Question for nurses

[Lackinghope]

If you are a nurse, especially if you work in a care home do you know what a volvulus is without googling?

Oral medication maybe appropriate as could transdermal. In fact transdermal may be more appropriate as its continuous release. An injection would wear off and is only a short term measure

Its important she’s reviewed by her palliative team who know her history and prognosis

Transdermal would not really be the best type of mediction as everyone absorbs differently and it is difficult to titrate.
With a volvulus I would not be advocating oral medication, it may not be absorbed.

Hopefully the palliative care team will help with organising a syringe driver for symptom management.

I saw the palliative nurse today who said mum isn't ready for the anticipatory meds yet, I told her how much pain mum is in and that she's having difficulty swallowing, she watched mum have a sip of water and said her swallowing is fine, it's not, she dribbles most of it out.
They are going to spread her morphine over the day rather than just morning and night.

Transdermal patches can be incredibly effective pain relief and being continuous are useful. They are used often for cancer patients with moderate to severe pain. Many of our palliative patients use them with good effect

As the OP says her mum is not ready for anticipatory medication so like I said injectable medication would not be appropriate

I think as practitioners we all do things slightly differently 😆
Eg I wouldn't use patches for unstable pain, as they cannot be titrated effectively. They are brilliant for chronic pain, but I suppose the main thing is that the patient has analgesia in place.

Hopefully with input from the palliative care team the pain will be better controlled. I would still be concerned that oral medications are not being properly swallowed or absorbed going on the info the OP has given.
@Lackinghope I hope your mum starts to feel more settled soon.

Dh had fentanyl patches when he was dying they weren’t great.

to you @LackinghopeI am thinking of you and your mum.

Thank you all. Spoke to the palliative care nurse again today and she said they are going to reduce mums pain meds because she's so sleepy! Why would they do this, she's end of life .
I asked the nurse what her objective was, why is it so important for mum to be awake, when she's miserable and in pain! She went and spoke to the doctor who has agreed to keep the meds the same , dr and nurse are going to see mum tomorrow, which means one of us is going to have to take time off work to be there as mum can hardly speak and doesn't know what day it is, she's never going to understand what they're on about.

Nurses can be reluctant to give morphine, is that what's she's on now, they just don't have the confidence. She's probably sleepy because she's unwell, not eating or drinking, nearing the end of her life, I think pain control and comfort are more important than a nurse being scared. Do you need to be there tomorrow, would you rather have facetime with the doctor instead?

Yes registered nurse and I know what it is.

Having said that I don’t know everything nor do I claim to, there’s always something new and always a learning opportunity.

I would absolutely google a condition I didnt know about not only to keep my patient safe but to also protect my pride/dignity so I don’t look stupid in front of patient/family.

Sorry you are all going through this op, it’s a really difficult situation.

in terms of medication being reduced - there is a balance between pain being under control & not putting your mum on enough opiates that it compromises her breathing. There was a very big and serious investigation into an end of life pathway some years back due to this (Liverpool care pathway). In broad terms It concluded that improper use of end of life medication accelerated the process. As everyone is aware, assisted dying is not legal in the UK so the medication is to make your mum as comfortable as possible without sedating her to the point of no longer taking breaths for herself.

I hope the next hours or days are as comfortable as they can be for your mum.

Politely, I have never met a specialist palliative care nurse who is nervous about giving morphine or lacking in confidence. It’s a very regular occurrence.

I know its common, but like pp Btowngirl says there are those who are still reluctant if they fear it brings about death. I worked in palliative care myself, both in hospitals and carehomes. Thanks to the misunderstood LCP and Shipman.

Yes it’s a well known surgical emergency .

So sorry you are going through this. I can't understand their rationale, as you said your mum came out of hospital on end of life care and is not eating.
Pain relief should be given if someone is in pain. There is no excuse for someone being in awful pain, there are plenty of analgesia options.

Give me strength!!!!!
Had the care home manager call me saying shes seen the meds update and she's not happy with mum being on 20mg am and 20mg pm . She wants mum on 10mg 4 times a day .

We should in the middle of them bickering over meds !!!!

That is ridiculous. Is it modified release morphine she is on morning and evening? That makes sense.
Short acting morphine 4 times a day regularly makes no sense at all.

And mum has been on this dose since she came out of hospital weeks ago, so not sure why the care manager has suddenly dishes not happy with it.

i asked CHM (care home manager) if it was slow release and she didn't know. If mum has it x4 a day it won't see her through the night will it?

Yes but not because of being a nurse- a friends child had one

But that's the same dose, 40mg in 24hrs. I'd ring back and ask what the medication is, we can try and help.

It's morphine

No. The short acting liquid morphine only works for a couple of hours at most. This is why long acting should be given 12 hours apart, morning and evening. This ensures there is some morphine in her system for the full 24 hours.
Can the care home manager really refuse to give the dose if the hospital have prescribed it? How on earth can she not know what type of morphine they are giving, but say no we cannot give it? It sounds like they don't understand different forms of morphine 🙄

I'm not even sure why the CHM is getting involved, unless she is a registered nurse herself. This is causing us more stress in an already horrible situation.

CHM also said mum can't have liquid morphine as it will burn her mouth.