Benefits Of Morphine Use In Hospice

Benefits of Morphine Use in Hospice
Paityn Nielsen
Chamberlain College of Nursing
April 4, 2015

Abstract
The objective of this paper is to provide evidence of the importance of morphine use for patients on hospice. Managing pain with morphine for patients on hospice can be challenging including overcoming the many misconceptions related to morphine. Many families and patients on hospice believe morphine to be the “death drug” however oftentimes the benefits associated with the use of morphine are not adequately explained. A multitude of studies have been published describing the benefits to the patient through the proper administration of morphine. Research supporting this position have been identified by The American Journal of Emergency Medicine (Bounes, Charpentier, Houze-Cerfon, Bellard, & Ducasse, 2007), Nursing: Scope and Standards of Practice (Bickford, Brewer, Cones, Humes, & Wurzbacher, 2010), Johns Hopkins Nursing Evidence-Based Practice – Model and Guidelines (Dang & Dearholt, 2014) and through various reputable sources on the internet.

Benefits of Morphine Use on Hospice
The processes identified by (Dang & Dearholt, 2014) have proven to be a significant resource to substantiate the use of morphine for patients in hospice. As further emphasized and defined, “The nursing process structures practice through the following problem-solving stages: assessment, diagnosis, outcome identification, planning, intervention, and evaluation” (Dang & Dearholt, 2014). As nurses complete their assessment, they make decisions from the information they have gathered from the patient. This information is then assessed, analyzed and ultimately leads to the diagnosis. With the desired outcome in mind, the nurse then identifies the appropriate plan of action specific to the patient’s needs. During the course of the plan of action, it is essential that the plan is constantly evaluated and must be fluid, flexible and open to changes. Oftentimes, patients on hospice require interventions to address immediate unforeseen issues, for instance if the patient’s pain is not being controlled properly.
Discussion: Evidence Based Practice
How can patients on hospice benefit from the use of morphine? Patients on hospice often suffer moderate to severe pain as they near the end of their life due to debilitating diseases such as various types of terminal cancer. These symptoms alone significantly reduce the patient’s quality of life and require them to endure unspeakable and inhumane pain and discomfort.
Morphine Administration Education
To help prevent patients from unnecessary suffering, it is imperative that family members and caregivers need to be educated on the proper use of morphine and the reasons that it is used. When a patient is being admitted to hospice, there is currently not a standard practice to teach patients, family members or care givers specifically and thoroughly about the option for morphine administration.
Benefits of morphine administration education. During admission to hospice, the comfort kit is talked about but most nurses do not go into the specific reasons for morphine use and the benefits of it. Many patients, family members and care givers have legitimate fears of using morphine and if administered believe it to be the ultimate cause of death for their loved one. Implementing simple yet comprehensive education practices into the standard admission process into hospice would reduce the apprehension and fears associated with the use of morphine.
Comfort in the Final Stages of Life
When morphine is not properly administered, patients are in more pain than they need to be. In hospice, morphine is used for pain relief and for shortness of breath. When a patient is having shortness of breath the first thing nurses turn to is morphine. But when patients or caregivers are afraid to use morphine there is unnecessary pain and suffering. According to the Dartmouth Atlas of Health Care between the years of 2003-2007, 61.3% of patients on hospice were on for some type of cancer diagnosis (The Dartmouth Atlas of Healthcare, 2015). It is no surprise that a study conducted by Palliative Medicine on pain associated with cancer concluded that “Pain was the most distressing symptom reported by cancer patients, and the primary reason to seek help from palliative care physicians.” (Dehghan, Ramakrishnan, Ahmed, & Harding, 2010). When people have uncontrolled pain they often go to the emergency department for relief. If the pain can be properly controlled in their homes then it reduces unnecessary hospital visits.
Leading a Team Based Solution
As the leader of spear heading the education process for administering morphine when necessary during hospice, the team will consist of a Medical Director, Director of Nursing and a Registered Nurse. The team of four will work together to develop a protocol for educating all relevant parties at the time of the patient’s admission to hospice about the uses, benefits, risks and administration of morphine.
Roles, responsibilities and definitions of morphine education protocol. The protocol will contain standard practices but will also be tailored specifically to each patient’s needs and drawn up to teach the patient, care giver and family member about why morphine is used and the benefits as it relates to pain relief and shortness of breath. The Medical Director is important because she is the doctor, the one authorized to prescribe the appropriate medication and the expert on the uses of morphine therefore a valuable resource to other members of the medical team. The Director of Nursing and the admitting RN will work together to develop the protocol on how to best teach patients and family members about morphine. They can work together on the best ways to alleviate the fears or reservations patients and families may have.
Evidence to Support the Use of Morphine During Hospice Care
The research articles that were found for this paper are both qualitative and quantitative. Three of the research articles are in support of the use of morphine while one showed evidence that transdermal fentanyl patches provided better pain control then sustained release oral morphine in hospital patients. The studies had a controlled group, and randomized groups. The authors tried to provide as accurate as possible data. The strength of this research is that it provided evidence that patient who used morphine fared better than patients that did not. Family members had less stress and anxiety caring for the patients when their pain was controlled.
