The idea of prolonging suffering is horrifying to me. Being forced to care for pts with GCS 3, no movement to any stimuli with multiple skin tears and pressure ulcers makes me HATE my job. Mind this is the family refusing to change code status for their own selfish reasons, the opposite of pts wishes the majority of the time.
If I was a decent writer I'd love to write an article/story of sorts titled "dying isnt always a bad thing" as told by an ICU nurse. Depriving palliative patients of end of life medication is selfish and cruel.
Specializes in MCH,NICU,NNsy,Educ,Village Nursing.
OP, I mean this in the most gentle way possible - it is not to be rude or to imply that you are a bad nurse. I'm sure you are a fine nurse.
But...are you sure that palliative care is the right specialty for you? You seem to have a lot of conflict about it. You also don't seem to have a very clear understanding of what palliative care is and what end-of-life care involves. Maybe a different specialty would allow you to have more job satisfaction and better sleep?
My thoughts exactly. OP....maybe it would be better for you t change specialty since this seems to be causing you much angst.
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.
Death is a part of life. I am comforted by the fact that many meds we provide comfort measure/ "actively dying" patients make them more comfortable. I hope that by talking to the patient (if family can not be there) they know they are not alone & dont have to be in pain or have trouble breathing.
I think you really need to examine your feelings on dealing with this population a little better. If the patients and /or their families can become comfortable with this difficult decision, you may needbto reflect on your personal difficulty. If a patient is dying & chosen to end treatment and/ or accept comfort measures, I would wonder why you professionally cant accept that decision.
If you truly question the order than ask the doctor about dosing or speak to your coworkers.
I gave my own father morphine around the clock until he eventually passed. He had stage IV squamous cell carcinoma with mets to the lungs and bones. I don't regret it and I don't feel that It hastened his death. He was in agony prior to getting morphine and ativan on board. Please try to understand that these folks are going to die, with or without medication. The medication simply makes the process bearable.
I have continued to follow this thread, lack of technology has prevented me from commenting further.
I have recently started a new role, and there is small proportion of my work is Palliative care. I know that I am good at my job, and I have a good raport with my patients, and in my previous role my manager in an appraisal did remark that I had an exemplary bedside manner. I know I can be good in this job, but I also realise that this means I have to face my issues in respect of Palliative care. I am very keen to work through these issues. Hence why I have asked for help.
It would never be my intention to allow people to suffer needlessly. I just want to be safe and be sure that I am not causing harm. Isnt that what we are suppost to do?
When I hear about a patient Iv cared for dying, I do take it very personally, and spend allot of time reflecting about the care Iv given to them..
I have read the thread, and I have issues and queries...
* I note that some of you have spoken about a PCA. I have wondered why patient controlled analgesia devices are not used in Palliative Care, as they are in post surgery care. why is this so? Is this because of the monitoring that would be required?
* Terminology such as 'dying anyway' suggest that we are giving up on our patient, is there any more proactive language used in palliative care. Oddly when people refer to 'stat doses' that sounds more negative, however when refered to as 'PRN medications' sounds more positive.
* I have had lengthy discussions with my piers over the years, some very senior nursing sisters who have, added fuel to my thoughts about the link between these medications and the nearness they are to euthanaisa, I may very well be paraphrasing but they have said that.
* Blase, yes I have witnessed that, one former colleague, once actually said she thought that the morphine she gave must have caused her patients demise as they didnt survive longer than an hour.. and that is only one example of such.
* Someone mentioned sublingual Morphine, is this something used often in Palliative Care, Iv not heard of it?
*What exactly is the dying phase? what things should I look for, I know I dont recognise the symptoms. I am the eternal optomist in these matters.
*It was suggested that giving these PRN doses have peaks and troughs in terms of effectiveness, but syringe drivers are a constant steady flow... Does this suggest that they are safer for the patient?
The people in my new team that Im working with seem to be very kind, and I have even heard one of my Nursing Sisters say that it can take years to adjust and to feel confident with Palliaitve care. I will be having some formal training in due course. I have approached a colleague and asked her to be my buddy interms of having someone to mentor me through this issue. I hope to spend time with specialist nurses and the hospices. I have infact spent time on my holidays reading palliative care text books. Although I have of late learnt that these patients are managed and treated for reversable causes, and there are homepathic pathways to comfort patients, all of which i didnt know.
