It’s been nearly 30 years since the evening as a fairly new nurse I had been assigned to the oncology floor. I still remember my patient (a young woman in her mid thirties with advanced ovarian cancer) the mother of the two young boys who sat with her husband as they forlornly waited at her bedside, squeezing her pale hands while she lay gasping with heavy breaths, and no longer cognizant of the rest of us. The little boys kissed their mother goodbye and went home with their grandmother. This young mother had been hospitalized a few days prior to my shift while suffering a pain crisis, requiring significant medication adjustment to alleviate her suffering; it was obvious to the medical staff that she was coming to the end of her life. Now her family was understanding this as well and attending vigil at her bedside.
I have never forgotten the look on the oncology doctor’s face when he gave me the order for a morphine injection, STAT; it was a look of great sadness mixed with concerned yet intense and determined resignation. And I have never forgotten the sinking feeling I had, as I watched her chest slowly stop the agonized rise and fall with each breath, her respirations slowed to a minimum, taking her last final gasp shortly after I gave the intravenous injection. The husband seemed to take a gasp at the same time, and quietly sobbed while I checked for a pulse. Terror and guilt struck my heart with conviction that I had done the deed, giving her that last injection. Both the pharmacology and the physiology of the facts in this instance argued she was very close to death, that the morphine was not a fatal dose, but simply happened to be the final dose. But I have carried that sense of dread with me through the years, at the bedside of others.
Yes, that same sense, during my mother’s final hours, as I alternated morphine in her subcutaneous site with other medications, and the family members remarking on the amount of medicine she had required at the end. Was I responsible for that, too, I wondered? Afterwards I did a lot of soul-searching and questioning of how well I had handled mom’s symptoms at the end of life (and I was a hospice nurse!). While my mother-in-law lay dying in the hospital and we tried valiantly but vainly to attain an earlier fight to arrive at her bedside in time, I phoned the hospital and had a conversation with the night nurse about her struggle to breathe. I was the one who asked Sandy, the nurse, to give her the doses of Dilaudid that the doctor had ordered as a “PRN”. That feeling of deja vu, when my brother-in-law remarked “that narcotic they gave mom—that killed her you know”. There have been many times I have been the one to give those last drops of morphine or other medication, as those of us around the bedside of a dying person all watched the physical closing of a life.
We hospice nurses, who understand that those final hours of life often hold this pitfall, have explained to families in many ways, it is not the last dose of medicine that “killed” your loved one, it was the disease that gained the final foothold, and life came to a close, as it would have with or without the medicine that was given. Someone will always be the one to give that final dose.
Thanks for sharing your thoughts about this. I know that a lot of us have had the same conversations in our heads — or with a colleague.
I always thought that the “last dose” simply relieved the pain or air hunger or distress enough to allow the body to release, to finish the journey. I know this and yet, as your posting tells, there is still the questioning. Thanks, amy.
The final dose is not, of necessity, the fatal dose — mortality and disease, together, these are the fatal dose. Thank you for sharing this deep, if at times difficult, distinction. As always, your subtle wisdom and clarity of thought add invaluable insight to the ever changing and difficult public discourse on end of life issues.