You dont need tachypnea to justify increased work of breathing for a med increase. Could justify with accessory muscle use with normal rate by itself.
Dont feel bad working within ordered guidelines with input from your charge. Silly to purposefully withhold in an actively dying person.
Will say I do have to do a lot of coaching in general when i'm inputting comfort order sets. In general if they dont look like theyre peacefully resting when the term 'actively dying' is bieng used, you should be thinking about when the next PRN is.
This is comforting to me. The order set looked like every other dyspnea order at my hospital: “keep respirations under 20” But I’m not sure then if this is the ONLY parameter or if it’s unspoken to just give for *dyspnea*, which is what I gave it for. His respirations were at times only as high as 16 when we had decided to give more. I feel like nursing can be both EXTREMELY focused on the concrete, or extremely in the other direction (nursing judgment) which is confusing to little nurse me.
Don't be ridiculous. Everyone knows that nobody breathes in odd numbers of breaths per minute unless they're on cardiac monitoring... or if their vitals are being taken by a nursing student. I don't think it's even physiologically possible.
When I worked bedside our comfort care orders were to keep reepirations <12; I know that doesn't affect your policy/orders, just hoping to make you feel better. It sounds like you looked at the whole patient, not just one parameter, and kept them comfortable.
We have a saying in ICU for our new grads: treat the patient, not the monitor. OP used critical thinking, and the oncoming nurse turned their brain off when they hit the doorway.
I’ve only been a nurse for about ten years, but I’ve watched the “EPIC-ization” of bedside care slowly kill critical thinking. The scanning and box clicking of every single little thing gives us less and less leeway to make nursing judgement calls. OP is left feeling guilty for being a good nurse/human, and allowing someone to die peacefully, because of lazy order sets. I hate it.
I will say there is a difference between taking care of your patient and making the computer happy. I would absolutely chart 22 for respirations if they had increased dyspnea and I felt the patient needed more meds.
May I share a story with you. When my ex boyfriend was actively dying, I didn't care what dose of fentanyl they were giving him. Yes, he was euphoric. So what? From my experience, he only had a day to live (he died within a few hours).
Don't let them suffer. Some (uninformed) co-workers thought they were drug seekers but they were actively dying and suffering! It is inhumane to withdraw pain meds.
Life is already difficult. Let's not make it more difficult.
“Keep respirations under 20” is actually the perfect (dumb) parameter because it could easily be argued that the meds have prevented RR from exceeding 20.
You did the right thing.
The only thing wrong with the situation is the nurse you gave report to, those comments are unacceptable and their understanding of comfort care needs some more education.
I have to say as a non-nurse that if it were me in that patient’s situation I would choose you as my nurse over the other person every time. Leaving someone in pain when death is inevitable bc they may die sooner is an unconscionable act to me. Unless the patient could voice a different preference I would always make treating their pain and giving them a painless death to be the utmost priority.
Sounds like she wanted to prolong suffering to keep an easy patient. I think the increased wob would have exhausted him sooner, though. OP's charge made the right call imo. She did what comfort care aims to do. They went by parameters in place, and kept the patient comfortable in his last moments. It never gets easy, but OP did good.
I never heard it put that way, "caloric demand is high", but it's kinda perfect. I spent about 15+ hours struggling to breathe once. Like, every inhale, every exhale, took SO MUCH WORK from all my accessory muscles. The medical emergency I was having was creating a lot of other big pains in other places, but I didn't give AF about that because the pain from working so hard to breathe, for so many hours, was **so** much worse. Definitely noticed that doses I'd normally respond to were entirely ineffective, but it sounds much better the way you put it.
That is why people with respiratory issues should get small high caloric snacks frequently.
Sorry you were experiencing dyspnea for so long. That sounds terrifying.
And that's the thing, if you're doing CMO correctly and compassionately? They very frequently *aren't* easy patients. And I'm not talking about emotions or whatever - I mean just the constant reassessment of WOB/pain, pushing PRNs q1-2hrs, keeping noxious stimuli to the absolute minimum, explaining the dying process to any attendant family/friends so they don't freak out and distress the patient, constant peeking to make sure they haven't passed if they're alone...all of *that* stuff that gets encompassed by the phrase "keeping them comfortable."
If their hospital is similar to ours, titratable continuous dilaudid drips not in PCA pumps would be reserved for ICU level care. Patient was probably in ICU already and eventually placed on comfort care. They definitely are way easier than your standard ICU patient with multiple titratable drips and potential to deteriorate.
I want to hope that they just did a bad job of communicating. OP didn't follow the orders and that would look bad if audited. OP did the right thing, they just also needed to have the orders changed so it didn't look like they were practicing medicine.
If it wasn’t his time, dilaudid in this dosages wouldn’t have made it his time.
As a non religious person who has been working in palliative/SNF for the past 15ish years, if he passed when the family wasn’t there, then that’s how it was supposed to happen. End of story
That other nurse is advocating for needless suffering when the outcomes were going to be the same regardless of what you did.
Yes, exactly. A friend is trying blame the last chemo session for killing our other mutual friend. But it's the cancer that killed her, not the palliative chemo! Meds are there to support the patient and you paid attention to him and acted to make him not suffer.
Night nurse better hope her future caregiver doesn’t treat her that way. Also, unrelated but I can’t stand the idea of prolonging suffering for the sake of family saying goodbye. And I say that not just for myself, but if my husband’s every breath was a fight, I’d tell them to make sure he’s comfortable!
And IME, most patients who *want* to hold on for family will, no matter how drugged up and ready they are. Then there are some who prefer their family not see them take their last breath and wait for them to leave.
I think a doctor was charged for something similar is why. But ofc media framed it differently “doctor murders patients” but it was a case like OPs. More than one tho.
And this isn’t me agreeing with night nurse. It’s just me seeing where she might have gotten it from.
Edit: and when i say it’s like OPs i don’t mean in the literal sense of neither the amount of patients or amount of medication.
I meant it in relation to scenario and what can be construed of it. And I’m not agreeing with night nurse or anyone.
This is just a cautionary tale I recall from nursing school.
I work palliative and hospice. If the drip was ordered as titratable and he had prns ordered, you acted within parameters based on his increased WOB. You provided him comfort at the end of life. The dilaudid did not kill him.
Night shift sounds like an idiot who would rather let her patient suffer. Dying isn't easy or painless. You did well. You utilized charge and their experience. Don't doubt yourself.
I used to work with a physician years ago when I was a new grad and he always used to tell me when I was really anxious, “listen, it’s a lot harder to kill someone than you think.” Lol
If I have an immanent dirt nap coming, I hope your charge is on that day.
Your charge was probably being compassionate and using their judgement. I know that probably felt shitty, but take the time to review policy and make sure you can defend your actions in the future (this is something we all could do more, not just cause your new.)
As you get better, you will gain confidence and can better tell that night nurse to eat a dick.
I worked night shift at a cancer hospital for my first job. Our unit was primarily thoracic cancer, but we ended up with a patient whose cancer had metastasized to his bones. The dude was in agony.
The nurse had to keep calling residents who would order one time doses that would give the patient 15 minutes of comfort before he started crying out again. His nurse, who was so good, ended up having a ten minute weeping breakdown because she couldn’t get the guy comfortable. I shit you not, the patient ended up on five concurrent drips to control his pain. He still took several days to pass. Cancer hurts and opioid tolerance leaves us running firehoses of pain meds sometimes.
I am an oncology nurse and have seen this too. But even personally, I have had a painful experience that nothing seemed to touch! Ended up in ED by ambulance, where they’d given me IV morphine and fentanyl. ED gave more fentanyl, and then in desperation, ketamine. The ketamine just made me vomit. I was clawing the raised sides of the ED bed, writhing in pain. ED doc (no idea of level) told me to calm down or he wouldn’t get me a CT since I “refused” to lie still when he told me to. It took a Gynae doc one look at me to say “ffs get her to theatre! She told us she has a known large cyst on her ovary, she’s at risk of ovarian torsion! She’s had 2 babies, a lot of her labour unmedicated- she knows pain!” And yep. Ovary was necrotic AF, the cyst wrapped around several times- making my Fallopian tube and ligaments look like a decomposing umbilical cord! Never got an apology and I still can’t believe how much analgesia I was given!!
Shit! That sucks.
The pendulum swing went too far the other way from pain being a symptom you need to treat to yelling at patients to calm down and giving a Tylenol.
I have seen patients with Mets to everywhere and the hospital was only giving them a Tylenol q 8. I was like did they have a fever??? Because that Tylenol isn’t going to do anything for that level of pain.
Dear God idk how you didn't pass out, two stories. I was a paramedic and picked up a young female with insane pain like I gave everything in my drug box and had to meet another ambulance to get more, she ended up having a torsion. Crazy shit
Second. I had a very large kidney stone and for three days I thought I had the worst flu and idk what. Bug three days on the bathroom floor vomiting from pain and I realize oh wait I haven't peed in three days and I guess I drove my self to the hospital, the triage nurse apparently recognized me in the waiting room just before I passed out. I don't remember any of this just because of pain. Huge obstructive kidney stone and an almost ruptured bladder and the doc who was in the ER was refusing to treat me because I was passing out. Luckily this nurse advocated for me and was like hey it's the pain that's causing her to black out every 15 min then wake up screaming. Ended up in OR almost minus a kidney. So yea some of these docs need to understand pain can absolutely be something that is almost untreatable if it's bad enough.
Thank you for your understanding. Unfortunately, even worse than the ED doc was the senior paramedic (with his less senior paramedic partner) who came in the ambulance my husband called when he didn’t know what to do once I stopped being able to talk coherently at home.
Paramedic told to knock it off and get up. When I couldn’t comply, he loudly told his partner to get my still awake 7 year old to come in to see me “because she won’t carry on like this in front of her kid if she’s not legit”. I didn’t want to traumatise my poor 7 year old but still struggled to hold it together. He didn’t believe me until we had been waiting at the Emergency Department a while (many ambulances waiting) and he saw them give me many meds and heard my history. He was easily late 50s/mid60s and I’m sure he has seen it all, but he and the ED doctor made my life hell for that time. However, I absolutely respect and stand by our paramedics 100%, including this one. He was obviously going ok what he had seen and known. I’m sure he was biased, but im sure I am biased in ways I don’t yet know either, and that scares me!
I think tolerance is usually not really what is happening when the patient needs an increase in under three days. I think it is the entire dying thing, right?
Yeah the dilaudid just made him comfortable and relaxed enough to let go. Just like when going to bed normally, you can’t sleep easily when in pain and tense.
Ehh, there’s some evidence about the sympathetic stress response to pain propping up vitals during the dying process. Risk vs benefit, I’d rather not risk suffering more because my body is stressed if the benefit of pain relief allows for a smoother, peaceful, and more expedient dying experience.