It would never be my intention to allow people to suffer needlessly. I just want to be safe and be sure that I am not causing harm. Isnt that what we are suppost to do?
If I remember the Nursing Code of Ethics correctly, nurses should provide humane care, whether that care is restoration of health, alleviation of suffering or supportive care at the end of life. The two ethical principles of beneficence (the duty to benefit another) and non-maleficence (the duty to do no harm) should guide us. As I've mentioned before, I don't work with end of life care, but my interpretation of harming the patient would be failing to alleviate pain and other suffering.
I have read the thread, and I have issues and queries...
* I note that some of you have spoken about a PCA. I have wondered why patient controlled analgesia devices are not used in Palliative Care, as they are in post surgery care. why is this so? Is this because of the monitoring that would be required?
I wouldn't be surprised if patient controlled analgesia is used occasionally in pallative care when and if it's suitable. I'm curious though, I get the feeling that you think it would be a better option than a syringe driver. If I'm right, why do you think it would be?
Have you worked with PCA? Are you imagining a scenario where the patient administers a dose only when they experience pain and that the pump is "inactive" for the rest of the time?
The way PCA works is normally that a nurse first administers a loading dose that provides the required analgesia (either by pre-setting the PCA pump to deliver it or by direct administration) and the pump is then programmed to deliver a continuous background infusion. On top of that the patient can also self-administer a bolus dose by pushing a button. You would also normally program a lockout interval/time which means for a certain amount of minutes the patient can't self-administer another bolus dose (the lockout interval is determined the size of the bolus dose, and the pharmacokinetics/pharmacodynamics of the medication. You need to take the time it takes to reach peak plasma concentrations after bolus administration into consideration).
The important thing to realize that the only real difference here is that while both the syringe driver and the PCA will both provide a continuous infusion, the PCA also allows the patient to administer extra medication (the bolus). So unless you want to skip the continuous background infusion on the PCA or set it to a very low and likely insufficient rate/dose and force the patient to experience unnecessary breakthrough pain, you are not eliminating the factor that seems to frighten you.
Another thing about patient controlled analgesia; the patient has got to have the cognitive and physical ability to activate the pump's dosing button. That's not always the case at the end of life. But even if they were still physically able to push the button and had the required cognitive funtion to understand the relationship between pain and the act of pushing the button to activate the analgesic pump dosing function to relieve that pain, would you want them to have to wake up over and over again from pain just so that they could push a button?
*It was suggested that giving these PRN doses have peaks and troughs in terms of effectiveness, but syringe drivers are a constant steady flow... Does this suggest that they are safer for the patient?
Please define safe. I feel despite all the advice and information given in this thread, that your focus is still on your fear of hastening your patient's demise. I wish your focus would be on providing your patient comfort and dignity.
I definitely don't think that you are being deliberately cruel or that you wish pain on your patient, but I do think that your fear of potential adverse effects of opioids is affecting how you address this whole issue.
You cannot adequately treat pain that can be unimaginably excruciating with only PRNs! Undertreating pain in the dying patient to the point that PRNs are frequently needed is in my opinion not humane.
* I have had lengthy discussions with my piers over the years, some very senior nursing sisters who have, added fuel to my thoughts about the link between these medications and the nearness they are to euthanaisa, I may very well be paraphrasing but they have said that
Euthanasia is the act of intentionallyending a life. Did the nurses you have talked to really have the intent to end the patient's lives when they provided pain relief? If they administered the medications with the purpose of ending their lives, then it was euthanasia. If they administered the medication for the purpose of relieving pain, it wasn't.
* Terminology such as 'dying anyway' suggest that we are giving up on our patient, is there any more proactive language used in palliative care. Oddly when people refer to 'stat doses' that sounds more negative, however when refered to as 'PRN medications' sounds more positive.
I'm not an American nurse. We don't use the term "stat" where I work. But doesn't "stat" mean immediately/without delay? Why does giving a medication immediately sound negative but "as needed" sound good to you? The "need" part, means that the patient first has to experience pain, before the medication is needed and subsequently administered. Why put a dying patient through that cycle? (PRNs will still likely be needed, but it shouldn't be the baseline pain treatment method).
* Blase, yes I have witnessed that, one former colleague, once actually said she thought that the morphine she gave must have caused her patients demise as they didnt survive longer than an hour.. and that is only one example of such.
