Terminal Agitation

LadyFree28, BSN, LPN, RN · Jan 23, 2015

This all I have:

((((((HUGS)))))

icuRNmaggie, BSN, RN · Jan 23, 2015

Two questions and I am not asking for a reply:

Was she on a morphine gtt?

Do you have a diverter in your unit who is tampering with the narcotics?

cmfrt_care_rn · Jan 24, 2015

I have been in that situation before, but only once. As a CHPN with 7 years exclusively in a residential hospice and having seen many many deaths, that situation is rare. You have my empathy and I understand what you are going through. I wrote about the experience in a journal without identifying information of course, and that helped me get it out. I wrote it as a letter to the man who passed in such a horrific way despite our best efforts. Hugs to you. It sounds like you did everything you could. I thought icuRNMaggie's question about someone diverting was good, and something I didn't think of but should have.

Gooselady, BSN, RN · Jan 24, 2015

That is horrible I did a lot of comfort care in my last job and that sense of not being able to get the patient comfortable (much less at least not agitated or in agony) is fresh in my mind. Fortunately, what you described doesn't happen often. It seems like the younger patients have the 'hardest' time dying, their bodies do not give up the fight so easily.

My preceptor at this previous job told a story over and over again (apparently it really traumatized her) of a young female cancer patient on comfort care, who they could not get even remotely comfortable no matter what they gave her. She went into a coma a few hours before she died and THAT finally stopped her agony I had maybe two or three patients who died 'catastrophically', meaning not peacefully and with the dignity I mean to provide, but not to the degree you or my preceptor described.

One patient was a transfer from ICU, an elderly woman who went into cardiogenic shock during an angiogram, had a history of chronic pain, and the team and family decided to pursue comfort care. Now having an ICU doc write comfort care orders is not ideal in the first place, but her doctor refused to give us benzos because he could not in 'good conscience' write meds for her that would make her die faster (???)

He had her on a morphine drip with an enormously high cap. She began doing that twitching thing as some do when the opiate does gets high, and again and again he refused to change her to a different opioid or order benzos. This very elderly lady was literally shaking the bed, it was tonic clonic sz like activity. Her family was huddled on the couch clutching each other in horror. I was in charge and had to take this doctor head on. I finally talked him out of upping her morphine cap to 500mg an hour (I am not joking. We had 'prns' of 50mg of morphine to boot!) and into a Dilaudid gtt -- which he ordered at this enormous rate (still no benzos) so that finally the pharmacy had to call him and tell him they were going to run out of Dilaudid carpujects for the whole hospital.

Night shift took over and the patient expired two hours after the Dilaudid gtt was started (no benzos). These things you don't forget, and thank goodness are rare. I know you did everything within your power, and sometimes even that isn't good enough. Thankfully, most of the time it is good enough :)

bluegeegoo2, LPN · Jan 25, 2015

No, unfortunately we don't hang morphine at my facility, and point 2 is certainly something to consider that hadn't crossed my mind.

Thank you all for your replies and support. I'm glad to know that these types of deaths are few and far between.

auntmeme · Jan 25, 2015

First, HUGS to you for everything did finding ways to help get her comfortable. Don't feel as you failed her, you were there for her in a time of need and did a lot to make sure she could become comfortable. Not sure how young she was, but I can't imagine dying at a early age. The fear of the dying process, the feeling of wanting to live longer, etc., ugh. :down: Was her family with her at this time? Did she ever get to express how she felt about the dying process with any of the hospice staff? When my mother passed away from cancer, my siblings and father voiced to her it was okay to go. We remained by her bedside until she passed, each taking turns in shifts so she was never alone...and she passed very peacefully. Then years later, my father-in-law who was ill didn't have closure with some of his family members, the hallucinations, pacing, agitation was horrible. Hospice finally decided to take him to the hospital to give him a morphine drip which finally worked to allow him to pass peacefully. However, in the back of my mind I was sad because I knew he truly wasn't at peace within him self to "let go". I just recently came across a book titled "Final Gifts" written by Maggie Callanan and Patricia Kelley. I really enjoyed this book it answered some of my personal questions and has allowed me to help explain to family members what they think are "crazy things" have meaning.

Red Kryptonite · Jan 25, 2015

I work hospice and all I can say is that we do our best, and we do a lot of good, but it will never be perfect, and we can't help everyone as much as they might need.

I've seen terminal restlessness that was not aided by any intervention, and it's truly awful for everyone involved. I'll add my hugs to the others.

bluegeegoo2, LPN · Jan 26, 2015

First, HUGS to you for everything did finding ways to help get her comfortable. Don't feel as you failed her, you were there for her in a time of need and did a lot to make sure she could become comfortable. Not sure how young she was, but I can't imagine dying at a early age. The fear of the dying process, the feeling of wanting to live longer, etc., ugh. Was her family with her at this time? Did she ever get to express how she felt about the dying process with any of the hospice staff? When my mother passed away from cancer, my siblings and father voiced to her it was okay to go. We remained by her bedside until she passed, each taking turns in shifts so she was never alone...and she passed very peacefully. Then years later, my father-in-law who was ill didn't have closure with some of his family members, the hallucinations, pacing, agitation was horrible. Hospice finally decided to take him to the hospital to give him a morphine drip which finally worked to allow him to pass peacefully. However, in the back of my mind I was sad because I knew he truly wasn't at peace within him self to "let go". I just recently came across a book titled "Final Gifts" written by Maggie Callanan and Patricia Kelley. I really enjoyed this book it answered some of my personal questions and has allowed me to help explain to family members what they think are "crazy things" have meaning.

She was in her very early 60's, and d/t negative family dynamics no family was present, though one of her children did attend to her needs.

ktwlpn, LPN · Jan 30, 2015

She was in her very early 60's, and d/t negative family dynamics no family was present, though one of her children did attend to her needs.

That's it,then,her spirit was struggling.

casi, ASN, RN · Jan 31, 2015

Lots of hugs in your direction. These types of patients are just heartbreaking. It sounds like you did everything right working with hospice and advocating for your patietn.

I'd talk to your DNS about the potential of using IV or sub-q drips on patient's like this.

I tend to get hospice or the MD to titrate morphine (or any narcs) up until unconscious. I think the highest dose I've seen was a TCU patient on Dilaudid IV drip at 1-2mg (I can't remember), Valium IV q3h, intrathecal dilaudid q3h. It was pretty insane. Before she started going unresponsive she was on Dilaudid 24mg PO q3h.

edmia, BSN, RN · Jan 31, 2015

Oh that's very sad. I'm sorry for you and the patient.

Our hospice offers palliative sedation for cases like this. But we have an IPU.

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