I received the following comment on my Blog. "They are overmedicating Mom” (The family said of hospice professionals). “Following a brief rally, she slept most of the time and died within a week." Her sons concluded she was being overmedicated with pain medication; with less medication, she would wake up and be alert again. They wanted Mom back, understandably, but that was not to be and it was not because of the pain medication...she was dying.
You are correct in your assessment. Mom probably did not die because she was over medicated. The family concerns you mention are so often exactly what people believe, however. That if Mom just didn’t have the pain medicine she would talk with them, would be alert and may even not have died when she did.
What most people don’t know is that months before death from disease or old age the dying process begins. A person begins eating less and less, sleeping more and more and withdrawing inward, talking less and less.
In the weeks before death a person is asleep more than awake, eating almost nothing and generally does not initiate conversation. They will respond when spoken to although often are confused.
In the days to hours before death a person is generally non responsive, meaning they may be moving and talking but not making sense and not responding to the world around them. This is the normal progression of gradual dying from disease or old age.
How much medication a person has is not the issue here. This progression will occur with or without medication. Withholding the medication will not have the patient waking up and talking if indeed death is days to hours away. Withholding the medication will leave the patient less comfortable (if pain has been an issue in the disease process then maybe in severe pain), overly agitated, restless and possibly with aggravated air hunger (difficulty breathing).
The guideline to use for administering narcotics as death approaches is to look at the person’s disease history. If pain has been an issue through out the disease process then continue giving the narcotic’s prescribed dosage. (Over the course of time the dosage of pain medicines is often increased.)
If pain was not an issue during the disease process then just because a person is dying does not mean pain is present and that a narcotic is appropriate. For restlessness a mild tranquilizer is effective. For labored breathing a very small amount of Morphine can ease that discomfort.
Dying is not painful. Disease causes pain. Know that we the watchers generally have a more difficult time watching our loved one die than our loved one who is actually dying does. The person dying is so withdrawn and removed from their body in the days to hours before death from disease or old age they are not experiencing their body and its sensations in the same manner as a healthy person.
I made the new DVD, New Rules for End of Life Care, in part to address the misconceptions people generally have about the use of narcotics during end of life care including the separate issues of addiction and of dying. Educating families that caring for someone at the end of their life is very different from caring for someone who is going to get better is crucial during this challenging time.
16 comments
As far as the comments from Betty Bartlow I am in full agreement my sister was recently placed in hospice she she and I were up and talking about going to Laughlin the following weekend she was fine then all of a sudden hospice nurse came in and wanted to take her to the Hospice Care Center Ryan’s house and within 24 hours max my sister had passed away and I know it’s because of over-medicating. And I’d also like to mention the fact that when I went to see her I had asked her nurse how my sister was doing and the only words that came from that woman’s mouth was and I quote " she’s dying" I don’t find that to be a very compassionate nor professional answer to give a family member I obviously already aware of the fact that my sister was ill and dying the answer I might have been looking for was how is her mind set how is her blood pressure so on their monitoring ( so-called) which of course I was told the reason for them wanting to take her to this facility to begin with to monitor her I was never given any answer other than the one I just listed above.
Hi Candy, good for you for speaking up about not giving morphine at end of life when the patient’s action does not require it. Unfortunately many physicians do not understand end of life comfort and pain management. Dying is not painful and there are way too many healthcare professionals that do not understand the concept. I have just written a new booklet about pain at end of life for the very reason that lay people as well as healthcare just don’t understand pain at end of life. My hope is that it will bring some understanding to a much misunderstood healthcare issue.
Blessings to you in the work you are doing. End of life care expertise is very much needed in hospitals and nursing facilities. It is not just an area for hospice. Barbara
I was a hospice nurse for about 15 years, had my HPNA certification. For I chose to give it up after, moving as I did not find a hospice that was aligned with the hi quality hospice care I had come from. That being said, I am now working on a med/surg floor. I have a GIP hospice patient that is resting with eyes closed noisy respiration’s of 10, no grimacing, frowning etc, she is completely non responsive, I had not given any medications as her symptoms don’t support giving a prn, which is all she has. I was told by the nursing supervisor that the hospitalists are not going to be happy if she isn’t given the prn morphine. I told her that I couldn’t justify giving her morphine prn if there are no symptoms. If the doctor wants it given there should be a routine order. What are your thoughts?
