As an experienced hospice nurse, I understand that working in can be emotionally and physically challenging. In this presentation, I will share my knowledge and expertise on death and dying and comfort medications, including morphine, to help guide you in providing the best care for your patients. The presentation outline can be found here.

I. Introduction

  • Welcome and introduction.
  • Overview of and the role of hospice nurses.
  • Explanation of what we will cover in the presentation.

II. The dying process at the end of life

  • What is the dying process?
  • Signs and symptoms of approaching death.
  • How to provide comfort care to patients in their final days.

III. Comfort medications in hospice care

  • Understanding hospice comfort medications.
  • PRN medications for comfort care.
  • Risks and benefits of comfort medications.
  • The role of hospice nurses in managing medications.

IV. Morphine in hospice care

  • What is morphine?
  • Why is morphine used in hospice care?
  • Dosage and administration of morphine.
  • Risks and benefits of morphine.

V. Conclusion

  • Summary of key points.
  • Encouragement and support for CNAs working in hospice care.
  • Q&A.

By the end of this presentation, you will better understand the dying process, the use of comfort medications, and the role of hospice nurses in providing quality end-of-life care. Remember that as a hospice nurse, your presence and can make a significant difference in the lives of your patients and their families.

SECTIONS

I. Introduction

Welcome everyone! This is a presentation about death, dying, and keeping patients who are dying comfortable, as well as covering the most common medications used and how none of them are euthanizing.

Hospice is about helping the patient have a “good death.” A “good death” is free from avoidable distress and suffering for the patient, their family, and their caregivers. It is a death that is in general accord with the patient's and family's preferences. We do nothing to hasten the process intentionally; sometimes, our involvement means a longer lifespan for the patient.

Hospice is a team effort that involves the hospice team — an , a CNA, a social worker, a chaplain, a bereavement specialist, and volunteers, including a  — and the caregiver team, which for home patients is a family and friends, and for facilities, people like yourself. We all need to work together as a team to help our patients have a good death.

My name is Peter Abraham, and I work as a visiting hospice registered nurse case manager. Let me touch on that briefly as, over time, as med techs, CNAs, LPNs, and RNs for facilities, you will work with people like me. Like most of us, we have “any other duty” as assigned. Still, the main goal of the hospice is to help identify where the patient is at in their journey to death (approximately how much time they have to live) and work with the caregivers and providers (doctors, nurse practitioners) on recommendations for medications and treatments. We also provide education to the caregivers and the patients in their journey.

Today, we are going to take a birds-eye view of the dying process, discuss the most common medications used to keep the terminally ill patient comfortable and discuss how to know what medications to give and when. We will also specifically cover the most common fears about morphine and lorazepam. We will then conclude with some words of advice and a question-and-answer session.

II. The dying process at the end of life

Human life is a continuum. In the simplest of terms, we go from actively living through a transitioning phase to actively dying.

As the patient heads toward the transitioning stage, they will sleep more, experience more fatigue and less energy, and have decreased appetite and thirst. As you notice this happening, please don't push them to do more, but do report the changes to the hospice nurse.

Remember that we can all go at any time without warning, and the natural process of dying includes a transitioning phase and an active dying phase. The transitioning phase is where the patient is in and out of consciousness and can have periods of increased and agitation that can present in many ways, including increased falls (this period is often referred to as terminal ). We might see a (the surge of energy) where the patient may see things and people not present and eventually go into a comatose-like state. Actively dying is typically when the patient is comatose and has at least one period of tachycardia (a heartbeat typically in the 110's, upwards of 200 beats per minute) along with observable respiration changes either hyperventilating (you may hear the phrase Cheyenne stoking), hypoventilation and often with apnea (appearing not to take a breath).

Signs that a person may be approaching transitioning typically involve several noticeable areas:

  • Periods of confusion, including asking or yelling for help without being able to answer why.
  • Periods of restlessness and agitation can either be slow, repetitive movements or may appear unable to settle.
  • Periods of picking at things not present or appearing to manipulate things we cannot see.
  • Increased falls are often associated with confusion, restlessness, and agitation.
  • Decreased urinary output.
  • periods can be as simple as the patient eating or drinking far more than usual after several weeks of hardly eating or just taking bites of food and sips of liquids, with the person declaring they are healed and capable of doing anything.
  • Changes of complexion that appear dusky, grey, or pallor than usual.
  • Periods where the patient appears to look through you vs at you.