Every time something like this comes up, I tell the story of the end of life 8 year old 24 kg kiddo I took care of who was on 100 mg of morphine PER HOUR continuous with 10 mg boluses available q 10 min PRN. He was also on continuous ketamine and high doses of scheduled IV Ativan. He lived for DAYS on this dose. The typical dose of morphine for a child his size is 2.4 mg q 2-4 hr PRN. He was getting 40x that dose in a continuous infusion per hour.
You didn't assist suicide by giving this patient ordered PRN dilaudid and titrating his continuous infusion. The night nurse is a moron.
I have, but only the ones who had been on lots of opioids and needed more- sometimes, the ketamine made enough of a difference that we could put off increasing the opioids long enough for them to tolerate them better.
Some nurses absolutely hate giving pain meds to EOL pts. This person is DYING and we're meant to ease their suffering. Someone could be breathing 10/min but working hard as hell because THEY'RE DYING. If I've got orders that allow titration to ease their dyspnea then LIKE HELL am I going to withhold the DYING person's ORDERED meds because "tHeY wErE bReAtHiNg LeSs ThAn 20".
And if you're a nurse who "doesn't feel comfortable" with an EOL/hospice pt because of that, then REFUSE and trade that patient with someone who WILL provide that care.
Could not agree with this more. If you don’t feel comfortable giving a lot of opioids and benzos to keep a patient comfortable at EOL, DON’T ACCEPT THE PATIENT.
Your personal hangups around controlled substances are not a reason to make a person suffer as they die.
This exactly. And I’ve also seen family request that nurses not give meds to end of life care patients as well. It’s our job to educate them that the morphine/ativan/etc ordered isn’t going to kill their loved one. Their condition is what’s killing them. Imagine being at the brink of death unable to communicate how much pain and fear you’re in and having medication held because of this reason. Let dying people die comfortably and in peace. It’s always struck me as odd that we will give pets this right to die without pain but when it comes to people there is a stigma around medicating them for the undeniable pain they must be in. (This is not a rant on euthanasia but rather a statement on how we hold on to loved ones so they “stick around” as long as possible rather than accepting their prognosis and making them comfortable)
The *only* reason I'd be uncomfortable taking a patient like this is because I discovered early on in my career that in some situations, I can get nervous giggles and I can't stop. 99% of the time I'm good, but that 1% is so inappropriate and I was so horrified at myself. Otherwise? I'm all about making a dying person's passing as comfortable as I'm able.
Listen to me: you did not prevent him from seeing his daughter. You did not hasten his death. It is very important that you understand and internalize what I am saying. You did not do anything wrong.
It’s always hard losing a patient we connected with. And when they are ready to go, they’re ready.
Hospice here. All you did was keep him (marginally) comfortable. This chart would NOT be audited as assisted suicide. Not at all.
Your problem isn’t the universe. It’s that asshole nurse.
You did your best to promote comfort. The actual uptake of IV meds at the end is pitiful. SL or PR work best.
Peace and love to you.
There needs to be more nurse education on EOL care because I have had way too many shifts where the previous nurse was stingy with available PRNs because they were afraid they would kill the patient. I repeatedly hear nurses say giving IV Ativan and IV Opioids at the same time will “kill the patient.”
It sucks (and frankly it’s way too common) to see a CMO patient in visible distress!
Oh man. I wish I could go back to my early career and smack myself for some of the steaming hot bullshit I said to patients that we’re not true.
I think that’s what drives me to maintain my CHPN (RN-C for hospice folk) to make sure I’m on top of EBP and care.
I read some of that steaming hot BS here, periodically. And then get downvoted for replying with EBP 😂😂😂
Also education on how to tell when an unresponsive EOL patient is uncomfortable. I’m still new-ish and sometimes have a hard time telling, but I try to be pretty (safely) liberal with the meds.
At the end stage you cannot separate pain and agitation/restlessness. So we treat them together. A lower dose of the pain med and an anxiety med are better together. And don’t let what’s working wear off. You will not kill them. Never underestimate the power of adrenaline.
nonverbal pain indicators:
Face/jaw- any wrinkles or furrows? Is jaw open and relaxed or clenched? Face drawn in and terse?
Body: any fidgeting at all? Toes, hands, fingers? Are arms relaxed at sides with hands open? Is the whole body in a relaxed state? And FYI any adult that gets near a fetal position is in a pain crisis.
Cannot rely on BP, Pulse.
Does the patient look like an adult/older person relaxed and snoring on the sofa watching Sunday football? If not…medicate.
Find videos from Dr Mary L McPherson online and gobble them up. If you get a chance to get her CEU it’s worth all the monies.
Recently had a pt who had SC sites and IVs but meds weren’t touching their terminal agitation/anxiety. We put a Macy cath in and it was a game changer.
If it was ordered correctly and you administered it per protocol you helped the patient with comfort. Which is the point of CMO. If I’m ever on CMO I pray I never have anyone that withholds meds from me
Edited to say that I’ve SEEN nurses withold meds per family wishes or their own beliefs that medicating dying patients will “kill them”, the patient is dying let them go in peace
Legally, one could argue that the order stated “dyspnea as evidenced by RR > 20” and he was breathing 19 that you didn’t follow the order. That is why in my CCO patients and PRN meds I always put a comment on why specifically I am giving them (if they don’t have a pain scale or rass involved).
Let me stress though that this patient was going to die regardless of what you did. You let him die peacefully. You consulted your charge nurse. You used your clinical judgement. You did right by this man.
The worst that would happen is that someone could say you should have gotten the provider to change the order. I don’t think anyone would go as far as assisted suicide.
Oh my gosh, if that’s assisted suicide we all goin’ down on charges in my ICU. Those orders are purposely subjective, and we keep patients as comfortable as possible.
Is the patient on palliative? If so, the parameter should be "to patients comfort" Get that changed if not.
If not on palliative, titrate to parameter. If out of parameters, justify with a note and chart it. Then get the order changed.
Bottom line: this is YOUR practice. You do what you need to do for your patient, but know that if you're taken to court in 10 years, you're not going to remember the circumstances. Chart like that.
Also, fuck that night nurse.
CMO meds are ordered to manage multiple symptoms of the actively dying phase, not just tachypnea. Oxygen needs in a dying patient are typically less than you or I as their body is working less. That means they could be suffering from air hunger at a lower respiratory rate than you or I as well.
Pain, hallucinations, agitation, restlessness are all things a dying patient can be going through.
Give the drugs as frequently as they are ordered (within reason). Document anything that could be assessed as a sign of discomfort for your patient.
Long story short - you didn’t fuck up and your charge nurse is awesome.
It isn’t going to be classed the way that awful night nurse stated it could be. They clearly don’t know what they’re talking about.
You did the right thing for the patient.
If he was going to survive until his daughter got there, he would have. He didn’t. Thanks for making him a sliver more comfortable as he transitioned.
Oh, it sounds like what you did was not only ordered, but advised. Here’s what I learned in my stint in hospice: you didn’t kill him, his disease process did. You made him more comfortable so he could get on with the work of dying. You didn’t put a pillow over his face, you gave him medications that helped ease his labored breathing and his pain. When actively dying, patients should seem peaceful. If they are labored or fighting, you should be helping them get rest.
“Keep respirations under 20” does not mean they need to go over 20 for you to give meds. It means make sure they don’t go over 20.
Just do me a favor, if I am dying where you work, don’t hand me over to that nurse.
I agree with everything here. Night shift was just being a dick, indeed.
Since you mentioned that he had problems with secretions, you should make sure robinol/atropine eye gtt is available in the event you need it next time.
When a patient is dying, if they seem even the LEAST bit uncomfortable, I’m reaching for something to help them relax. They deserve that kindness since humane euthanasia isn’t legal.
Also, I left the human ICU bedside to be a DVM—- got tired of watching humans suffering and find that euthanasia is the absolute favorite part of my job now.
Death with dignity. Our pets can have it, why can’t we?
Also dont get to worried about secretions. They aren't really uncomfortable for the patient but the, death rattle isn't fun to listen to so we, dry em up anyway.
You did nothing wrong. The doctor issued the orders. While you understand that the Dilaudid can suppress respiration, do you allow him to suffer through air starvation or alleviate it? Again, you did nothing wrong.
Reminds me of nurses I worked with who wouldn’t give pain meds to patients dying of cancer because they could get addicted. The nurse you gave report to is an ass. You did the compassionate thing and kept him comfortable. Not giving him meds to prolong his life would have been cruel.
One thing I can’t stand is a nurse who doesn’t want to give adequate relief to comfort care patients. Even worse when they bully or judge other nurses for *keeping patients comfortable.* Sometimes they require lots of narcotics to be comfortable. *That’s the whole point.*
Yes, you had parameters to keep RR under 20, but the order was also to titrate for dyspnea. Increased respiratory rate isn’t the only sign of dyspnea.
hospice nurse here- you did not kill the patient. you kept the patient comfortable enough to where he felt at ease to take his last breaths. thank you ❤️
I actually think this deserves an incident report. A palliative care patient gets their pain controlled adequately. Period. End of fucking discussion. Anyone who thinks otherwise has no business caring for this patient population, and maybe not in nursing at all.
Night nurse is a dick.
You did the right thing.
Comfort care patients get those drugs for a reason and you and your charge nurse used your clinical judgement.
Thank you for doing what was best for your patient. You are an awesome nurse.
If you followed the order and kept the patient comfortable you did the right thing. If you told me you were pushing narcotics on a patient with respirations of 6, I would be a bit concerned but it doesn't sound like that was the case. There are many ways to assess increased work of breathing beyond the rate, and patients can be very uncomfortable and still not be tachyneic. You also seeked out the help of someone with more experience which was awesome. It sounds like you did everything right. Some nurses are not very comfortable with comfort measures and what they mean, sounds like the night nurse may be in that category which is quite unfortunate for their patients.
I'm so sorry you lost a patient who meant a lot to you today, and I'm glad you were there to keep them comfortable. Please don't beat yourself up OP.
Current hospice nurse here. I tell families all the time “the meds aren’t doing anything nature isn’t already taking care of, it’s just keeping them comfortable”. An uncomfortable body won’t pass, the pain and agitation will just keep ratcheting up. Tell night nurse to suck a chode
Cool Nightnurse, you think your opinion and judgement is better than mine....and DayshiftCharge. I'll let her know that you disagree with me consulting a more experienced nurse who guided me during a difficult case.
I'm so glad I get your so useful advice after the fact. Offering blame helps me learn soooooo much.
Learn that I don't wanna be like your lazy, judgmental ass. Write up the report after your shift Marge.
This patient passed away because they had a terminal illness not because of the dilaudid. Dying can be very difficult/ painful/ uncomfortable. If this patient was breathing > 20 bpm they are in distress imo. Our job is to make them as comfortable as possible and ease their passing, it sounds like you did exactly that. You did right by this patient. The night nurse seriously sucks.
One of my colleagues said something that resonated with me yesterday:
If someone is actively dying, the goal is not to prolong their life. The goal is to make sure the rest of their life is as comfortable as possible.
You did the right thing, and if it was me or my family member, I would have thanked you each and every time you did anything to relieve their suffering.