I assume this was a patient who was gravely ill and not an otherwise healthy person receiving opioids for management of pain? A dying person is very likely to die 15 minutes, 30 minutes, 47.5 minutes, 1 hour or 2 hours (or insert any random number of minutes) after receiving morphine. It's not the morphine, it's the disease process. I have no idea how your colleague could decide that the morphine was the culprit. I'm assuming that the morphine your colleague adminstered wasn't the first morphine dose that patient ever received? How did s/he decide that that dose, but not the dose given the previous day or earlier the same day, killed the patient?
I have infact spent time on my holidays reading palliative care text books. Although I have of late learnt that these patients are managed and treated for reversable causes, and there are homepathic pathways to comfort patients, all of which i didnt know.
I'm not sure what you're referring to here? I was thinking that perhaps you meant holistic, but if you mean homeopathy, it has no proven effect at all beyond placebo. There really is no reason to think that it could possibly have any effect since homeopathic remedies competely lack ingredients capable of having a plausible pharmacodynamic mechanism (it's just water) The stuff has been so diluted that nothing of whatever was mixed in the water from the beginning, remains in the solution).
OP, I have to be honest with you. I commend you for trying to learn and reflecting about your work and ethics, but after reading all your posts I worry that there's a risk that your personal fears might get in the way of properly treating your patient's pain.
I have continued to follow this thread, lack of technology has prevented me from commenting further.
I have recently started a new role, and there is small proportion of my work is Palliative care. I know that I am good at my job, and I have a good raport with my patients, and in my previous role my manager in an appraisal did remark that I had an exemplary bedside manner. I know I can be good in this job, but I also realise that this means I have to face my issues in respect of Palliative care. I am very keen to work through these issues. Hence why I have asked for help.
It would never be my intention to allow people to suffer needlessly. I just want to be safe and be sure that I am not causing harm. Isnt that what we are suppost to do?
What do you view as "causing harm"? Treating pain in an end of life patient is not going to cause them harm. These patients are dying. They will die with or without pain medication. The difference is their level of suffering. It really is that simple.
When I hear about a patient Iv cared for dying, I do take it very personally, and spend allot of time reflecting about the care Iv given to them..
This is an odd statement to me. You "take it personally" when a terminally ill patient dies? When you reflect on the care you have given to them, you should reflect that their passing was comfortable and that you were there for them at the end of their lives. EVERYONE is going to die. You are, I am, and every single one of your patients will eventually die. Your palliative patients are in the process of dying now.
I have read the thread, and I have issues and queries...
* I note that some of you have spoken about a PCA. I have wondered why patient controlled analgesia devices are not used in Palliative Care, as they are in post surgery care. why is this so? Is this because of the monitoring that would be required?
They are. In my current role as an infusion liaison, I have sent pediatric patients home to die on a PCA. When I worked in the hospital, our end of life patients were on PCA (though it was really NCA by that point) and continuous infusions.
Monitoring is not required for end of life patients. If someone is actively dying they can be on a PCA with no monitors and no vital signs. We aren't going to intervene for vital sign changes for an end of life DNR patient so there's really no reason to monitor them, unless the family desires to see the monitor.
* Terminology such as 'dying anyway' suggest that we are giving up on our patient, is there any more proactive language used in palliative care. Oddly when people refer to 'stat doses' that sounds more negative, however when refered to as 'PRN medications' sounds more positive.
Do you understand the goal of palliative care? Your focus is on symptom relief, not cure. Accepting that a patient has a terminal illness is not "giving up."
Not that I find this relevant to this discussion but STAT and PRN don't mean the same thing.
* I have had lengthy discussions with my piers over the years, some very senior nursing sisters who have, added fuel to my thoughts about the link between these medications and the nearness they are to euthanaisa, I may very well be paraphrasing but they have said that.
Well, anyone who believes this is just wrong. Analgesia at the end of life is NOT euthanasia.
* Blase, yes I have witnessed that, one former colleague, once actually said she thought that the morphine she gave must have caused her patients demise as they didnt survive longer than an hour.. and that is only one example of such.
Oh for crying out loud. If you give a patient who is dying morphine, it's not the morphine that kills him. It's the underlying disease. The patient is dying. We are not "helping them along." We are easing their suffering at the end of their lives. Please refer back to the first post I made on this thread and my 24 kg patient who was receiving 100 mg of morphine AN HOUR at the end of his life with 10 mg boluses available q 10 min PRN and lived for days on this dose. When he died, he didn't die of respiratory depression from morphine. He died of brainstem herniation from his progressive brain tumor. And because of the morphine, he didn't suffer at the end. I took care of him the day we started him on continuous morphine and the pain he was in was not something anyone should ever let go untreated.