Tangible and Intangible Data Supporting Morphine Administration
The use of morphine towards the end of the patient’s life can lie on both extreme sides of the spectrum as noted in the quote “The availability and correct use of opioids is essential for the successful delivery of pain control.” (Dehghan, Ramakrishnan, Ahmed, & Harding, 2010). Conversely, the same study also concluded, “The experience of pain had an impact on both patients and family. It took both physical and psychological forms, resulting in fear, despair and hopelessness, where the thought of death becomes a welcome resource. Families, witnessing their loved ones suffer, reported emotional distress.” (Dehghan, Ramakrishnan, Ahmed, & Harding, 2010). “Morphine is the standard opioid against which others are judged and is usually (Leppert, Majkowicz, & Forycka, 2013)in a sustained release oral formulation for the treatment of chronic pain. Severe constipation, however, may affect some patients’ quality of life more than their pain” (Allan, 2001). When morphine is prescribed to a hospice patient it is liquid form that absorbs under their tongue. With morphine, Senna is always prescribed to try and prevent constipation.
In the study done by Vincent Bounes, MD (Bounes, Charpentier, Houze-Cerfon, Bellard, & Ducasse, 2007) and colleagues related to morphine use it was discovered that group A who received an initial dose of 0.05 mg/kg morphine then 0.025 mg/kg every 5 minutes and group B who was given initial dose of 0.1 mg/kg morphine then 0.05 mg/kg every 5 minutes had the same pain relief after 30 minutes. However group A had better pain relief after 10 minutes of the first dose of morphine. According to this information within 30 minutes pain will be controlled at the same level with low doses of morphine. A higher does can be given to alleviate pain quicker then dropped back down to a lower dose. 70% of physicians agreed that the best way to administer morphine is orally.
Recommendations and Proposed Implementation for Change Due to the research gathered the recommendation for change is to provide specific teaching related to morphine to the patient and family members on admission to hospice. The plan for implantation is to work with the Medical Director, Director of Nursing and the Registered Nurse. A teaching tool will be produced that will address commonly asked questions or fears for patients starting the use of morphine. The teaching tool will contain; reasons for morphine use (shortness of breath, pain), peak time of morphine, side effects (and ways to manage the side effects), proper administration, and frequently asked questions and concerns. The specific steps would be to draw up the teaching tool, teach the admitting nurses how to present the teaching tool and provide the information to the family. Studies that provide proof of the benefits of morphine will be available to be given to patients and caregivers if further evidence is needed to prove benefits of morphine.
Establishing Benchmarks, Measuring, Interpreting and Reporting Data
The desired outcome is that patients and family members will have a proper understanding for the use of morphine and the benefits. Patients and families will not have any fear of using morphine. The knowledge that the patients and family members have prior to teaching will be measured and the knowledge that they gain after the teaching will be measured. A survey will be done with the patient and family that is able to participate asking questions about how they felt before the morphine education and after the teaching. This information will be reported to the key stakeholders. The best way to present this to the key stakeholders is through results done by survey. Before teaching is done on the morphine the patient and primary caregiver will participate in a survey to see what they know about morphine and the level of pain the patient is in. Upon discharge from hospice or the death of the patient then the primary caregiver will participate in another survey to assess what they learned about morphine and how well the pain was controlled. The information will be present in a comparison report to the key stakeholders. The results from the initial survey will be compared to the result after teaching was done.
Scalability for Mass Implementation to Benefit Patients on Hospice If the results from the pilot study are successful then the information can be provided to other hospice agencies. This information will be applicable to hospice as a whole. To ensure that this process is implemented and remains permanent the system will be monitored. A third party company will be hired to conduct surveys to patients to find out if proper teaching was done about morphine. Information gathered from the pilot study will be presented to the company internally. If this pilot study is successful then all hospice patients will benefit from the information gained. It would benefit all hospice companies to present this information to their patients and families. This information would prevent unnecessary suffering of patients. This information could be published in a nursing journal and shared with Directors of Nursing at hospice companies.
Conclusion
In life everyone experiences pain at some point. Some have chronic and some have acute pain. Cancer patients on hospice can experience excruciating pain. The best way that doctors and nurses control that pain is through the use of morphine and other drugs. The problem is that a lot of people fear morphine and therefore do not use it. Many have misconceptions on the use of Morphine. Caregivers of patients at times refuse to administer morphine because they believe that when they do it will kill the patient. The truth is that morphine provides relief from pain for patients on hospice. Morphine has a short half-life and is processed through the body in an hour. It is fast acting to help provide relief of pain because it acts on the central nervous system. Morphine helps to control shortness of breath along with pain.