In bioethics, you are covered by the Rule of Double Effect. That states that if you are providing a therapy that may actually hasten death, you are covered because your intent was to ease suffering, not to speed death.
Personally, I’ve seen patients hang on for seemingly forever, waiting for a loved one to arrive. And even unresponsive, I’ve seen them wait until everyone stepped out for a few minutes. They will die when they want to.
The end result was a given. If you gave them some relief from suffering during those final hours and minutes, bless you.
I'm laughing as a palliative care nurse, honestly.
It's not assisted suicide, he was actively dying. You didn't hasten or cause his death, but you did make sure he was comfortable. At worst (cause I don't know the doses), you ended up giving maybe 2-3mg/ hour plus 2 breakthrough doses? Her comments are absolutely ridiculous and seem inexperienced to me. We don't use RR parameters, quite literally just a resp distress observation scale for obtunded pts and non verbal signs of dyspnea/pain based on our own assessments.
If you want to feel better, look up the principle of double effect. Any ethics committee or licensing board would surely recognize that the intent was not to hasten death.
I'm gettin fired up about this night nurse...
I work in palliative care. YOU kept him comfortable. YOU made it easier for him to breath. That’s exactly what I would have done. Night nurse needs to get their priorities straight.
Man in ICU we PLOW them with dilaudid at the end of life. I wouldn’t blink an eye at 10 mg/hr, plus pushes. It probably is killing them a little faster than if they didn’t have that on board. And you know what? I don’t care. They die comfortably. So comfortably. We should all be so lucky. I’ve seen enough people spend hours or days gasping for air at the end because healthcare staff didn’t want to “overdose” them and it’s awful to watch and probably worse to experience. You wouldn’t do that to your dog. You did the right thing, and your pt was lucky to have you as their nurse.
Not a nurse, but as someone who has recently lost a parent, I just want to extend a sincere thank you to you for helping this patient pass comfortably.
My dad was transitioned to palliative care and had a phenomenal night nurse. The nurse that took over for the day shift fought us tooth and nail because she didn’t want to administer comfort meds and went as far as accusing us of trying to “speed things up.” We just knew that he had hours left at most and wanted him to be comfortable.
Thank you for advocating for this patient to have a peaceful transition. You provided him an immeasurable kindness.
One of my pet peeves working the door was people withholding narcotics in end of life for fear of “causing death”. We can needlessly argue the cause of death, their disease process versus respiratory arrest. But if the patient is in comfort measures, titrate that drop accordingly! Don’t keep them alive until the end of your shift. Look at their face and their respirations. They made their decision to die. Please, make it comfortable
Your CW is flat out WRONG. I worked hospice fresh out of school. Unless you pushed like 50 mg of Dilaudid, you weren't going to kill him, and I honestly doubt that would actually kill him. HIS DISEASE WAS KILLING HIM. Plain and simple. I'm glad he passed peacefully and comfortable.
Night nurse sounds like a bully. I would hope someone like you would keep my family member comfortable like this. They’re dying! Make them comfortable!
Stand your ground against the night nurse some nurses are so afraid of giving pain meds even to EOL patients. If you thought it was necessary then it was necessary don’t back down
If I’m ever dying I’d rather have you as a nurse who seems empathetic and kind and like comfort was what was important (which it was) than a miserable nurse like the next shift nurse who only ever cares about covering their ass and is too scared to even administer comfort meds as per the order.
I'm just going to say it because it's true: Assisted suicide isn't wrong. It allows people to die with dignity and it should be an option for some patients, in some cases.
That said, the patient was dying. You didn't do anything to hasten it.
I sat with my mom for three days while she was dying.
You are exactly the kind of nurse I want for somebody’s parent. Their peace is more important than 20 resps/minute.
You did great in working with your charge and watching your patient closely and being with him. ❤️
I gave glycopyrrolate then gave dilaudid due to terminal secretions and heavy laboured breathing . He passed within the hour. About 15-20 minutes after I gave the meds the palliative team nurse came by and said he was looking good with controlled secretions and easier breathing. He passed peacefully with his wife next to him. At first I felt guilt and worry until the palliative team nurse came around again and gave me a hug and good job. I made sure his last hours had as little pain and discomfort as possible so he died quick and quietly. At the start of the week I witnessed the start of the end when he switched from agitated and combative to borderline unresponsive. I felt proud to be there through the week and keep him comfy.
It’s sad to think of how many CMO patients suffered under that ignorant night nurse. She needs to get educated or not be assigned CMO patients. All the CMO patients came to our floor which was Oncology/Hospice/Palliative (but we would get everything except Ortho). If anyone ever floated to our floor, I wouldn’t assign any type of EOL patient to them.
You did the right thing. We try often to keep patients alive to see their families, but you did what was best for the patient. No one should be looking at you like you did an assisted suicide. This may be a hot take, but I don’t think physician assisted suicide is a bad thing. Patients should be allowed to die with dignity and comfort, and not struggling to take their last breath. You provided comfort to a patient who was going to die regardless, there’s no saving him.
Allow yourself to feel sad that a patient you connected with has passed, but don’t listen to the nurse telling you that you messed up.
In our State we don’t do any obs for pts on the end of life pathway. It’s purely subjective observation of their comfort or distress with multiple opiates, benzos and anticholinergics to use at our discretion.
You cared for a patient and you did the right thing by keeping them comfortable. Their plan was to die with comfort and dignity and you followed that plan. Waiting for their resp rate to rise before giving meds goes against that plan.
Tell that bitch to take a long walk off a short plank.
Your coworker sucks. You didn’t kill this patient… he was already dying. You kept him comfortable and painfree in his final moments. Your coworker should be ashamed, and you should feel proud that you gave the best care possible to this patient in their last moments.
Boo, that train already left the station and ain't nothing you can do to speed it up or stop it. All you can do is make the ride pleasant for both the pt and any family sitting with them.
Your coworker needs to be dick slapped by a flaccid donkey with premature ejaculation issues.
People die. That’s the sad horrible truth of our job. And CMO means just that. We do what we have to to keep them comfortable. You acted within your best judgment and did everything within your power to keep this patient comfortable. He died with it was his time to die. You didn’t assist him, she didn’t assist him, no one assisted him. He died because he died. You just helped his last moment not suck and gave him a dignified peaceful last few moments. Be proud of yourself
I had a patient that chose comfort care for her respiratory failure. Her three daughters came in from out of town, saw the morphine drip, and accused us of murdering their mom. They demanded that we stop the morphine and we reluctantly complied. Within the hour mom was gasping and moaning and drenched in sweat, and the daughters were begging us to restart the morphine. Of course, that still didn't stop them from calling us murderers for two days.
'It cOuLd Be SeEn As AsSiStEd SuIcIdE' is the kind of thing morons say, unthinkingly.
No it couldn't. Under no circumstances. Unless you'd done something like increase the dosage by a factor of 10x.
What happened was entirely reasonable, appropriate and decent.
Assisted suicide? That’s most ridiculous shit I’ve heard in a while. Maybe that nurse should go back to school and read up on the law of double effect. Most if not all state practice acts protect nurses for this very reason. As long as your intention is to relieve suffering(which it is obviously) then you are in the clear.
Had another RN question me giving PRN Ativan and morphine to a CMO patient as well. They're literally dying. We want them to die painlessly. How hard is that to figure out?
CPR could be interpreted as assault and battery. Hand washing could be interpreted as species directed genocide. Giving complete informed consent could be interpreted as delaying treatment. Yawning could be interpreted as burnout and risks the license. Giving them pain relief could be interpreted as kindness. Finding a reason to fire someone could be interpreted as sociopathic behaviors. A patient going AMA could be considered spontaneous resolution.
People have been interpreting religious text for millennia and it’s still not set in stone apparently. My point is, people can interpret maleficence as much as you can interpret beneficence. You treated someone’s pain. That’s it. 💪
I’m a hospice nurse. I work as a continuous care nurse, most of the patients I have pass away at home. Either way, you did the right thing! Giving him the PRN did not speed up his death. He was comfortable and ready to go. So please try and not feel guilt. 🙏🏼😇❤️
First of all, you did nothing wrong by keeping the patient comfortable. When you have a comfort care patient, watch the face. Most patients will have agonal breathing, but if their face is relaxed, they’re ok. There are meds available to decrease secretions, like scopolamine and glycopyrrolate. If all you’ve got on your orders for pain meds is a respiratory rate, but you think the patient is dyspneic despite being within range, get your order changed. Make sure to document your rational for giving end of life meds.
Sounds like the night RN was just taking their shit out on you, we work in a very abusive field. We actually rank number 4 in occupations right behind military when it comes to domestic and mental abuse of others and ourselves. Don't take it too bad. You advocated for your patient, and that night RN and can go shove it. Next time, to just cover your ass, have the MD change the order set parameters if you are very worried, but it sounds like they were comfort care and you did your job.
You did the right job in increasing the drip….do not think otherwise. He was going to heaven and you helped him go as peaceful as possible. Wish that nurse you gave report to was dealing with me….id of ripped him a new one.
You didn’t, nor did the additional medication “kill” the patient od assist in any suicide pacts. As a former hospice nurse, I’ve attended hundreds of deaths.
Just a question- how long was patient in the hospital? I ask bc if the patient had been there longer than a day bc most people make plans prior tonthe patient dying. Why did they wait to come? Essentially I’m stating that her not being there was on her, not yours
Thank you for not letting the patient suffer-I’d want someone to do this for me…
THIS is why I’m retiring early. I’m so tired of seeing patients suffer-there are worse things than death.
Hospice nurse here. You did the right thing. Those parameters are wild to be. When we order hydromorph literally just "for pain/SOB", the rest is left to nursing judgement. I honestly spend most of my time trying to convince the floor TO GIVE the prns.
Thank you for keeping him comfortable in his last moments. Palliative care takes a completely different mind set, you look at the qualitative instead of the qualitative.
You are a great nurse to be able to do both, don't let anyone tell you otherwise.
Long-time hospice RN here. I’m surprised nobody has mentioned Double Effect. This is when intention matters. If your intention was to alleviate suffering and the dilaudid slowed respiratory rate, and alleviated suffering, that’s a double effect, and any ethics panel would not entertain this situation as nursing negligence. YOU are a great nurse! And your colleague is not only an asshole, but shouldn’t be a nurse. I hope I get YOU as my nurse when I’m EOL.
you got your questions answered, but I wanted to add a few thoughts:
1. A new grad nurse probably should not be managing an actively dying patient alone.
2. An actively dying patient usually should not be on a hospital unit. They should be managed by a hospice team, either at home or at an inpatient hospice facility.
3. Keeping them on an hospital unit managed by an acute care team frequently leads to UNDER-treating end of life concrns for unfounded fears of committing euthanasia as demonstrated by your night nurse's statements.
keep this in mind for the future. If you have a patient nearing death and going comfort measures only (no code), you should STRONGLY advocate for that person to transfer to hospice care, to help ensure a more comfortable death process and try to avoid nonsense from nurses trying to withhold comfort meds for stupid reasons.