* Someone mentioned sublingual Morphine, is this something used often in Palliative Care, Iv not heard of it?
In home hospice, yes this is used.
*What exactly is the dying phase? what things should I look for, I know I dont recognise the symptoms. I am the eternal optomist in these matters.
What symptoms are you trying to recognize? And why? Your goal in the dying patient should be to comfort. The biggest reason I can think of for wanting to recognize how close someone may be to the end would be to call the family in. Other than that, your focus should be on the patient and his comfort level. If he is groaning or exhibiting signs of air hunger, you should administer PRNs.
*It was suggested that giving these PRN doses have peaks and troughs in terms of effectiveness, but syringe drivers are a constant steady flow... Does this suggest that they are safer for the patient?
You really need to lose this thought that these medications are going to harm the patient. Opioids are titrated to effect at the end of life. See above about my pediatric patient who required doses of morphine that could kill a tiny horse at the end of his life. We didn't start out by bolusing him with 100 mg, he was started at a continuous rate of 1 mg/hr and then the dose increased as needed to control his pain.
The people in my new team that Im working with seem to be very kind, and I have even heard one of my Nursing Sisters say that it can take years to adjust and to feel confident with Palliaitve care. I will be having some formal training in due course. I have approached a colleague and asked her to be my buddy interms of having someone to mentor me through this issue. I hope to spend time with specialist nurses and the hospices. I have infact spent time on my holidays reading palliative care text books. Although I have of late learnt that these patients are managed and treated for reversable causes, and there are homepathic pathways to comfort patients, all of which i didnt know.
Based on your spelling and use of the term "nursing sisters", I am assuming you are not in the United States. Is there a palliative care team that is managing these patients where you work? There are non-medication therapies that can be used for symptom management at the end of life but you should never withhold appropriate analgesia in favor of something else because you are afraid that morphine is euthanasia. I am going to echo others' concerns and say that this really doesn't seem like the right field of nursing for you. You are too focused on your fear that these medications will kill the patient and also that the patient dying means that you did something wrong. A comfortable and peaceful death is THE GOAL for these patients.
It would never be my intention to allow people to suffer needlessly. I just want to be safe and be sure that I am not causing harm. Isnt that what we are suppost to do?
Yes, but for palative and hospice patients chronic pain and air hunger is whats causing them harm. Palative care is symptom management, and providing morphine to ease respirations is managing the symptom that the dying process is causing. I know its hard to wrap your mind around the idea that youre suddenly allowing the very things you usually try to prevent, but death is the guaranteed outcome for these folks and you have the ability to make it as peaceful and painfree as possible.
* I note that some of you have spoken about a PCA. I have wondered why patient controlled analgesia devices are not used in Palliative Care, as they are in post surgery care. why is this so? Is this because of the monitoring that would be required?
Because patients aren't able to self administer towards the end of the process and because morphine is not only given for pain, but for air hunger and labored breathing.
* I have had lengthy discussions with my piers over the years, some very senior nursing sisters who have, added fuel to my thoughts about the link between these medications and the nearness they are to euthanaisa, I may very well be paraphrasing but they have said that.
The drugs do NOT cause folks to die, they make the process easier for them to handle. If the person isn't ready to die they will become tolerant of the meds and "rally back". I have someone right now who just did that very thing. Also, end of life medications are NOTHING like assisted death medications.
* Blase, yes I have witnessed that, one former colleague, once actually said she thought that the morphine she gave must have caused her patients demise as they didnt survive longer than an hour.. and that is only one example of such.
No, it just doesn't work like that.
* Someone mentioned sublingual Morphine, is this something used often in Palliative Care, Iv not heard of it?
Yes, the morphine given is PO, but it's given with a small oral syringe and administerd slowly. The patient absorbs some of it through the mucus membranes and swallows the rest if that reflex is still intact. Otherwise the body absorbs it..
Specializes in Mental Health, Gerontology, Palliative.
snip
* I note that some of you have spoken about a PCA. I have wondered why patient controlled analgesia devices are not used in Palliative Care, as they are in post surgery care. why is this so? Is this because of the monitoring that would be required?