The transitioning process can last seconds to weeks but, more commonly, is less than one week. The active dying process occurs shortly after transitioning is complete, and a person can be in the active dying stage for seconds to several weeks.

The transitioning period can be very scary for the patient, the family, and the caregivers around the patient. Our job is to provide a combination of an environment (often one that focuses on reduced stimulation) and comfort medications that help the patient remain as calm and pain-free as possible.

Failure — out of fear or misunderstandings of the intent for the medications — to give the comfort medications as promptly and as frequently as they are needed can cause the patient to linger in a state of suffering for which most people don't want as part of their journey.

III. Comfort medications in hospice care

Most patients will require comfort medications as part of their journey towards a good death. None of the medications utilized by hospice are euthanizing agents. None of them speed up the dying process.

The most common hospice comfort medications are as follows:

  • Acetaminophen suppositories to manage fever and mild pain at the end of life.
  • Atropine 1% drops under the tongue, hourly as needed for excess oral secretions often referred to as the death rattle or death gurgles. It is important to note the atropine bottle looks like an eye dropper, but the medication goes under the tongue and never into the patient's eyes.
  • Bisacodyl suppositories manage constipation that can occur before the dying phase; when someone is actively dying, we typically do not worry about constipation.
  • Compazine, Zofran or similar to manage nausea and vomiting.
  • Lorazepam pills or liquid to manage anxiety, shortness of breath, and restlessness that can occur during the journey towards the end of life.
  • Liquid morphine to manage pain, shortness of breath, and restlessness.

It is important to learn each of these medications, their dose, frequency, and when to give them. If you have a hospice patient and feel they are uncomfortable and don't know what to do, always call the hospice provider for help.

These medications are usually given as needed, which is often referred to as PRN. PRN medications should be listed in the medical record along with the reasons for giving them and the dose and frequency. You should assess the need to give PRN medications with any patient interaction.

If the patient is anxious, give an anti-anxiety PRN medication. The most common is Lorazepam, with a maximum daily dose of 10 mg.

If the patient is having moderate to severe pain, then giving an opioid such as liquid morphine is very appropriate. The maximum daily dose for morphine is 1,600 mg. Keep that in mind, as the common single dose ranges from 5 mg to 20 mg with varying frequencies.

The most common of all comfort medications except Acetaminophen (Tylenol) and Bisacodyl (Dulcolax) are sedation (a level of drowsiness) and constipation. Liquid morphine can sometimes cause nausea and vomiting, especially when given on an empty stomach. It may also cause itching, which, if it does not resolve on its own, will require an antihistamine/allergy medication such as Loratadine (Claritin).

Part of the hospice nurse's job is to assess patients based on their chief complaints and observational areas of discomfort (e.g., a patient may not complain about itching but may be scratching all over), and then make recommendations to the patient's provider for medications and treatments.

Pain Assessment in Advanced Dementia Scale (PAINAD) is an exceptionally good reference for how to assess pain in dementia patients or patients who are not good at sharing their level of pain.

It is especially important to stay ahead of a patient's symptoms of anxiety and pain, if you wait until the pain or anxiety is full blown, you may see zero relief from the medications. So always assess often, give often, and document so you can let the hospice nurse know, and then the hospice nurse can assess if the doctor should be contacted for routine orders.

Part of your job as a critical part of the team is reporting observations of discomfort or areas that don't feel or seem right to the hospice nurse.

IV. Morphine in hospice care

Morphine is a strong medicine that helps to reduce severe pain the patient may be experiencing. It works by attaching to certain body parts to block the feeling of pain. The dose needed to help a patient be as comfortable as possible will vary from person to person.

Liquid morphine is often used in hospice care for several reasons:

  • It can be given buccally (between the cheek and the gum line back where the molars are normally located) slowly to those patients who have trouble swallowing or cannot swallow anymore.
  • It works quickly, sometimes as fast as fifteen minutes.
  • It has a short half-life of two hours. The half-life of a medication is how quickly the dose that remains in the body will be cut in half. For example, 10 mg of morphine will have the effect of only 5 mg of morphine in two hours.