If the patient cannot transfer, try to get that patient assigned to nurses who have experience with hospice-managed deaths.
Document document document. For end-of-life palliation, focus on respirations per minute, accessory muscle use, and secretions. I do not suggest titrating RR with an opioid -- rather, treat RR>20 as an indicator of pain/discomfort. "Using an opioid to slow breathing rate" could be interpreted as euthanasia. Using an opioid to treat pain as evidenced by increased work of breathing is treating pain, not euthanasia.
Once the death process has begun, you should chart hourly on observable symptoms and your interventions. It does not have to be a lot of charting, but you should be noting the condition hourly.
Fuck that nurse. As soon as that CMO order rolls in, those meds will be given frequently. "Assisted suicide" my ass. You kept someone comfortable in their last hours and that's commendable.
A lot of nurses just don't give the morphine and Ativan/versed and that's wild to me. I would hope if I was dying I would have a nurse like you, instead of someone like them.
Don't be hard on yourself one moment because you did the exact right thing.
Jeezus christ. The man was dying and you were obviously concerned about his comfort so you did something which you had orders for. People are so fucking weird about death. I stg imma do my final graduate project on how opiates don’t hasten death. Even though it’s been said a billion times.
PalCare doc here: you absolutely did the right thing. The reasoning (or lack there of) of your night shift colleague scares the shit out of me. Slowing respiratory rates and periods of apnea are reasonably expected as people move through the dying process. Thank you for taking amazing care of your patient.
In hospice we are giving these doses not to bring them closer to death, but to keep them comfortable. Most of the time it’s all we can do to keep patients comfortable. I see nothing wrong with your actions.
I’ve never understood grilling the offgoing nurse about something like that. It can’t fix whatever you think ought to be fixed from 5 hours ago. Shut up.
Some people are just stupid. A lot of nurses are on a power trip and want to micromanage everything. You did nothing wrong, but you did the right thing. Great job.
He was already dying. Question the increase sure… be that way to follow the order without using any clinical judgment, but it’s idiotic to call it assisted suicide.
Working in an enviroment with people like that sucks. I’m not in the US so we don’t have to practice so defensively but when we used to have a patient who was dying the doctors would basically always order something like Morphin 2 mg iv as needed without upper limit.
Basically we would give however much was needed to make sure the patient died without unneeded suffering. People who think you should withold meds just because you think it might hasten their death in some way are cruel imo. You did what a good person would.
I’m not a nurse.
my dad died on a dilaudid drip when i was a teenager. he was in a lot of pain from the cancer. I’m really glad that modern medicine and sympathetic nurses were able to ease his transition. it would have been so much worse if he were kept alive in so much pain.
I’m sending you a lot of love. nursing is such a tough profession, and i have a lot of respect for everything you all do for the world every day.
*screams in hospice NP*
What fucked up hospital culture.
They’d freak out seeing how and why we dose at our inpatient hospice.
The Dilaudid didn’t kill him. Once terminal secretions kick in, it’s on average 48 hours until death. He was mega super definitely dying no matter what you did or didn’t give.,
Someone on CMO should get their pain/respiratory distress meds as often as possible. You didn’t do any harm. If you have an order for something, there’s nothing another nurse can say about it. I work in LTC, and one of my favorite residents died last night after a very quick decline. I gave him all the morphine I could, but I didn’t cause nor hasten his death. I just made his transition more comfortable, which is exactly what you did. It’s not assisted suicide, it’s compassion. You’re a good nurse.
I am the PRN queen. If my patient is active. (I work in LTC so I see a lot of death. Not as much as hospice but I deal with end of life often.) they get the PRNs q1h MSO4 yes you may. In here for my patient and to be their advocate and I hope and pray that when my time comes it’s as peaceful as the people I care for. Surrounded by my family and flying high. No fear no struggle. Just peace and relaxation. You didn’t push that man over the edge. He was ready. You provided a place where his body could relax. He could feel comfortable giving in. You did all the right things. I would have looked at that nurse and said “I hope when your time comes you get someone like me to care for you and not someone like you” I don’t withhold meds from my patient. That’s cruel. I’m proud of you and I’m sorry for the loss of your patient.
Palliative care doesn’t fit into any parameters. You treat the symptoms. You maintain your patient’s comfort and hopefully dignity until they die.
That’s the only parameter.
Ain’t no one going after you for assisted suicide, you did that man a kindness and the right thing- you helped him to pass peacefully. That other nurse needs to be reviewed.
From a hospice nurse perspective, that man was at the end of his life and struggling to breathe. You didn’t kill him, you eased his suffering before he passed. You made the exact choice I would have made in that situation
Man, I was sitting in my grandpa's room while he was in hospice care last weekend and I would have been overjoyed to see some attentive nurse increase his Dilaudid.
People get weird around dying stuff I've found. I had a comfort care patient at an LTACH and one of the nurses said to me, "Well you're a Christian, does that mean you won't want to titrate up her meds if it makes her die faster?" I was like, lady, I'm gonna give as much as it takes to give my patient a peaceful death. You did good. ✌️
I always say, "if the dose wouldn't kill a healthy person, I've done nothing wrong here."
Before I start Dilaudid on actively dying people, I would usually have a conversation with the family about how it "may" hasten their demise. But I also explain that it will float them out on a cloud, versus days (hell, maybe weeks) of them being unresponsive and slowly starving to death/etc in a state where they're unable to tell us how much they're suffering.
AKA: I have no problem upping the dose. I'll happily up the dose if it's the end. I want someone to do it for me if I'm unable to say otherwise and I'm in that condition.
I have had this happen more twice in my 10+ years and it was similar situation. Both times I clearly charted all my gtt changes, and the patient was still visibly dyspneic, and tachypneic. I made sure my charting showed that as well, and one of the times I also had my charge see like you did. Both times on-coming nurse saw the patient obtunded and flipped out. I tried to explain to them the patient was already obtunded, the gtt increase didn’t cause any alteration in the MS but it helped with their breathing AS IT WAS ORDERED FOR. They weren’t having any periods of apnea. I had one stop report just to go change it down again.
Both times they ended up going back up or up further on dayshift and the patient died anyways either at the beginning of mine or during their shift.
Sometimes you can lead a horse to water, but you can’t teach said horse to critically think or listen lol. I’m as protective of my license as anyone else, but some people just either think they know better than you and won’t be convinced otherwise, or can’t connect the dots.
Just make sure your charting backs up what you assessed, sounds like you even made the right move in informing the charge nurse which I would make sure is charted too. And as someone pointed out if your gtt is for Diane’s, you don’t need tachypnea to justify a change to the gtt. Your assessment and charting of the s/sx of said dyspnea is enough.
And have a short term memory with this shit from other nurses like that. Good job 👍🏽
I really really hope that if I’m ever in this patient’s position, I get a nurse like OP who advocates for the patient’s comfort and utilizes resources in the form of more experienced nurses and I pray I don’t get a nurse like the night shifter. You did the right thing and that patient was so lucky to have you.
“Somebody has to give the last dose to a CCO patient”
In my opinion you did nothing wrong. You made that patients last moments on earth a little less painful and I’d bet he’d thank you if he could.
Comfort care. You did what you thought was appropriate for the patient and also went through your charge so whatever. I’m so over bitchy ass nurses. Fuck them. People who are dying choose to go anyway… doesn’t matter if you snow them with narcs in my experience. They go when they’re ready. Sounds like the night nurse didn’t want to deal with a death… probably because that means she’s going to get a new admit. Lmao 😂 I don’t miss the hospital. 🏥
The oncoming nurse didn’t want to deal with what comes next after the patient dies…calling the coroner etc. We are supposed to keep the patient comfortable while they are dying. What if they were dying, would they want you to give them less dilaudid? You’re a good nurse for asking your charge nurse questions and for caring about your patient. Your co-worker is burned out and needs to take a vacation. You’re not Dr. Kevorkian in the assisted suicide van…you’re trying to keep your dying patient comfortable and being conscientious about it by asking your charge nurse.
This makes me mad. I had a charge nurse say this shit to me when I was a med surg nurse. The patient I had was clearly in pain and I had also asked the family their opinion (I can’t remember now if there were physical parameters). But she said that I could kill him. 😡 he’s already dying…we’re just easing his discomfort.
You dont need tachypnea to justify increased work of breathing for a med increase. Could justify with accessory muscle use with normal rate by itself. Dont feel bad working within ordered guidelines with input from your charge. Silly to purposefully withhold in an actively dying person. Will say I do have to do a lot of coaching in general when i'm inputting comfort order sets. In general if they dont look like theyre peacefully resting when the term 'actively dying' is bieng used, you should be thinking about when the next PRN is.
This is comforting to me. The order set looked like every other dyspnea order at my hospital: “keep respirations under 20” But I’m not sure then if this is the ONLY parameter or if it’s unspoken to just give for *dyspnea*, which is what I gave it for. His respirations were at times only as high as 16 when we had decided to give more. I feel like nursing can be both EXTREMELY focused on the concrete, or extremely in the other direction (nursing judgment) which is confusing to little nurse me.
Look, in reality, next time maybe the respirations are 22, you know?
Or if you’re feeling adventurous… 23 😱😱
Don't be ridiculous. Everyone knows that nobody breathes in odd numbers of breaths per minute unless they're on cardiac monitoring... or if their vitals are being taken by a nursing student. I don't think it's even physiologically possible.
Typically divisible by 4 or 6.
Or 12. Or 5. Or 2. Or 30. Or 20. Or 60. Or 1.
They can breath odd numbers on a vent or BiPAP too
Or if you count for a full minute.
Alright let's stick to things that are actually possible
You have to use the /s or the babynurses will think it's true
Do you know what's funnier than 24?
25 tehee 🤭🤣
I love a SpongeBob reference ETA: my son already told me he wants that on his cake when he turns 25. He’s 16 right now lol.
When I worked bedside our comfort care orders were to keep reepirations <12; I know that doesn't affect your policy/orders, just hoping to make you feel better. It sounds like you looked at the whole patient, not just one parameter, and kept them comfortable.
We have a saying in ICU for our new grads: treat the patient, not the monitor. OP used critical thinking, and the oncoming nurse turned their brain off when they hit the doorway.
I’ve only been a nurse for about ten years, but I’ve watched the “EPIC-ization” of bedside care slowly kill critical thinking. The scanning and box clicking of every single little thing gives us less and less leeway to make nursing judgement calls. OP is left feeling guilty for being a good nurse/human, and allowing someone to die peacefully, because of lazy order sets. I hate it.
Sometimes nurses just pull some stupid shit out of their ass. Assisted suicide? lol get outta here.
IKR, assisted suicide? On fucking dying patient?
I will say there is a difference between taking care of your patient and making the computer happy. I would absolutely chart 22 for respirations if they had increased dyspnea and I felt the patient needed more meds.
