose of morphine. He was on continuous ketamine and high doses of ativan in addition to this. Our PCAs couldn't handle the doses of morphine he was on (PCA syringes were either 30 or 60 mg of morphine) so we needed to use an epidural pump hooked up to his PICC line and Pharmacy had to make special bags of morphine for him. I never felt any qualms about how we were treating him. His aggressive brain tumor was killing him. Either we were going to keep him comfortable or he was going to suffer. It's as simple as that. The only logical and compassionate option is to keep him comfortable.

Tenebrae, BSN, RN · Aug 21, 2017

Hello
I know that there will be allot of people disagree with me here
Am I only nurse that is quite simply terrified of syringe drivers?

Dunno

If I had a choice, I'd much rather manage a syringe driver instead of an IV pump. If the sub cut line needs to be changed its usually a hell of alot easier to get subcut access than IV access with many people

I just feel like I'm helping someone die. I didn't want to be a nurse to help someone die.. I wanted to be able to provide comfort and health..

A key word in your sentence is comfort. if a person has a terminal diagnosis or other life limiting illness, every patient I've dealt with in my five years of nursing has specified among other things the desire to be comfortable when their death comes.

Are they really agents of death?

They are tools to provide symptom management and hopefully increase a patients level of comfort and make their final time on earth as peaceful and stress free as possible.

In a community setting I've seen them used with patients with intractable nausea that simply couldn't be controlled with oral antiemetics as well as symptom management in the last days when a person is unable to take oral medications or isn't getting sufficient relief from oral medications.

How can you make peace with it all ?

Even before my mum was diagnosed with stage four lung cancer and my brother in law was diagnosed with pancreatic cancer, my approach to their use was governed by the thought "if this was my family member I would want to know that everything possible was being done to help them.

Please help me.. If got to get involved with it all tomorrow and I can't sleep..and I'm on the verge of a panic attack already..
Milly

The first time I ever placed a subcut line was in a house of a palliative patient with all their family around. I was about four months out of nursing school and post registration. There is an old adage "fake it until you make it". Apparently the patient or their family didnt know I'd never done it before because I got really high compliments.

I was terrified the first time as a student when I had to deal with a dying person. My preceptor gave me some excellent advice which I have followed since then. "Your patients and their family need you to be strong for them and keep it together for them. That doesn't mean you may not want to duck into the utility room and have a wee cry and stamp your feet, however then you have pull up your big girl britches and get back out there"

And sometimes you may need to get some chocolate on the way home from work, I was a big fan of blasting out my favourite head banging musical playlist.

Its critical to find a way to leave this stuff in the work place. Nursing is already stressful enough without carrying to weight of people who have died or are in the process of dying

Tenebrae, BSN, RN · Aug 21, 2017

I'm thinking it's like a PCA without the patient controlled part. Like a PCA with a basal rate only.

https://www.infusystem.com/images/manuals/Niki%20T34.pdf

These are the ones we use

Tenebrae, BSN, RN · Aug 21, 2017

I had hoped for some encouragement..
Iv hardly slept. Can hardly breathe and I just want to cry.. Hoping beyond all hope that I manage to survive today without a panic attack.

If you wanted me to hold your hand and justify your anxiety over what is essentially a tool to manage symptoms, sorry lovely it wont happen.

If you want some strategies around their use in palliative care, happy to help

Tenebrae, BSN, RN · Aug 21, 2017

When I first started working oncology I asked one of the experienced nurses how she got used to seeing all of the death. She said, "They will die whether I'm here or not. Because I'm here I get to ensure they're dying a comfortable and dignified death. That's an honor and a privilege."
It's really that simple.

:yes:

This, a thousand times

MaleICURN, BSN · Aug 21, 2017

I will always come back to my 8 year old, 24 kg patient who was on 100 mg of morphine AN HOUR with 10 mg boluses available q 10 min PRN at the end of his life when this topic comes up. The normal dose of morphine for a (non-palliative) child is 0.05-0.1 mg/kg q 2-4 hrs. In one hour, this child was getting approximately 4x what a child his size would normally receive in a day. He lived for DAYS on this dose of morphine. He was on continuous ketamine and high doses of ativan in addition to this. Our PCAs couldn't handle the doses of morphine he was on (PCA syringes were either 30 or 60 mg of morphine) so we needed to use an epidural pump hooked up to his PICC line and Pharmacy had to make special bags of morphine for him. I never felt any qualms about how we were treating him. His aggressive brain tumor was killing him. Either we were going to keep him comfortable or he was going to suffer. It's as simple as that. The only logical and compassionate option is to keep him comfortable.