References

Bickford, C. J., Brewer, K. C., Cones, M. E., Humes, Y., & Wurzbacher, E. (2010). Nursing: Scope and Standards of Parctice . Silver Spring: Nursesbooks.org.

Bounes, V., Charpentier, S., Houze-Cerfon, C.-H., Bellard, C., & Ducasse, J. (2007, February 23). Elsevier. Retrieved from Elsevier: http://www.elsevier.com/locate/ajem

Dang, D., & Dearholt, S. L. (2014). Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines. Indianapolis: The Honor Society of Nursing, Sigma Theta Tau International.

Dehghan, R., Ramakrishnan, J., Ahmed, N., & Harding, R. (2010). The use of morphine to control pain in advanced cancer: an investigation of clinical usage in Bangladesh. Palliative Medecine.

Leppert, W., Majkowicz, M., & Forycka, M. (2013). Attitudes of Polish Physicians and Medical Students toward Breaking Bad News, Euthanasia and Morphine Administration in Cancer Patients. Palliative Medicine.

The Dartmouth Atlas of Healthcare. (2015). Retrieved from http://www.dartmouthatlas.org/data/table.aspx?ind=177

Category
Points Possible
Points Earned
Description
Introduction
25
22
The introduction to your plan is nursing focused, with an evidence-based problem and potential solutions clearly identified.
You did not discuss the change model.
Change Plan; Practice Question (Steps 1–5)
50
50
Practice question is identified.
Scope of the problem discussed (including supportive statistics).
Stakeholders identified.
Team is identified
Change Plan; Evidence (Steps 6–10)
50
45
Your summary of evidence is detailed but is presented in a very confusing manner.
Recommendation for change is based on evidence and is thorough.

Change Plan; Translation
(Steps 11–18)
50
48
The action plan should include a more specific timeline to include all elements of the plan.
.
Plan for implementation is thoroughly discussed.

Summary
25
25
Good job summarizing the key points and steps of the change plan.
APA Format
25
20
There are multiple errors in APA formatting.
Total
225 points
210
Nicely done Josie.

References: Bickford, C. J., Brewer, K. C., Cones, M. E., Humes, Y., & Wurzbacher, E. (2010). Nursing: Scope and Standards of Parctice . Silver Spring: Nursesbooks.org. Bounes, V., Charpentier, S., Houze-Cerfon, C.-H., Bellard, C., & Ducasse, J. (2007, February 23). Elsevier. Retrieved from Elsevier: http://www.elsevier.com/locate/ajem Dang, D., & Dearholt, S Dehghan, R., Ramakrishnan, J., Ahmed, N., & Harding, R. (2010). The use of morphine to control pain in advanced cancer: an investigation of clinical usage in Bangladesh. Palliative Medecine. Leppert, W., Majkowicz, M., & Forycka, M. (2013). Attitudes of Polish Physicians and Medical Students toward Breaking Bad News, Euthanasia and Morphine Administration in Cancer Patients. Palliative Medicine. The Dartmouth Atlas of Healthcare. (2015). Retrieved from http://www.dartmouthatlas.org/data/table.aspx?ind=177 Category