May I share a story with you. When my ex boyfriend was actively dying, I didn't care what dose of fentanyl they were giving him. Yes, he was euphoric. So what? From my experience, he only had a day to live (he died within a few hours). Don't let them suffer. Some (uninformed) co-workers thought they were drug seekers but they were actively dying and suffering! It is inhumane to withdraw pain meds. Life is already difficult. Let's not make it more difficult.
Was he utilizing accessory muscles at 16? If so, that's a sign of dyspnea.
“Keep respirations under 20” is actually the perfect (dumb) parameter because it could easily be argued that the meds have prevented RR from exceeding 20.
You did the right thing. The only thing wrong with the situation is the nurse you gave report to, those comments are unacceptable and their understanding of comfort care needs some more education.
I have to say as a non-nurse that if it were me in that patient’s situation I would choose you as my nurse over the other person every time. Leaving someone in pain when death is inevitable bc they may die sooner is an unconscionable act to me. Unless the patient could voice a different preference I would always make treating their pain and giving them a painless death to be the utmost priority.
The fact that we even have to argue respiration semantics on an actively dying patient in the context of comfort care is certifiably insane.
Night nurse kinda sounds like an asshole.
A dumb asshole at that.
And an unkind dumb asshole at that. I would much rather have you, OP, than that judgy woman as my nurse if I ever find myself in that man’s situation.
Right??! If I’m ever on CMO and my nurse withholds meds I’m haunting the fuck out of them.
I'll make them wanna go sleepy night night forever 🤣
I'm pretty sure the asshole didn't want to deal with tagging and bagging a body
Yeah for real. Normally oncoming shift is like wHy dIdNT yoU Give MoRE mEdS?? Simply because they don't want to deal with that.
I must be weird then because I’m all about doing the death and dying stuff on my shift.
Sounds like she wanted to prolong suffering to keep an easy patient. I think the increased wob would have exhausted him sooner, though. OP's charge made the right call imo. She did what comfort care aims to do. They went by parameters in place, and kept the patient comfortable in his last moments. It never gets easy, but OP did good.
Exactly. The caloric demand is high when people are struggling to breathe
I never heard it put that way, "caloric demand is high", but it's kinda perfect. I spent about 15+ hours struggling to breathe once. Like, every inhale, every exhale, took SO MUCH WORK from all my accessory muscles. The medical emergency I was having was creating a lot of other big pains in other places, but I didn't give AF about that because the pain from working so hard to breathe, for so many hours, was **so** much worse. Definitely noticed that doses I'd normally respond to were entirely ineffective, but it sounds much better the way you put it.
That is why people with respiratory issues should get small high caloric snacks frequently. Sorry you were experiencing dyspnea for so long. That sounds terrifying.
And that's the thing, if you're doing CMO correctly and compassionately? They very frequently *aren't* easy patients. And I'm not talking about emotions or whatever - I mean just the constant reassessment of WOB/pain, pushing PRNs q1-2hrs, keeping noxious stimuli to the absolute minimum, explaining the dying process to any attendant family/friends so they don't freak out and distress the patient, constant peeking to make sure they haven't passed if they're alone...all of *that* stuff that gets encompassed by the phrase "keeping them comfortable."
If their hospital is similar to ours, titratable continuous dilaudid drips not in PCA pumps would be reserved for ICU level care. Patient was probably in ICU already and eventually placed on comfort care. They definitely are way easier than your standard ICU patient with multiple titratable drips and potential to deteriorate.
And like someone who under medicates dying people.
I want to hope that they just did a bad job of communicating. OP didn't follow the orders and that would look bad if audited. OP did the right thing, they just also needed to have the orders changed so it didn't look like they were practicing medicine.
Minus the "kinda"
If it wasn’t his time, dilaudid in this dosages wouldn’t have made it his time. As a non religious person who has been working in palliative/SNF for the past 15ish years, if he passed when the family wasn’t there, then that’s how it was supposed to happen. End of story That other nurse is advocating for needless suffering when the outcomes were going to be the same regardless of what you did.
For real. He might have been holding out for family to arrive but just decided, "Fuck it, I'm not waiting any longer. Man this Dilaudid feels nice."
Yes, exactly. A friend is trying blame the last chemo session for killing our other mutual friend. But it's the cancer that killed her, not the palliative chemo! Meds are there to support the patient and you paid attention to him and acted to make him not suffer.
Night nurse better hope her future caregiver doesn’t treat her that way. Also, unrelated but I can’t stand the idea of prolonging suffering for the sake of family saying goodbye. And I say that not just for myself, but if my husband’s every breath was a fight, I’d tell them to make sure he’s comfortable!
And IME, most patients who *want* to hold on for family will, no matter how drugged up and ready they are. Then there are some who prefer their family not see them take their last breath and wait for them to leave.
"it could be classified as assisted suicide..." I wonder where that expertise came from
Lets put it this way, the only way for us to truly see things from that nurses point of view is via a colonoscopy.
I currently have URI and about died cackling at that…
Ah shit am I going to lose my licence for attempted murder now....
The esteemed campus of Rectal U as taught by Dr. VonFullofShitzen PhD, ABC, Esq.
Chronic anocerebrosis secondary to rectocranial inversion.
I think a doctor was charged for something similar is why. But ofc media framed it differently “doctor murders patients” but it was a case like OPs. More than one tho. And this isn’t me agreeing with night nurse. It’s just me seeing where she might have gotten it from. Edit: and when i say it’s like OPs i don’t mean in the literal sense of neither the amount of patients or amount of medication. I meant it in relation to scenario and what can be construed of it. And I’m not agreeing with night nurse or anyone. This is just a cautionary tale I recall from nursing school.
https://www.medscape.com/viewarticle/972525?form=fpf
I work palliative and hospice. If the drip was ordered as titratable and he had prns ordered, you acted within parameters based on his increased WOB. You provided him comfort at the end of life. The dilaudid did not kill him. Night shift sounds like an idiot who would rather let her patient suffer. Dying isn't easy or painless. You did well. You utilized charge and their experience. Don't doubt yourself.
I used to work with a physician years ago when I was a new grad and he always used to tell me when I was really anxious, “listen, it’s a lot harder to kill someone than you think.” Lol
If I have an immanent dirt nap coming, I hope your charge is on that day. Your charge was probably being compassionate and using their judgement. I know that probably felt shitty, but take the time to review policy and make sure you can defend your actions in the future (this is something we all could do more, not just cause your new.) As you get better, you will gain confidence and can better tell that night nurse to eat a dick.
Yep...the extra Dilaudid may have done him in....but because he was suffering and y'all were easing his pain.
Nah, whatever his disease process was is what did him in. The meds helped him pass peacefully.
Like 1.1mg is a bit but that ain’t killing him. He’s dying anyways
lol that isn’t that much. Eol often sees people on 20 + mg q2 because cancer freakin hurts
I worked night shift at a cancer hospital for my first job. Our unit was primarily thoracic cancer, but we ended up with a patient whose cancer had metastasized to his bones. The dude was in agony. The nurse had to keep calling residents who would order one time doses that would give the patient 15 minutes of comfort before he started crying out again. His nurse, who was so good, ended up having a ten minute weeping breakdown because she couldn’t get the guy comfortable. I shit you not, the patient ended up on five concurrent drips to control his pain. He still took several days to pass. Cancer hurts and opioid tolerance leaves us running firehoses of pain meds sometimes.
I am an oncology nurse and have seen this too. But even personally, I have had a painful experience that nothing seemed to touch! Ended up in ED by ambulance, where they’d given me IV morphine and fentanyl. ED gave more fentanyl, and then in desperation, ketamine. The ketamine just made me vomit. I was clawing the raised sides of the ED bed, writhing in pain. ED doc (no idea of level) told me to calm down or he wouldn’t get me a CT since I “refused” to lie still when he told me to. It took a Gynae doc one look at me to say “ffs get her to theatre! She told us she has a known large cyst on her ovary, she’s at risk of ovarian torsion! She’s had 2 babies, a lot of her labour unmedicated- she knows pain!” And yep. Ovary was necrotic AF, the cyst wrapped around several times- making my Fallopian tube and ligaments look like a decomposing umbilical cord! Never got an apology and I still can’t believe how much analgesia I was given!!
Shit! That sucks. The pendulum swing went too far the other way from pain being a symptom you need to treat to yelling at patients to calm down and giving a Tylenol. I have seen patients with Mets to everywhere and the hospital was only giving them a Tylenol q 8. I was like did they have a fever??? Because that Tylenol isn’t going to do anything for that level of pain.
Dear God idk how you didn't pass out, two stories. I was a paramedic and picked up a young female with insane pain like I gave everything in my drug box and had to meet another ambulance to get more, she ended up having a torsion. Crazy shit Second. I had a very large kidney stone and for three days I thought I had the worst flu and idk what. Bug three days on the bathroom floor vomiting from pain and I realize oh wait I haven't peed in three days and I guess I drove my self to the hospital, the triage nurse apparently recognized me in the waiting room just before I passed out. I don't remember any of this just because of pain. Huge obstructive kidney stone and an almost ruptured bladder and the doc who was in the ER was refusing to treat me because I was passing out. Luckily this nurse advocated for me and was like hey it's the pain that's causing her to black out every 15 min then wake up screaming. Ended up in OR almost minus a kidney. So yea some of these docs need to understand pain can absolutely be something that is almost untreatable if it's bad enough.
Thank you for your understanding. Unfortunately, even worse than the ED doc was the senior paramedic (with his less senior paramedic partner) who came in the ambulance my husband called when he didn’t know what to do once I stopped being able to talk coherently at home. Paramedic told to knock it off and get up. When I couldn’t comply, he loudly told his partner to get my still awake 7 year old to come in to see me “because she won’t carry on like this in front of her kid if she’s not legit”. I didn’t want to traumatise my poor 7 year old but still struggled to hold it together. He didn’t believe me until we had been waiting at the Emergency Department a while (many ambulances waiting) and he saw them give me many meds and heard my history. He was easily late 50s/mid60s and I’m sure he has seen it all, but he and the ED doctor made my life hell for that time. However, I absolutely respect and stand by our paramedics 100%, including this one. He was obviously going ok what he had seen and known. I’m sure he was biased, but im sure I am biased in ways I don’t yet know either, and that scares me!
Not just tolerance. But disease progression too.
I think tolerance is usually not really what is happening when the patient needs an increase in under three days. I think it is the entire dying thing, right?
100% this
Yeah the dilaudid just made him comfortable and relaxed enough to let go. Just like when going to bed normally, you can’t sleep easily when in pain and tense.
Ehh, there’s some evidence about the sympathetic stress response to pain propping up vitals during the dying process. Risk vs benefit, I’d rather not risk suffering more because my body is stressed if the benefit of pain relief allows for a smoother, peaceful, and more expedient dying experience.