Liquid morphine often comes in a bottle with a concentration of 20 mg per 1 mL. The syringe used to give morphine is a 1 mL syringe. The dosing of morphine ranges from 5 mg (0.25 mL = 1/4th of the syringe) to 10 mg (0.50 mL = 1/2 of the syringe) to 20 mg (1.00 mL or the entire syringe). It is always wise to double-check the dose for each patient.

While liquid morphine can be given under the tongue, I'm told by my patients the taste is very bitter; it is best given slowly over 30 seconds, give or take, buccally by where the patient's molars are in the gum line itself.

The main of morphine are sedation (drowsiness) and constipation. Additional side effects can be nausea and vomiting, especially if morphine is taken on an empty stomach (this typically does not impact the comatose patient), and generalized itching (which can be managed with an antihistamine or allergy medication).

The intended outcome of liquid morphine is relief of pain, shortness of breath, and restlessness.

Now, one of the most common myths about morphine is that morphine kills. The idea of this myth is that morphine shuts down the person's organs or stops their breathing, or both.

Do you remember my sharing that the maximum daily dose of morphine is 1,600 mg? Let's compare this to some common situations:

  • You have a patient receiving 10 mg of liquid morphine routinely every two hours (12 doses as a 24-hour day divided by two hours is 12). Every day, they are getting 120 mg (10 mg x 12 doses) of morphine, which is 7.5% of the maximum daily dose.
  • Another patient of yours is getting the full syringe (20 mg) of morphine hourly; then the patient would receive 20 mg x 24 doses or 480 mg of morphine, which is still only 30% of the maximum daily dose.

As someone who has had terminally ill patients die in my presence after doing something for them, I know it can be easy to feel like we killed them. One patient I gave morphine, and they passed in five minutes, another time I digitally removed feces from the patient's rectum, and they died a few minutes later. It is quite common that the patient will have something done to help them within the last hour of life, and we can misinterpret the results as being “our fault.” Let's remember the patient is terminal, and they are dying.

V. Conclusion

  • Hospice is about helping the patient have a “good death.” A “good death” is free from avoidable distress and suffering for the patient, their family, and their caregivers.
  • Hospice is not about speeding up the dying process. None of the medications used by hospice are euthanizing agents.
  • As caregivers, you can help by ensuring you report changes in condition to your charge nurse and hospice.
  • As caregivers, you may interact with a patient who is dying and witness their death. Know that if you were involved in giving comfort medications, it was not the medication that caused them to die; they were already terminally ill.
  • Lastly, if I may encourage you, all of you are on the front line dealing with patients and their families daily, often more often than any staff from hospice or other sources. You matter. You are making a difference over time. Continue to grow, continue to bloom.

Questions and Answers Session

RESOURCES

Outline of this presentation

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death.”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side, A Guide for Caring for the Dying at Home

Some key highlights from the book Gone from my sight: The Dying Experience by well-known and expert Barbara Karnes, RN:

One to Three Months Before Death

  • Withdrawal from the world and people
  • Decreased food intake
  • Increase in sleep
  • Going inside self
  • Less communication

One to Two Weeks Before Death

MENTAL CHANGES

  • Disorientation
  • Agitation
  • Restlessness
  • Picking at clothes
  • Confusion
  • Talking with the unseen

PHYSICAL CHANGES

  • Decreased blood pressure
  • Pulse increase or decrease
  • Skin color changes: pale, bluish
  • Increased perspiration (clammy)
  • Respiration irregularities
  • Congestion
  • Sleeping but responding
  • Complaints of the body being tired and feeling heavy
  • Not eating, taking little fluid
  • Body temperature: hot, cold
  • Decreased urine production — urine becomes tea-colored
  • Urine and/or bowel incontinence (writer note — it is common for there to be a release of urine more than anticipated and often stool if even a smear of feces hours to a day or two before death; I view this as the body preparing itself and cleansing itself for death).

Days or Hours to Death

  • Intensification of one to two weeks' signs
  • A surge of energy (“Rally”)
  • Decrease in blood pressure
  • Eyes glassy, tearing, half-open
  • Irregular breathing: stop, start (Cheyenne Stokes or Agonal)
  • Death Rattle breathing
  • Restlessness or no activity
  • Purplish, blotchy knees, feet, hands (mottling)
  • Pulse week and hard to find
  • Decreased urine output
  • May wet or stool the bed

Minutes to Death

  • “Fish out of water” breathing (Gasping breathing)
  • Cannot be awakened

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