I had a beautiful 23 months old girl. Trach, vent. Unable to breath on her own, vent on AC mode. Days by days, rather hours after hours her PIP increased, finally reaching > 50 cm H2O. Family decided to withdraw treatment. We placed her on Fentanyl drip. In maybe 2 hrs she was gone. Having her that night only as one patient, I was happy, when my Charge Nurse sent me home after "all". It was probably my most difficult to accept night. I drove home with tears in my eyes. It happens few years ago, but I still remember HER.

MunoRN, RN · Aug 21, 2017

I know my view isn't going to be popular, but I think you may lack the minimal competency for caring for this patient group, I do give you credit for trying to take steps to remedy that lack of competency.

You seem focused on the syringe driver, which is just an IV pump that infuses from a syringe instead of a bag. You seem concerned about the peak effects of a drug like morphine, yet the whole point of giving a continuous infusion via either pump or syringe driver is to reduce the peak effects of the drug and instead give a continuous effect with less peaks and troughs.

ladyandthetiger · Aug 21, 2017

Adequate pain relief is not euthanasia. This debate was settled in the 1970 -1980's thankfully!

Would you prefer the era when Drs withheld adequate pain relief from the terminally ill because "they might get addicted" or the drugs might lead to their death?

This may not be the right field for you if you are unwilling or unable to care for the dying on their terms instead of yours.

Susie2310 · Aug 21, 2017

milly, We are all different in terms of the areas of care where we feel most comfortable and best suited to. For example, some people thrive in the ER, ICU, psych, hospice, home health, pediatrics, etc., while other people find these areas (or others) too stressful or not suitable for them for a variety of reasons. If you come to the conclusion that this is not an area that is suitable for you, there are other areas of nursing.

Best wishes to you.

Knotanoonurse · Aug 21, 2017

I agree with everyone else - we don't euthanize humans in this country, and I assume you do not work on death row administering lethal injections.
That being said, why would providing comfort to a dying patient induce such hysteria? Take a deep breath. Now another ...
If you don't feel comfortable working with dying patient's there must be other nursing options better suited to your preferences and comfort level.
I've seen some mighty uncomfortable patient's attempting to transition from the mortal plane to the spiritual one - it is sometimes painful and anxiety provoking. Those people deserve comfort and a calm level of caring.
Maybe it's death itself that frightens you so much - which I do have to admit sucks. But we all do it eventually.
Might I recommend a wonderful book about death? It was written to help children understand death, but it's so simply amazing for people of all ages that I bought it for my husband a few weeks ago when we had to euthanize our beloved chocolate lab. It's called: Cry Heart, But Never Break. I highly recommend everyone of all ages read it.
It's a story about 4 children who live with their grandmother who has become sick. One night Death comes for a visit, but not wanting to scare the children he leaves his scythe outside. The children know the visitor's identity, and quickly hatch a plan to keep Death distracted by serving him coffee all night - if they succeed when the sun comes up he will have no choice but to leave empty handed.
Death is on to their plan, but is happy to sit for a while and just relax. Death is not cruel, and he has a very loving heart. When Death finally signals no more coffee the youngest asks why he must take their beloved grandma? Death tells the children a story about grief and joy, sorrow and delight to try to make them understand death is every bit a part of living as life is.
Death then goes upstairs, opens the window and tells the soul to fly and be free. The children all run upstairs to their grandma's room, but she is already gone. It is at this point Death tells the children they will have many joys and losses in life, and it's here he says the title of the story: Cry Heart, But Never Break.
Of course I shed tears after reading it, but I wasn't crying - I just had a picture book in my eye!

Sounds amazing. Thanks so much. When I 18, I worked as a nursing assistant on a cardiac floor. I was scared of death. After six more nuts or so, I. And to understand what the nurses meant when they said there things much worse than death.

I know people hate nursing theory, but I always think of Oren's self Care deficit theory. We are here to help people do what they would do for themselves if they could. Your dying patients can't control their pain. That is where you come into meet their needs. You are the to walk beside them. Only they take the final step. If this is not a good fit for you, there are many other options. All the best to you! â¤ï¸

luvmyc · Aug 22, 2017

Consider this - a bad way to die in medical hands is an all in, full heroic measures advanced life support resuscitation attempt. The patient lives there while person after person punch them in the chest, while others stab them repeatedly with sharp objects (cannulation attempts, arterial blood has sampling, maybe even a couple of tries with a bone gun). We repeatedly administer electric shocks powerful enough to cause burns and their body to spasm painfully - especially if they have a few broken ribs.
Pain relief and sedation don't scare me - I'll take that over a resus any day.

I couldn't agree more! Exactly why I made the decision I did.