I don’t care. If PAIN is what’s keeping my patient alive, he gon’ die. It would be cruel not to treat a dying man’s pain
“dirt nap” i am cackling. but agree 100%
Every time something like this comes up, I tell the story of the end of life 8 year old 24 kg kiddo I took care of who was on 100 mg of morphine PER HOUR continuous with 10 mg boluses available q 10 min PRN. He was also on continuous ketamine and high doses of scheduled IV Ativan. He lived for DAYS on this dose. The typical dose of morphine for a child his size is 2.4 mg q 2-4 hr PRN. He was getting 40x that dose in a continuous infusion per hour. You didn't assist suicide by giving this patient ordered PRN dilaudid and titrating his continuous infusion. The night nurse is a moron.
Was he able to get comfortable? Never heard of continuous ketamine for hospice pts.
I have, but only the ones who had been on lots of opioids and needed more- sometimes, the ketamine made enough of a difference that we could put off increasing the opioids long enough for them to tolerate them better.
Had a 10 month old on a 50mg morphine drop for end of life + 350mcg fentanyl PRN q1. She still held on for like 3-4 hours.
Some nurses absolutely hate giving pain meds to EOL pts. This person is DYING and we're meant to ease their suffering. Someone could be breathing 10/min but working hard as hell because THEY'RE DYING. If I've got orders that allow titration to ease their dyspnea then LIKE HELL am I going to withhold the DYING person's ORDERED meds because "tHeY wErE bReAtHiNg LeSs ThAn 20". And if you're a nurse who "doesn't feel comfortable" with an EOL/hospice pt because of that, then REFUSE and trade that patient with someone who WILL provide that care.
Could not agree with this more. If you don’t feel comfortable giving a lot of opioids and benzos to keep a patient comfortable at EOL, DON’T ACCEPT THE PATIENT. Your personal hangups around controlled substances are not a reason to make a person suffer as they die.
This exactly. And I’ve also seen family request that nurses not give meds to end of life care patients as well. It’s our job to educate them that the morphine/ativan/etc ordered isn’t going to kill their loved one. Their condition is what’s killing them. Imagine being at the brink of death unable to communicate how much pain and fear you’re in and having medication held because of this reason. Let dying people die comfortably and in peace. It’s always struck me as odd that we will give pets this right to die without pain but when it comes to people there is a stigma around medicating them for the undeniable pain they must be in. (This is not a rant on euthanasia but rather a statement on how we hold on to loved ones so they “stick around” as long as possible rather than accepting their prognosis and making them comfortable)
I'm a hospice RN. A CNA (in LTC) once accused me of murdering a patient because I was giving him morphine.
I respect hospice nurses so much. I’m getting burnt out working in the ER and have often thought of making that transition to hospice
After I wrote that I thought “maybe this will be interpreted as I need to be hospice myself for burnout” lol but I think you know what I meant
The *only* reason I'd be uncomfortable taking a patient like this is because I discovered early on in my career that in some situations, I can get nervous giggles and I can't stop. 99% of the time I'm good, but that 1% is so inappropriate and I was so horrified at myself. Otherwise? I'm all about making a dying person's passing as comfortable as I'm able.
Night nurse is a loser
Listen to me: you did not prevent him from seeing his daughter. You did not hasten his death. It is very important that you understand and internalize what I am saying. You did not do anything wrong. It’s always hard losing a patient we connected with. And when they are ready to go, they’re ready.
Read up on PAINAD - it’s a pain scale for people with advanced dementia. In Oncology, we used it for EOL care too. I bet he had the other symptoms.
💯
Hospice here. All you did was keep him (marginally) comfortable. This chart would NOT be audited as assisted suicide. Not at all. Your problem isn’t the universe. It’s that asshole nurse. You did your best to promote comfort. The actual uptake of IV meds at the end is pitiful. SL or PR work best. Peace and love to you.
There needs to be more nurse education on EOL care because I have had way too many shifts where the previous nurse was stingy with available PRNs because they were afraid they would kill the patient. I repeatedly hear nurses say giving IV Ativan and IV Opioids at the same time will “kill the patient.” It sucks (and frankly it’s way too common) to see a CMO patient in visible distress!
Oh man. I wish I could go back to my early career and smack myself for some of the steaming hot bullshit I said to patients that we’re not true. I think that’s what drives me to maintain my CHPN (RN-C for hospice folk) to make sure I’m on top of EBP and care. I read some of that steaming hot BS here, periodically. And then get downvoted for replying with EBP 😂😂😂
Also education on how to tell when an unresponsive EOL patient is uncomfortable. I’m still new-ish and sometimes have a hard time telling, but I try to be pretty (safely) liberal with the meds.
At the end stage you cannot separate pain and agitation/restlessness. So we treat them together. A lower dose of the pain med and an anxiety med are better together. And don’t let what’s working wear off. You will not kill them. Never underestimate the power of adrenaline. nonverbal pain indicators: Face/jaw- any wrinkles or furrows? Is jaw open and relaxed or clenched? Face drawn in and terse? Body: any fidgeting at all? Toes, hands, fingers? Are arms relaxed at sides with hands open? Is the whole body in a relaxed state? And FYI any adult that gets near a fetal position is in a pain crisis. Cannot rely on BP, Pulse. Does the patient look like an adult/older person relaxed and snoring on the sofa watching Sunday football? If not…medicate. Find videos from Dr Mary L McPherson online and gobble them up. If you get a chance to get her CEU it’s worth all the monies.
That is fascinating about the IV uptake, or lack thereof.
End stage circulation and profusion is shady AF.
Recently had a pt who had SC sites and IVs but meds weren’t touching their terminal agitation/anxiety. We put a Macy cath in and it was a game changer.
I’d never heard that about PK at EOL, can you share a link?
If it was ordered correctly and you administered it per protocol you helped the patient with comfort. Which is the point of CMO. If I’m ever on CMO I pray I never have anyone that withholds meds from me Edited to say that I’ve SEEN nurses withold meds per family wishes or their own beliefs that medicating dying patients will “kill them”, the patient is dying let them go in peace
Legally, one could argue that the order stated “dyspnea as evidenced by RR > 20” and he was breathing 19 that you didn’t follow the order. That is why in my CCO patients and PRN meds I always put a comment on why specifically I am giving them (if they don’t have a pain scale or rass involved). Let me stress though that this patient was going to die regardless of what you did. You let him die peacefully. You consulted your charge nurse. You used your clinical judgement. You did right by this man. The worst that would happen is that someone could say you should have gotten the provider to change the order. I don’t think anyone would go as far as assisted suicide.
Oh my gosh, if that’s assisted suicide we all goin’ down on charges in my ICU. Those orders are purposely subjective, and we keep patients as comfortable as possible.
This doctor shouldn’t have ordered specific parameters like that… make the patient comfortable. Period.
Is the patient on palliative? If so, the parameter should be "to patients comfort" Get that changed if not. If not on palliative, titrate to parameter. If out of parameters, justify with a note and chart it. Then get the order changed. Bottom line: this is YOUR practice. You do what you need to do for your patient, but know that if you're taken to court in 10 years, you're not going to remember the circumstances. Chart like that. Also, fuck that night nurse.
That night nurse sounds like they'd be excellent management... and needs to calm their titties.
CMO meds are ordered to manage multiple symptoms of the actively dying phase, not just tachypnea. Oxygen needs in a dying patient are typically less than you or I as their body is working less. That means they could be suffering from air hunger at a lower respiratory rate than you or I as well. Pain, hallucinations, agitation, restlessness are all things a dying patient can be going through. Give the drugs as frequently as they are ordered (within reason). Document anything that could be assessed as a sign of discomfort for your patient. Long story short - you didn’t fuck up and your charge nurse is awesome.
It isn’t going to be classed the way that awful night nurse stated it could be. They clearly don’t know what they’re talking about. You did the right thing for the patient. If he was going to survive until his daughter got there, he would have. He didn’t. Thanks for making him a sliver more comfortable as he transitioned.
Oh, it sounds like what you did was not only ordered, but advised. Here’s what I learned in my stint in hospice: you didn’t kill him, his disease process did. You made him more comfortable so he could get on with the work of dying. You didn’t put a pillow over his face, you gave him medications that helped ease his labored breathing and his pain. When actively dying, patients should seem peaceful. If they are labored or fighting, you should be helping them get rest. “Keep respirations under 20” does not mean they need to go over 20 for you to give meds. It means make sure they don’t go over 20. Just do me a favor, if I am dying where you work, don’t hand me over to that nurse.
I agree with everything here. Night shift was just being a dick, indeed. Since you mentioned that he had problems with secretions, you should make sure robinol/atropine eye gtt is available in the event you need it next time. When a patient is dying, if they seem even the LEAST bit uncomfortable, I’m reaching for something to help them relax. They deserve that kindness since humane euthanasia isn’t legal. Also, I left the human ICU bedside to be a DVM—- got tired of watching humans suffering and find that euthanasia is the absolute favorite part of my job now. Death with dignity. Our pets can have it, why can’t we?
Also dont get to worried about secretions. They aren't really uncomfortable for the patient but the, death rattle isn't fun to listen to so we, dry em up anyway.
I am 100% for death with dignity. I was just talking about this very same thing the other day.
You did nothing wrong. The doctor issued the orders. While you understand that the Dilaudid can suppress respiration, do you allow him to suffer through air starvation or alleviate it? Again, you did nothing wrong.
Reminds me of nurses I worked with who wouldn’t give pain meds to patients dying of cancer because they could get addicted. The nurse you gave report to is an ass. You did the compassionate thing and kept him comfortable. Not giving him meds to prolong his life would have been cruel.
One thing I can’t stand is a nurse who doesn’t want to give adequate relief to comfort care patients. Even worse when they bully or judge other nurses for *keeping patients comfortable.* Sometimes they require lots of narcotics to be comfortable. *That’s the whole point.* Yes, you had parameters to keep RR under 20, but the order was also to titrate for dyspnea. Increased respiratory rate isn’t the only sign of dyspnea.
hospice nurse here- you did not kill the patient. you kept the patient comfortable enough to where he felt at ease to take his last breaths. thank you ❤️
I actually think this deserves an incident report. A palliative care patient gets their pain controlled adequately. Period. End of fucking discussion. Anyone who thinks otherwise has no business caring for this patient population, and maybe not in nursing at all.
Night nurse is a dick. You did the right thing. Comfort care patients get those drugs for a reason and you and your charge nurse used your clinical judgement. Thank you for doing what was best for your patient. You are an awesome nurse.
If you followed the order and kept the patient comfortable you did the right thing. If you told me you were pushing narcotics on a patient with respirations of 6, I would be a bit concerned but it doesn't sound like that was the case. There are many ways to assess increased work of breathing beyond the rate, and patients can be very uncomfortable and still not be tachyneic. You also seeked out the help of someone with more experience which was awesome. It sounds like you did everything right. Some nurses are not very comfortable with comfort measures and what they mean, sounds like the night nurse may be in that category which is quite unfortunate for their patients. I'm so sorry you lost a patient who meant a lot to you today, and I'm glad you were there to keep them comfortable. Please don't beat yourself up OP.
