If I could have my choice, I would have a death that was entirely comforted by compassionate and loving tactile stimuli, but the truth is that we almost always need medication at the end of life, especially if pain or agitation is experienced. One of the struggles we often face is fear of the medications, especially Morphine or Methadone because of their names. People hear these words, and they think addiction or death, as though, regardless of the terminal diagnosis, those medications will cause a death faster. Some families refuse them completely.
I had a patient many years ago, she was in her 80’s and her main struggle was shortness of breath. The family was very against medication and wanted only to pray at the bedside to relieve her of her suffering. While I respected their faith, I asked her son to please allow me to give just a small dose of Morphine. I explained the benefits and the comfort I truly felt it would bring her. He refused, but in the same breath he kept saying to me, with his eyes filled with tears, “help my mom, please help my mom”. He and his brother were the decision makers, but his brother was in Japan, and he could not make any decisions without him. I climbed up in the bed with her, and I sat behind her to hold her as upright as I could and I too prayed that this would help, but I knew I couldn’t help her, and my own eyes filled with tears. I climbed off the bed, and I looked him in the eyes and I said, “I am going to the med cart and I am going to get a very small amount of Morphine and I am going to bring it back here. While I am gone, please call your brother, and let him know that I can help her but I need you to trust me.” Knowing there was still a chance they would refuse, and I needed to respect that, I went to the med cart and with shaking hands, I filled a syringe with only 5mg of Morphine and I walked back into their room. Her son looked at me and said, “We trust you”.
I gave his mother Morphine, and her breathing was calmed. This was a good result, and I was so thankful they agreed. I don’t want to come off as a medication pusher but sometimes; these medications are the difference between a death with suffering and a death with peace.
People are afraid of medication, and I get that. Before I became a nurse, I would have never thought that Methadone could bring as much relief as it does, because I can’t help but equate it to the devastating addictions and/or deaths that it can provoke. The purpose and the outcome are different when administering medications to someone healthy vs. someone at the end of their life.
In hospice I spend a lot of time with families educating them about each medication, explaining how they provide relief and comfort, and reassuring them that the doses we administer are not going to hasten their death. Education is a powerful tool. If used correctly, it can ease the fear that many people experience relative to the medications we use. Another fear is addiction, I can’t count how many times I have been asked, “will he/she become addicted”? While I never entertain that worry, their concern and their fear is real. I reassure them that becoming addicted is not a concern they need to have. I can say this with confidence because I know their end is near and these medications will only bring relief.
As clinicians, we understand the method of action for the medications we use, we know their benefits, we are usually prepared for their side effects, and we have become almost immune to the fear of them. But that doesn’t make it okay to downplay someone else’s fear and I truly believe if we take the time to educate and reassure them about the medications we would like to administer, we can relieve their fear rather quickly.
I had a patient once tell me that Morphine was like a thick velvet blanket, that when given, will slowly flow through the body with comfort and softness, finding the places that ache the most, and sink deep into them until they are gone. I use this analogy often. I also like to say things like “Morphine and Ativan/Lorazepam are good friends; they play nicely together” because people panic when we want to give more than one medication at a time. I will often say, "when you have pain, that can increase agitation, and when you have agitation, that can increase the pain. Given together, Morphine and Ativan/Lorazepam can often bring down both symptoms simultaneously." At the end of the day, whether it is said straight forward or warm and fuzzy, all that really matters is that the family trusts you to administer whatever medication you feel will reduce pain and suffering.
I want people to know that when someone is on hospice and dying from a terminal diagnosis, the medications we administer are not what ends the life. The diagnosis and the disease process ends the life, the medications remove the symptoms, the suffering, and the distress... allowing the body to succumb to what it was already doing, but with a little more peace, ease, and grace. That is my wish for all human beings.
It is all about trust. Our first responsibility with a patient and their family is to build trust. Once we establish that and can break down some of the walls, we can work together to ensure a softer landing, but in order to do that we need to communicate, educate, and respect the fears our patients and families might have.
xo
Gabby
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