A PCA requires the patient to be able to push the button which releases X dose of medication, the issue with that is that if a patient is unconscious they cant push the button. Also if you think about it in terms of peaks and troughs, medication only lasts for a set period of time.
A syringe driver delivers a constant amount of medication over a 24 hour period.
* Terminology such as 'dying anyway' suggest that we are giving up on our patient, is there any more proactive language used in palliative care. Oddly when people refer to 'stat doses' that sounds more negative, however when refered to as 'PRN medications' sounds more positive.
A stat dose is a dose to be given straight away.
A PRN dose is define as "when needed"
the term 'dying anyway' is a statement of fact. We have a choice as health professionals to ensure that the patient has the best death possible, in that they are peaceful, not in pain, and as minimal symptoms as possible.
I often use the phrase life limiting illness when talking with patients because its still acknowledging their terminal illness but somewhat softer than 'dying'
* I have had lengthy discussions with my piers over the years, some very senior nursing sisters who have, added fuel to my thoughts about the link between these medications and the nearness they are to euthanaisa, I may very well be paraphrasing but they have said that.
* Blase, yes I have witnessed that, one former colleague, once actually said she thought that the morphine she gave must have caused her patients demise as they didnt survive longer than an hour.. and that is only one example of such.
I once gave a patient four drops of clonazepam and they died about 10 minutes later. The amount of medication i gave was negligible.
To euthanise is to give someone medication and keep giving them medication until they die.
Palliative care is to give someone medication to manage their symptoms, this medication may or may not bring their death forward by hours/or days. If I give medications to someone who is dying I'm giving it with the rationale to treat their symptoms but understanding that this may bring the persons death forward.
* Someone mentioned sublingual Morphine, is this something used often in Palliative Care, Iv not heard of it?
Sublingual morphine would not be appropriate if the patient is unconscious also when they are in the end of life, their mouth drys out and I would wonder about their ability to absorb medication this route. The other night I gave a patient in end of life phase some clonazepam drops. When I went back several hours later there was a marked bright blue stain which suggests that the medication didnt absorb well.
*What exactly is the dying phase? what things should I look for, I know I dont recognise the symptoms. I am the eternal optomist in these matters.
If a person has a terminal illness all the optimism in the world isnt going to change that. This link explains the process well
*It was suggested that giving these PRN doses have peaks and troughs in terms of effectiveness, but syringe drivers are a constant steady flow... Does this suggest that they are safer for the patient?
Its more about efficacy. Its possible to manage a patients symptoms with PRN doses the idea with a syringe driver is that it would reduce/and or eliminate the need for PRN medication
Is this post for real? I'm beginning to wonder about some of the posts lately.."can I stay home and take care of my BF who has a patch on the back of his head" now this one..more and more this site seems to be drawing in either fakes/drama driven or really immature nurses..or so it seems.
There is a difference in euthanasia and hospice/palliative work. My mother-in-law passed away last june from a rare cancer. She had the surgeries to try to get it all, but it did not work. She refused chemo treatment. The pain was so bad that she was willing to go to another state for the assisted suicide assistance. She was in hospice and was well cared for up until the day she passed. Hospice nurses are some of the most loving nurses I have ever met (and I have met a few of them). They are not in it to kill the patient. In fact, its quite the opposite. They are in it to give the patient the best care they can give and still give them the dignity the patient deserves. Sometimes that dignity requires the use of drugs and equipment that normal people would blanch at.
I have seen death many a times in my life to where it does not bother me. I accept it for what it is: Death is part of the life-cycle. Does this make it easier? No, but it is what it is. Hospice/palliative care is where I hopefully plan to pursue my career. If I can help one person pass with ease instead of pain, I know I will have done my job.
As nurses we are called upon to give the best care available with the tools we have available. There are aspects we will not like, but for the sake and care of the patient, we have to do them. If this does not suite you, it maybe time to find something different.
DextersDisciple, BSN, RN
330 Posts
The idea of prolonging suffering is horrifying to me. Being forced to care for pts with GCS 3, no movement to any stimuli with multiple skin tears and pressure ulcers makes me HATE my job. Mind this is the family refusing to change code status for their own selfish reasons, the opposite of pts wishes the majority of the time.
If I was a decent writer I'd love to write an article/story of sorts titled "dying isnt always a bad thing" as told by an ICU nurse. Depriving palliative patients of end of life medication is selfish and cruel.