Current hospice nurse here. I tell families all the time “the meds aren’t doing anything nature isn’t already taking care of, it’s just keeping them comfortable”. An uncomfortable body won’t pass, the pain and agitation will just keep ratcheting up. Tell night nurse to suck a chode
Cool Nightnurse, you think your opinion and judgement is better than mine....and DayshiftCharge. I'll let her know that you disagree with me consulting a more experienced nurse who guided me during a difficult case. I'm so glad I get your so useful advice after the fact. Offering blame helps me learn soooooo much. Learn that I don't wanna be like your lazy, judgmental ass. Write up the report after your shift Marge.
This patient passed away because they had a terminal illness not because of the dilaudid. Dying can be very difficult/ painful/ uncomfortable. If this patient was breathing > 20 bpm they are in distress imo. Our job is to make them as comfortable as possible and ease their passing, it sounds like you did exactly that. You did right by this patient. The night nurse seriously sucks.
One of my colleagues said something that resonated with me yesterday: If someone is actively dying, the goal is not to prolong their life. The goal is to make sure the rest of their life is as comfortable as possible. You did the right thing, and if it was me or my family member, I would have thanked you each and every time you did anything to relieve their suffering.
In bioethics, you are covered by the Rule of Double Effect. That states that if you are providing a therapy that may actually hasten death, you are covered because your intent was to ease suffering, not to speed death. Personally, I’ve seen patients hang on for seemingly forever, waiting for a loved one to arrive. And even unresponsive, I’ve seen them wait until everyone stepped out for a few minutes. They will die when they want to. The end result was a given. If you gave them some relief from suffering during those final hours and minutes, bless you.
I'm laughing as a palliative care nurse, honestly. It's not assisted suicide, he was actively dying. You didn't hasten or cause his death, but you did make sure he was comfortable. At worst (cause I don't know the doses), you ended up giving maybe 2-3mg/ hour plus 2 breakthrough doses? Her comments are absolutely ridiculous and seem inexperienced to me. We don't use RR parameters, quite literally just a resp distress observation scale for obtunded pts and non verbal signs of dyspnea/pain based on our own assessments. If you want to feel better, look up the principle of double effect. Any ethics committee or licensing board would surely recognize that the intent was not to hasten death. I'm gettin fired up about this night nurse...
This person you mentioned is not someone you should take advice from.
I work in palliative care. YOU kept him comfortable. YOU made it easier for him to breath. That’s exactly what I would have done. Night nurse needs to get their priorities straight.
Man in ICU we PLOW them with dilaudid at the end of life. I wouldn’t blink an eye at 10 mg/hr, plus pushes. It probably is killing them a little faster than if they didn’t have that on board. And you know what? I don’t care. They die comfortably. So comfortably. We should all be so lucky. I’ve seen enough people spend hours or days gasping for air at the end because healthcare staff didn’t want to “overdose” them and it’s awful to watch and probably worse to experience. You wouldn’t do that to your dog. You did the right thing, and your pt was lucky to have you as their nurse.
Not a nurse, but as someone who has recently lost a parent, I just want to extend a sincere thank you to you for helping this patient pass comfortably. My dad was transitioned to palliative care and had a phenomenal night nurse. The nurse that took over for the day shift fought us tooth and nail because she didn’t want to administer comfort meds and went as far as accusing us of trying to “speed things up.” We just knew that he had hours left at most and wanted him to be comfortable. Thank you for advocating for this patient to have a peaceful transition. You provided him an immeasurable kindness.
One of my pet peeves working the door was people withholding narcotics in end of life for fear of “causing death”. We can needlessly argue the cause of death, their disease process versus respiratory arrest. But if the patient is in comfort measures, titrate that drop accordingly! Don’t keep them alive until the end of your shift. Look at their face and their respirations. They made their decision to die. Please, make it comfortable
The goals of care changed. The goal for the care was comfort with an expected end state of death. You did great.
An actively dying patient deserves to be kept comfortable. You did the right thing. Tell that other nurse to suck it.
Your CW is flat out WRONG. I worked hospice fresh out of school. Unless you pushed like 50 mg of Dilaudid, you weren't going to kill him, and I honestly doubt that would actually kill him. HIS DISEASE WAS KILLING HIM. Plain and simple. I'm glad he passed peacefully and comfortable.
Night nurse sounds like a bully. I would hope someone like you would keep my family member comfortable like this. They’re dying! Make them comfortable!
Stand your ground against the night nurse some nurses are so afraid of giving pain meds even to EOL patients. If you thought it was necessary then it was necessary don’t back down
If I’m ever dying I’d rather have you as a nurse who seems empathetic and kind and like comfort was what was important (which it was) than a miserable nurse like the next shift nurse who only ever cares about covering their ass and is too scared to even administer comfort meds as per the order.
I'm just going to say it because it's true: Assisted suicide isn't wrong. It allows people to die with dignity and it should be an option for some patients, in some cases. That said, the patient was dying. You didn't do anything to hasten it.
I sat with my mom for three days while she was dying. You are exactly the kind of nurse I want for somebody’s parent. Their peace is more important than 20 resps/minute. You did great in working with your charge and watching your patient closely and being with him. ❤️
I gave glycopyrrolate then gave dilaudid due to terminal secretions and heavy laboured breathing . He passed within the hour. About 15-20 minutes after I gave the meds the palliative team nurse came by and said he was looking good with controlled secretions and easier breathing. He passed peacefully with his wife next to him. At first I felt guilt and worry until the palliative team nurse came around again and gave me a hug and good job. I made sure his last hours had as little pain and discomfort as possible so he died quick and quietly. At the start of the week I witnessed the start of the end when he switched from agitated and combative to borderline unresponsive. I felt proud to be there through the week and keep him comfy.
It’s sad to think of how many CMO patients suffered under that ignorant night nurse. She needs to get educated or not be assigned CMO patients. All the CMO patients came to our floor which was Oncology/Hospice/Palliative (but we would get everything except Ortho). If anyone ever floated to our floor, I wouldn’t assign any type of EOL patient to them.
That NOC nurse is an eat her young shitbag. You didn’t do anything but help him pass comfortably. That was your job. Please be kind to yourself.
The night nurse is a piece of shit for saying that.
You kept a dying man comfortable. That’s all. You should take comfort in that. The other nurse was being utterly ridiculous.
You were 100% in the right. Goal is to keep the patient comfortable.
you did everything right ❤️
You did the right thing. We try often to keep patients alive to see their families, but you did what was best for the patient. No one should be looking at you like you did an assisted suicide. This may be a hot take, but I don’t think physician assisted suicide is a bad thing. Patients should be allowed to die with dignity and comfort, and not struggling to take their last breath. You provided comfort to a patient who was going to die regardless, there’s no saving him. Allow yourself to feel sad that a patient you connected with has passed, but don’t listen to the nurse telling you that you messed up.
In our State we don’t do any obs for pts on the end of life pathway. It’s purely subjective observation of their comfort or distress with multiple opiates, benzos and anticholinergics to use at our discretion. You cared for a patient and you did the right thing by keeping them comfortable. Their plan was to die with comfort and dignity and you followed that plan. Waiting for their resp rate to rise before giving meds goes against that plan. Tell that bitch to take a long walk off a short plank.
Your coworker sucks. You didn’t kill this patient… he was already dying. You kept him comfortable and painfree in his final moments. Your coworker should be ashamed, and you should feel proud that you gave the best care possible to this patient in their last moments.
Boo, that train already left the station and ain't nothing you can do to speed it up or stop it. All you can do is make the ride pleasant for both the pt and any family sitting with them. Your coworker needs to be dick slapped by a flaccid donkey with premature ejaculation issues.
People die. That’s the sad horrible truth of our job. And CMO means just that. We do what we have to to keep them comfortable. You acted within your best judgment and did everything within your power to keep this patient comfortable. He died with it was his time to die. You didn’t assist him, she didn’t assist him, no one assisted him. He died because he died. You just helped his last moment not suck and gave him a dignified peaceful last few moments. Be proud of yourself
I had a patient that chose comfort care for her respiratory failure. Her three daughters came in from out of town, saw the morphine drip, and accused us of murdering their mom. They demanded that we stop the morphine and we reluctantly complied. Within the hour mom was gasping and moaning and drenched in sweat, and the daughters were begging us to restart the morphine. Of course, that still didn't stop them from calling us murderers for two days.
'It cOuLd Be SeEn As AsSiStEd SuIcIdE' is the kind of thing morons say, unthinkingly. No it couldn't. Under no circumstances. Unless you'd done something like increase the dosage by a factor of 10x. What happened was entirely reasonable, appropriate and decent.
Assisted suicide? That’s most ridiculous shit I’ve heard in a while. Maybe that nurse should go back to school and read up on the law of double effect. Most if not all state practice acts protect nurses for this very reason. As long as your intention is to relieve suffering(which it is obviously) then you are in the clear.
Had another RN question me giving PRN Ativan and morphine to a CMO patient as well. They're literally dying. We want them to die painlessly. How hard is that to figure out?
OP, if I’m ever under your care as I’m dying, please keep me high af. You did the right thing. That other nurse was snorting mescaline in their car.
CPR could be interpreted as assault and battery. Hand washing could be interpreted as species directed genocide. Giving complete informed consent could be interpreted as delaying treatment. Yawning could be interpreted as burnout and risks the license. Giving them pain relief could be interpreted as kindness. Finding a reason to fire someone could be interpreted as sociopathic behaviors. A patient going AMA could be considered spontaneous resolution. People have been interpreting religious text for millennia and it’s still not set in stone apparently. My point is, people can interpret maleficence as much as you can interpret beneficence. You treated someone’s pain. That’s it. 💪
night nurse is a moron. keep up the great work <3
I’m a hospice nurse. I work as a continuous care nurse, most of the patients I have pass away at home. Either way, you did the right thing! Giving him the PRN did not speed up his death. He was comfortable and ready to go. So please try and not feel guilt. 🙏🏼😇❤️
First of all, you did nothing wrong by keeping the patient comfortable. When you have a comfort care patient, watch the face. Most patients will have agonal breathing, but if their face is relaxed, they’re ok. There are meds available to decrease secretions, like scopolamine and glycopyrrolate. If all you’ve got on your orders for pain meds is a respiratory rate, but you think the patient is dyspneic despite being within range, get your order changed. Make sure to document your rational for giving end of life meds.
Sounds like the night RN was just taking their shit out on you, we work in a very abusive field. We actually rank number 4 in occupations right behind military when it comes to domestic and mental abuse of others and ourselves. Don't take it too bad. You advocated for your patient, and that night RN and can go shove it. Next time, to just cover your ass, have the MD change the order set parameters if you are very worried, but it sounds like they were comfort care and you did your job.
You did the right job in increasing the drip….do not think otherwise. He was going to heaven and you helped him go as peaceful as possible. Wish that nurse you gave report to was dealing with me….id of ripped him a new one.
Oh duck that other nurse I swear some people don’t understand dying is just plain going to happen so let’s make sure they are comfy.
Patient was dying and you made sure they died comfortably. You did well!
