The Best Pain Med. Beside Morphine That Will Work For A Hospice/als Patient

leslie :-D · Aug 27, 2007

is she c/o pain, dyspnea or anxiety?

how often are the prn's being given?

the als pts i've had, have been overcome with anxiety.

i'd up the ativan and give it q3-4 rather than q6.

and what is she getting for the scheduled morphine?

leslie

miche18 · Aug 28, 2007

we have some of our patients who are still full code. few days ago 8/25/07 the Doc convince the family to make him dnr, and he passed on 08/27/07

txspadequeenRN, BSN, RN · Aug 28, 2007

what about adding some methadone or oxyfast?

i worked at a hospice hospital, i'm working with an end-stage als patient. she is currently receiving (pca continuous morphine 4.5mg, she is on morphine 4mg/2ml q2h prn, ativan 0.5ml q6h prn, and 1mg ativan schedule, 10mg/5ml morphine q2prn.) and still she is asking for more pain med. can someone please tell me what else the doc can give to her to manage her pain?, and what can she get for sleep aide?. i do not know what else to do for her, i need help. thank very much:angryfire

txspadequeenRN, BSN, RN · Aug 28, 2007

it makes me crazy when hospice patients are full codes....

we have some of our patients who are still full code. few days ago 8/25/07 the doc convince the family to make him dnr, and he passed on 08/27/07

kstec, LPN · Aug 28, 2007

I just had an interview at a hospice place and they told me that alot of the hospice patients are full codes, I don't understand. How can a patients who is diagnosed to pass away soon, be ethically resuscitated? I was also told they will put in feeding tubes. I don't understand. I'll find out at the end of this week if I get the job, which sounds very interesting yet sad. As for getting info on pain, I'm just taking this all in for any of my future patients if I get the job. Do they used Fentanyl patches alot, or do they decrease respirations to much? Just curious.

aimeee, BSN, RN · Aug 29, 2007

I just had an interview at a hospice place and they told me that alot of the hospice patients are full codes, I don't understand. How can a patients who is diagnosed to pass away soon, be ethically resuscitated?

There are a number of things at work here.....for instance, an end stage heart or COPD patient may have been resuscitated before and its hard for the patient/family to grasp that it won't work again for them. And maybe it will...who can say with certainty. Another issue is that often at the point of entry into hospice the patient/familly are just beginning to come to grips with that idea that they are dealing with a TERMINAL illness. Signing the DNR is just too much at once for them. Usually, if we have some time to work with them, they come to a point eventually where they are ready to realize that a DNR order is actually a blessing that will allow them to exit peacefully from the world. But if they dont, that's okay too. The important thing is that they make a truly informed choice, and we are very honest with them about what they can expect when they make that choice.

I was also told they will put in feeding tubes. I don't understand.

A feeding tube is appropriate when it is believed that it will improve the patients quality of life. For instance, lets use the end stage cardiac patient example again and say it was best estimate that they had a 3-6 month life expectancy at their entrance to hospice (nobody is really that good at prognostication, but lets accept that for the sake of example)....shortly after they enter hospice care they suffer a stroke, which leaves them with impaired ability to swallow but they are still able to communicate with the use of a message board. They indicate that they are feeling hunger and they want a feeding tube. It would be perfectly consistent with the care plan to arrange for that person to receive a feeding tube.

As for getting info on pain, I'm just taking this all in for any of my future patients if I get the job. Do they used Fentanyl patches alot, or do they decrease respirations to much? Just curious.

The use of fentanyl patches varies a great deal from practice to practice. We prefer to use them only when there is a true need for round the clock pain relief and the patient is unable to take an oral long acting med. As for decreasing respirations too much, properly applied that should not be an issue, just as it is not an issue with other forms of narcotic. Any narcotic can decrease respirations to a dangerous level if a large dose is given to a narcotic naive person. You never want to start a narcotic naive patient on a fentanyl patch right off. We start with other immediate release forms of narcotic until we have arrived at the proper dose for relief, the body has had time to adjust, and then convert. The other issues with fentanyl are that there can be differences in absorbtion rate (patients with a higher temp absorb more quickly), people apply them incorrectly (put them over bony prominence), there are often adherence problems (sweaty oily skin) and they are one of the more costly forms of narcotic.

As for the ALS patient in the topic, more information is needed to offer helpful advice. Where is the pain? What is the nature of the pain? Are they getting an anxiolytic along with the morphine? Maybe addition of a tricyclic? This might help potentiate the pain relief, and aid in sleep relief and depression relief. Now and then you do get a person that just doesn't respond to morphine the way others do....methadone, fentanyl, or dilaudid would be alternatives but there's no way to know about this individual but to try.