Presentation: Death, Dying, and Comfort Medications in Hospice Care

Published on April 21, 2023

Updated on April 13, 2024

As an experienced hospice nurse, I understand that working in hospice care can be emotionally and physically challenging. In this presentation, I will share my knowledge and expertise on the topics of death and dying, as well as 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 hospice care 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 CNA's working in hospice care.
  • Q&A.

By the end of this presentation, you will have a better understanding of 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 compassion 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 “.” A “” is one that 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 intentionally hasten the process, and sometimes our involvement means a longer lifespan for the patient involved.

Hospice is a team effort that involves the hospice team — RN Case Manager, a CNA, a , a chaplain, a bereavement specialist, and volunteers including a  — and the caregiver team which for home patients is family and friends, and for facilities, people like yourself. We all need to work together as a team to help our patient 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 over time. Like most of us, we have “any other duty” as assigned, but the main goal of the hospice RN case manager 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 patient in their journey.

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

II. The dying process at the end of life

Human life is a continuum where in the simplest of terms we go from actively living through a transitioning phase into actively dying.

As the patient heads towards the transitioning stage, they will sleep more, have more fatigue, less energy, 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.

Keeping in mind that we can all go at any time without warning, the natural process of dying includes a transitioning phase and an actively dying phase. The transitioning phase is where the patient is in and out of consciousness, can have periods of increased restlessness and agitation that can present in many ways including increased falls (this time period is often referred to as terminal restlessness), is where we might see a rally (the of energy), includes where the patient may see things and people not present, and will 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 a several noticeable areas:

  • Periods of confusion including asking or yelling for help without being able to answer why.
  • Periods of restlessness and agitation that can either be slow repetitive movements or just may appear not able to settle.
  • Periods of picking at things not present or appearing to manipulate things we cannot see.
  • Increased falls often associated with confusion, restlessness, and agitation.
  • Decreased urinary output.
  • Rally periods that can be something as simple as the patient eating or drinking far more than normal after several weeks of hardly eating or just taking bites of food and sips of liquids to the person declaring they are healed and capable of doing anything.
  • Changes of complexion that appear dusky, grey, or pallor than normal.
  • Time 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 to the patient, the family, and caregivers around the patient. It is our job to provide a combination of environment (often one that focuses 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 own 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 end of life.
  • Atropine 1% drops under the tongue, hourly as needed for excess oral secretions often referred to as the 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 prior to 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 , 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 the medications. If you have a hospice patient and feel they are uncomfortable and don't know what to do, always call the hospice provider for their help.

Most of the time these medications are given as needed, which is often referred to as PRN. PRN medications within the medical record should list reasons for when they are given along with the dose and frequency. You should be assessing the need to give PRN medications with any patient interaction.

If the patient is anxious, give an anti- 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 give an opioid such as liquid morphine if 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 side effects of all comfort medications except for Acetaminophen (Tylenol) and Bisacodyl (Dulcolax) are sedation (a level of drowsiness) and constipation. Liquid morphine sometimes can cause nausea and vomiting especially when given on an empty stomach; and may cause itching which if it does not resolve on its own will require an antihistamine/allergy medication such as Loratadine (Claritin).

Part of the job of the hospice nurse is to assess patients based on the patient's chief complaints as well as observational areas of (i.e. 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, given 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 being a critical part of the team is reporting observations of or areas that just 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 parts of the body 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 the course of 30 seconds give or take buccally by the where the patient's molars are in the gum line itself.

The main side effects 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 with 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 within the last hour of life, the patient will have something done to help them, 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 one that 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 to your charge nurse as well as 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 offer you encouragement. All of you are on the front line dealing with patients and their families every day; 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 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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