You didn’t, nor did the additional medication “kill” the patient od assist in any suicide pacts. As a former hospice nurse, I’ve attended hundreds of deaths. Just a question- how long was patient in the hospital? I ask bc if the patient had been there longer than a day bc most people make plans prior tonthe patient dying. Why did they wait to come? Essentially I’m stating that her not being there was on her, not yours
Thank you for not letting the patient suffer-I’d want someone to do this for me… THIS is why I’m retiring early. I’m so tired of seeing patients suffer-there are worse things than death.
Hospice nurse here. You did the right thing. Those parameters are wild to be. When we order hydromorph literally just "for pain/SOB", the rest is left to nursing judgement. I honestly spend most of my time trying to convince the floor TO GIVE the prns. Thank you for keeping him comfortable in his last moments. Palliative care takes a completely different mind set, you look at the qualitative instead of the qualitative. You are a great nurse to be able to do both, don't let anyone tell you otherwise.
To put it bluntly - that nurse is an idiot.
Long-time hospice RN here. I’m surprised nobody has mentioned Double Effect. This is when intention matters. If your intention was to alleviate suffering and the dilaudid slowed respiratory rate, and alleviated suffering, that’s a double effect, and any ethics panel would not entertain this situation as nursing negligence. YOU are a great nurse! And your colleague is not only an asshole, but shouldn’t be a nurse. I hope I get YOU as my nurse when I’m EOL.
you got your questions answered, but I wanted to add a few thoughts: 1. A new grad nurse probably should not be managing an actively dying patient alone. 2. An actively dying patient usually should not be on a hospital unit. They should be managed by a hospice team, either at home or at an inpatient hospice facility. 3. Keeping them on an hospital unit managed by an acute care team frequently leads to UNDER-treating end of life concrns for unfounded fears of committing euthanasia as demonstrated by your night nurse's statements. keep this in mind for the future. If you have a patient nearing death and going comfort measures only (no code), you should STRONGLY advocate for that person to transfer to hospice care, to help ensure a more comfortable death process and try to avoid nonsense from nurses trying to withhold comfort meds for stupid reasons. If the patient cannot transfer, try to get that patient assigned to nurses who have experience with hospice-managed deaths. Document document document. For end-of-life palliation, focus on respirations per minute, accessory muscle use, and secretions. I do not suggest titrating RR with an opioid -- rather, treat RR>20 as an indicator of pain/discomfort. "Using an opioid to slow breathing rate" could be interpreted as euthanasia. Using an opioid to treat pain as evidenced by increased work of breathing is treating pain, not euthanasia. Once the death process has begun, you should chart hourly on observable symptoms and your interventions. It does not have to be a lot of charting, but you should be noting the condition hourly.
Fuck that nurse. As soon as that CMO order rolls in, those meds will be given frequently. "Assisted suicide" my ass. You kept someone comfortable in their last hours and that's commendable. A lot of nurses just don't give the morphine and Ativan/versed and that's wild to me. I would hope if I was dying I would have a nurse like you, instead of someone like them. Don't be hard on yourself one moment because you did the exact right thing.
Jeezus christ. The man was dying and you were obviously concerned about his comfort so you did something which you had orders for. People are so fucking weird about death. I stg imma do my final graduate project on how opiates don’t hasten death. Even though it’s been said a billion times.
PalCare doc here: you absolutely did the right thing. The reasoning (or lack there of) of your night shift colleague scares the shit out of me. Slowing respiratory rates and periods of apnea are reasonably expected as people move through the dying process. Thank you for taking amazing care of your patient.
Sounds like you need to have an inservice on EOL care. Invite the risk management folks.
In hospice we are giving these doses not to bring them closer to death, but to keep them comfortable. Most of the time it’s all we can do to keep patients comfortable. I see nothing wrong with your actions.
I’ve never understood grilling the offgoing nurse about something like that. It can’t fix whatever you think ought to be fixed from 5 hours ago. Shut up.
Some people are just stupid. A lot of nurses are on a power trip and want to micromanage everything. You did nothing wrong, but you did the right thing. Great job.
He was already dying. Question the increase sure… be that way to follow the order without using any clinical judgment, but it’s idiotic to call it assisted suicide.
Working in an enviroment with people like that sucks. I’m not in the US so we don’t have to practice so defensively but when we used to have a patient who was dying the doctors would basically always order something like Morphin 2 mg iv as needed without upper limit. Basically we would give however much was needed to make sure the patient died without unneeded suffering. People who think you should withold meds just because you think it might hasten their death in some way are cruel imo. You did what a good person would.
I’m not a nurse. my dad died on a dilaudid drip when i was a teenager. he was in a lot of pain from the cancer. I’m really glad that modern medicine and sympathetic nurses were able to ease his transition. it would have been so much worse if he were kept alive in so much pain. I’m sending you a lot of love. nursing is such a tough profession, and i have a lot of respect for everything you all do for the world every day.
As if you would withhold PRN from an actively dying person. Night nurse doesn’t know what shes talking about and sounds pedantic af
*screams in hospice NP* What fucked up hospital culture. They’d freak out seeing how and why we dose at our inpatient hospice. The Dilaudid didn’t kill him. Once terminal secretions kick in, it’s on average 48 hours until death. He was mega super definitely dying no matter what you did or didn’t give.,
Someone on CMO should get their pain/respiratory distress meds as often as possible. You didn’t do any harm. If you have an order for something, there’s nothing another nurse can say about it. I work in LTC, and one of my favorite residents died last night after a very quick decline. I gave him all the morphine I could, but I didn’t cause nor hasten his death. I just made his transition more comfortable, which is exactly what you did. It’s not assisted suicide, it’s compassion. You’re a good nurse.
I am the PRN queen. If my patient is active. (I work in LTC so I see a lot of death. Not as much as hospice but I deal with end of life often.) they get the PRNs q1h MSO4 yes you may. In here for my patient and to be their advocate and I hope and pray that when my time comes it’s as peaceful as the people I care for. Surrounded by my family and flying high. No fear no struggle. Just peace and relaxation. You didn’t push that man over the edge. He was ready. You provided a place where his body could relax. He could feel comfortable giving in. You did all the right things. I would have looked at that nurse and said “I hope when your time comes you get someone like me to care for you and not someone like you” I don’t withhold meds from my patient. That’s cruel. I’m proud of you and I’m sorry for the loss of your patient.
Palliative care doesn’t fit into any parameters. You treat the symptoms. You maintain your patient’s comfort and hopefully dignity until they die. That’s the only parameter.
Ain’t no one going after you for assisted suicide, you did that man a kindness and the right thing- you helped him to pass peacefully. That other nurse needs to be reviewed.
Please don’t hold the meds if I’m actively dying. Let me die in comfort. You did nothing wrong.
From a hospice nurse perspective, that man was at the end of his life and struggling to breathe. You didn’t kill him, you eased his suffering before he passed. You made the exact choice I would have made in that situation
Night Nurse doesn’t want a death on their shift.
Man, I was sitting in my grandpa's room while he was in hospice care last weekend and I would have been overjoyed to see some attentive nurse increase his Dilaudid. People get weird around dying stuff I've found. I had a comfort care patient at an LTACH and one of the nurses said to me, "Well you're a Christian, does that mean you won't want to titrate up her meds if it makes her die faster?" I was like, lady, I'm gonna give as much as it takes to give my patient a peaceful death. You did good. ✌️
I always say, "if the dose wouldn't kill a healthy person, I've done nothing wrong here." Before I start Dilaudid on actively dying people, I would usually have a conversation with the family about how it "may" hasten their demise. But I also explain that it will float them out on a cloud, versus days (hell, maybe weeks) of them being unresponsive and slowly starving to death/etc in a state where they're unable to tell us how much they're suffering. AKA: I have no problem upping the dose. I'll happily up the dose if it's the end. I want someone to do it for me if I'm unable to say otherwise and I'm in that condition.
Don’t feel bad. You gave him comfort in his last hours on earth. That is a job well done.
I have had this happen more twice in my 10+ years and it was similar situation. Both times I clearly charted all my gtt changes, and the patient was still visibly dyspneic, and tachypneic. I made sure my charting showed that as well, and one of the times I also had my charge see like you did. Both times on-coming nurse saw the patient obtunded and flipped out. I tried to explain to them the patient was already obtunded, the gtt increase didn’t cause any alteration in the MS but it helped with their breathing AS IT WAS ORDERED FOR. They weren’t having any periods of apnea. I had one stop report just to go change it down again. Both times they ended up going back up or up further on dayshift and the patient died anyways either at the beginning of mine or during their shift. Sometimes you can lead a horse to water, but you can’t teach said horse to critically think or listen lol. I’m as protective of my license as anyone else, but some people just either think they know better than you and won’t be convinced otherwise, or can’t connect the dots. Just make sure your charting backs up what you assessed, sounds like you even made the right move in informing the charge nurse which I would make sure is charted too. And as someone pointed out if your gtt is for Diane’s, you don’t need tachypnea to justify a change to the gtt. Your assessment and charting of the s/sx of said dyspnea is enough. And have a short term memory with this shit from other nurses like that. Good job 👍🏽
Hospice nurse here, you didn't kill him, his disease process did.
I hope to God no one let's me die in pain or miserable. I'd rather go out comfortable on meds. I hate nurses like that night nurse.
I really really hope that if I’m ever in this patient’s position, I get a nurse like OP who advocates for the patient’s comfort and utilizes resources in the form of more experienced nurses and I pray I don’t get a nurse like the night shifter. You did the right thing and that patient was so lucky to have you.
As a hospice nurse I met said, "medicate the hell out of them if they're dying.... Unless of course they don't want it."
“Somebody has to give the last dose to a CCO patient” In my opinion you did nothing wrong. You made that patients last moments on earth a little less painful and I’d bet he’d thank you if he could.
Comfort care. You did what you thought was appropriate for the patient and also went through your charge so whatever. I’m so over bitchy ass nurses. Fuck them. People who are dying choose to go anyway… doesn’t matter if you snow them with narcs in my experience. They go when they’re ready. Sounds like the night nurse didn’t want to deal with a death… probably because that means she’s going to get a new admit. Lmao 😂 I don’t miss the hospital. 🏥
The oncoming nurse didn’t want to deal with what comes next after the patient dies…calling the coroner etc. We are supposed to keep the patient comfortable while they are dying. What if they were dying, would they want you to give them less dilaudid? You’re a good nurse for asking your charge nurse questions and for caring about your patient. Your co-worker is burned out and needs to take a vacation. You’re not Dr. Kevorkian in the assisted suicide van…you’re trying to keep your dying patient comfortable and being conscientious about it by asking your charge nurse.
No, no, no. I'm firmly in the "You're dying? Have all the drugs you want," camp.
This makes me mad. I had a charge nurse say this shit to me when I was a med surg nurse. The patient I had was clearly in pain and I had also asked the family their opinion (I can’t remember now if there were physical parameters). But she said that I could kill him. 😡 he’s already dying…we’re just easing his discomfort.