Hi Josh, to answer your question of what is too much medication when end of life is approaching: there is no specific answer. Pain management is an individualized matter, not a one size fits all formula. I recommend always start with a low dosage and add up. This takes longer to find comfort but eliminates the over medicating stupors that occur when you start high. Too often healthcare professionals mistake the normal dying process for an indication of pain. Dying is not painful, disease causes pain. Pain medicine or anxiety reducing medication is often given to mask the signs of the normal dying process (yes, even some hospice nurses are doing this). My belief is that education of the family and significant others about the normal dying process and what it looks like reduces the fear brought to the bedside and eliminates the need to medicate. There is restlessness, random hand movements, moaning, picking, signs that can indicate pain but also are part of the normal dying process. How do you tell which is which? If pain has been part of the disease process in the months and weeks before dying begins then pain is what you are seeing. Medicate that pain with however much medication is necessary to provide comfort. BUT, if pain was not part of the disease history and now the person is showing signs of agitation, restlessness, and picking then it is not pain but the body trying to release itself for this earth. In that case there is no need to medicate with narcotics. Maybe a simple relaxant if the agitation presents the possibility of the patient falling out of bed or hurting themselves but not narcotics. The key here is not medications but education. Thank you for your comments. You present a situation that is all too common. Blessings! Barbara
Hi, I have been a nurse for about four and a half years in long term care. I know this site is to educate families on end of life care but if I may, I have a few question I would like to ask you. In your opinion of course, nothing taken officially. What would you consider to be to much when referring to comfort medication? To be more exact, what situation would alert your nursing judgement and tell you they are getting to much? I understand of course we can use our judgement as nurses on how much a resident/patient gets but all nurses are not created equally and may give certain medications when they should not to avoid drifting into what could be classified as a chemical restraint (over medicating). Don’t miss understand, I am all for giving comfort meds when they are warranted with proper signs of pain/discomfort such as increased respirations, pulse rate, and others. For example, patient A is awake, alert, and mostly oriented but are starting the iminnent declining process that is expected with some sudden and serious drops in function for a period of time. Noting patient can still express thier needs to staff. Hospice nurse B writes order ( Dr. Prescribed of course…) For morphine 1 ml every hour as needed and lorazepam 1 ml four times daily routinely (6am, 11am,4pm,10pm roughly). I also understand that tolerance is a factor with all medication but despite tolerance these meds can biuld up in there system over time and considering the disease process and how it may effect tolerance. As a hospice type nurse writing orders for my people (patients) should you not start low on your dosing and work your way up as pain or discomfort increases during the process? I care deeply for my patients and there families. I do not want to take away there ability to function or communicate in there last days unless it’s necessary. This has been a recent concern of mine because of a particular situation. In this particular situation I believe it was due to nurses that lack the proper experience in these types of situation, not saying there bad nurses. I will state I am no expert nor am I without mistakes of my own in my short career, it’s called a practice for a reason. Highlighting though that long term care is all I know. That being said, I have seen the dying process take place many times, possibly on a average upwards of two, three, or more every month for over 4 years ( Do the math). At what point do you say “no” and to whom? I will state for any concerned families that may be reading this. Hospice services along with others like it are are a good idea and I am in no way downplaying there effectiveness or reliability. They are at times necessary for that member of your family/friend and whom ever is watching the process take place . This situation I have been reffering to has not been common nor do i believe intentional in any wa, just a lack of experience. Nurses of course are responsible for one another in a work place and must be mindful of each other actions, especially care/treatment from outside sources such as hospice ex. As a family member never be afraid to ask questions! ALLWAYS ASK QUESTIONS, keep an understanding of what’s going on. As a nurse I strongly believe that caring for famly members and their needs are equally as important, just in a different aspect (information, teaching,comforting) . Again I’m no expert, I am speaking from my experiences/situations only stating what I believe are the appropriate action/responsibility of a nurse and agree with the very informative content of this site. I also apologize for the very long and overly detailed comment to ask only a few questions (note: nurses are OCD). Thank you too anyone who took time to read my entire rant. your is appreciated. Extra points to whomever can find all 900 grammatical errors, for the ones looking. (yes, I’m aware there are many).
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