Too much Morphine-scopolamine+stesolide

[KarinBe]

Dear all nurses,

I´m writing this from Sweden so please excuse my sometimes broken English..

I really need your opinion on this:

A couple of years ago my beloved Mother who lived in a nursing home since she had her stroke 15 years earlier, died.

She got pneumonia and didn´t respond to the antibiotics they gave her.

I feel a tremendous guilt over her passing.

The last evening she got this rapid breathing, and when I sat down by her bedside at 12 that night it had gotten worse, deep and fast, up to 50 breathes per minute I think.

She was totally alerte and awake though.

After an hour or so I rang the nurse, she came and gave her an injection of 7.5 mg Morphine-scopolamine plus 5 mg Stesolide( sorry don´t know the names of these meds in English).

I think when I look back that it helped a little, but the breathing was still very fast and deep.

I felt so helpless and it was so hard watching her breath like that and I rang the bell again 30 minutes later.

I blame myself so much for this..I asked the nurse if she could have a little more since the breathing was still heavy.The nurse said yes and gave her another injection of what I later understood was the same dosis.

Two hours later my Mom was dead.

When I later ask for her medical journal, the last dosis wasn´t there! They hade erased it and this can only be interpreted as they had made a mistake.

I blame myself for not fully understanding the side effects of Morphine and I knew that it had to be 4 hours between the doses, but I guess I panicked.

I would be so grateful for any comment or opinion on this.

Thank you.

Kind regards

Karin

[Nascar nurse, ASN, RN]

I'm a Director of Nursing in a nursing home as well as a certified hospice nurse. Morphine is often used every hour at the end of life. I can only make an assumption that they got busy and forgot to record the dose rather than purposefully "erased" the does.

We weren't there and none of us could do any more than make assumptions as to if or if not the right thing was done for your mother and we are not allowed to give medical advice on this forum. Most concerning is you say this was a couple years ago and it's apparent how much guilt you still feel about the situation (although you probably have no real guilt to claim at all). I suggest you seek out some grief counseling to help you through this time. You're much more likely to find that more helpful than trying to dig up information that won't actually change a thing at this point. Peace!

[KarinBe]

Thank you so much, Nascar nurse, for your answer! I have done that, and will again. Even if you can not give medical advice, could you tell me something about that type of breathing?

[AnOldsterRN]

Hi KarinBe.

So very sorry about the loss of your mother.

Like me the previous commentator stated, we are not allowed to give medical advice on a forum. That being said, the first thing that came to mind when I read your post is what is called "Cheyne-Stokes breathing." This type of breathing is frequently seen in dying patients. It's a breathing that can be rapid and deep with breaths followed by a period of no breaths or a "pause" in breathing. Sometimes there may be "noisy"breathing that some refer to as a "death rattle." This could (or couldn't) be what your mom was experiencing.

Morphine is a drug that is given to people who are dying. It's also a respiratory depressant, meaning it could slow down breathing.

Pneumonia can be serious in the elderly who may also be compromised or have co-morbidities (example, congestive heart failure). I don't know if this was the case with your mom.

Im so very sorry that you are feeling guilt.

[KarinBe]

Thank you so much.

But the breathing had NO pauses, only rapid and regular for several hours.

What is the hardest to carry, is that she tried to show me that she didn' want to have that second injection, I saw that but didn' take notice, thinking the nurse knew what was best...

[AnOldsterRN]

I honestly don't think it was anything you could have prevented. Pneumonia is a bad thing.. can be deadly with older patients. The breathing leads me to believe that she was at end of life. The fact that she was receiving morphine under the circumstances would lead me to believe that she was end of life and on "comfort care."

I have no no idea why the second dose wasn't charted.

Like the other nurse said.. it's used every hour at end of life for comfort care. Perhaps it wasn't ordered to be given. I can only speculate.

I live with guilt too and it's been almost 10 years. Hurts terribly. My grandmother hated being poked. Doctor suggested a PICC line (inserted and used long term for IV administration). She didn't want that either, but I talked her into it. She was post operation for removal of cancer in her colon. The cancer didn't kill her. It was sepsis traced to the PICC line. Either someone did not use sterile technique when they inserted it, or proper technique when changing the dressing or administering meds.

Intruly feel for you. I'm so sorry for your grief.

[Glycerine82, LPN]

Please don't feel guilty. You wanted to ease your Mom's suffering during her time of passing. She was dying, and nothing you did or didn't do would have changed that.

Morphine is absolutely used in these circumstances and it assists the respiration's, makes them less labored and agonal.

I've given it and had the patient pass within moments, the fact is that death was just imminent in those situations. I hope you find peace, OP.

[KarinBe]

Thanks so much everyone for your posts.

But the thing is I don't think my Mom was that close, she was very alerte and awake, it was only her breathing that was very fast. I don't even think she was in pain but of course the laboured breathing must have been hard for her.

I was a fool to think I could change her breathing and by that help her!

it was just a normal active dying process and I so wish the nurse would have told me that:(

[Purple_Clover]

Was she diabetic?

[KarinBe]

No she wasn't. I think her fast and shallow( labored?) breathing( through nose) must have looked like Kussmaul's, but she wasn't diabetic.

I understand now that the second injection was lethal for her, she couldn't keep up the pace and from I understand, the morphine made her breathing more difficult. I can' believe that the nurse didn't understand this!

[notanumber]

Hi Karin,

I see Kussmaul's breathing frequently in the actively dying. Yes, it is most associated with DKA, but the metabolic changes occurring during organ failure (active dying) can cause it as well. It's a last ditch attempt by the body to restore acid-base balance. It's also not uncommon for Kussmaul's to transition into Cheyne-Stokes as death nears, but this does not always occur.

Morphine is very common for treating dyspnea (difficulty/discomfort in breathing) in end-of-life care. From your description alone, it seems likely that this was an appropriate intervention at the time. It also sounds like your mother was very close to death. Whether the morphine contributed to a quicker death is something none of us can say. While we don't give opioids (or any other medication) to cause death, the increased risk of causing CNS depression is secondary to comfort. Some things to think about. I'm sorry you're still dealing with these feelings of guilt and fear surrounding the circumstances of your mother's death. Is there a bereavement/counseling group nearby that could help? Some hospices offer them, and you might find it more enlightening than what can be offered on an internet forum.

[KarinBe]

Thanks so much, notanumber. Yes, I only think the nurse wouldn´t have given that second injection.It just made it harder for my Mom, it was I, a panicking daughter, that could have used some reassurance and comfort:(...

How long can they stay that tachypneic, like Kussmaul´s? What is the most common?

My Mom was breathing like that for 9 hours.

Thank you.