🧪 Case Study 3.3: “Can You Tell the Nurse Not to Increase the Morphine?”

🧪 Case Study 3.3: “Can You Tell the Nurse Not to Increase the Morphine?” 

Scenario Overview (Setting + People)

Setting: Skilled nursing facility (SNF) room, late afternoon. The patient is on hospice. The facility is busy. A nurse has recently adjusted the comfort medication schedule due to increased pain and agitation.

Patient: Mrs. Evelyn Harper, 82, advanced cancer with escalating pain and periods of confusion. She is intermittently alert, sometimes drowsy. When awake, she appears anxious and grimaces during movement.

Family:

• Diane (adult daughter): present most days, protective, exhausted, emotionally flooded. She is deeply afraid that medication will “hasten death” or “knock Mom out.”

• Tom (adult son): visits less often, tense, suspicious of hospice, strongly opinionated when present.

• Mrs. Harper’s sister (occasional visitor): quiet, prayerful, anxious.

Hospice Team Context:

• RN has assessed worsening pain and recommended an increase in medication per the care plan.

• Social worker is scheduled to follow up later in the week.

• You are visiting as the chaplain for spiritual care and family support.

What Happens (The Moment)

You enter the room. Diane meets you at the door, voice low and urgent:

“Chaplain, you’ve got to help me. They want to increase the morphine. I don’t want my mom drugged. I don’t want her to die because of that. Can you tell the nurse not to do it?”

Mrs. Harper is moaning softly. Her breathing is shallow. She opens her eyes briefly, then closes them again.

This is a high-stakes moment. Diane is not only asking for help—she is asking you to become a medical advocate outside your scope. If you step into that role, you risk harming trust, increasing conflict, and creating legal/clinical liability.

Beneath the Surface (Ministry Sciences + Whole-Person Lens)

1) Fear of “causing death”

Diane may be experiencing moral distress:

• “If I agree to this, I’m responsible.”

• “Am I killing my mother?”

• “What if she never wakes up again?”

This is ethical and spiritual pain, not only anxiety.

2) Grief and loss of control

Medication decisions can feel like the last “control lever” a family member has. Increased medication may symbolize:

• the nearness of death

• the end of conversation

• the end of “fighting”

3) Trauma history or mistrust

Sometimes families have histories of:

• poor medical experiences

• addiction concerns in the family

• religious guilt patterns

• fear of institutions

4) The patient’s dignity and comfort

Mrs. Harper is a whole embodied soul. Her suffering is spiritual and physical at once. Comfort care is not “giving up.” It is honoring dignity and relieving suffering through the appropriate clinical team.

Your Chaplain Goal in This Case

Your goal is not to solve medication decisions. Your goal is to:

• de-escalate fear

• protect scope of practice

• support the patient’s dignity and comfort

• help the family ask the right questions to the right person

• encourage calm, consent-based spiritual care

• coordinate appropriately with the team

Step-by-Step Chaplain Response (What to Do)

Step 1: Regulate your presence and slow the moment

Before responding, breathe. Keep your tone low and calm.

Say:

• “I can hear how afraid you are. This feels big.”

• “Let’s take this one step at a time.”

You are creating safety before content.

Step 2: Clarify your role without abandoning her

Do not say, “That’s not my job,” in a cold way. Keep it warm and clear.

Say:

• “I can’t direct medication decisions, but I can support you and help you talk with the nurse so you get clear answers.”

• “I’ll stay with you while we ask the right questions.”

Step 3: Protect dignity: attend to the patient first

Look at the patient, not only the family member.

Say (to patient, if appropriate):

• “Mrs. Harper, I’m here with you.”

• “Would you like me to pray quietly, or just sit with you?”

If she cannot respond, keep it gentle and minimal. Do not treat her like an object while the family debates.

Step 4: Help the family form clear questions for the RN

Your job is to help Diane communicate, not to override the plan of care.

Offer questions like:

• “What is the goal of this adjustment—comfort, anxiety relief, or both?”

• “How will you monitor her breathing and comfort?”

• “Is there a way to balance alertness and pain relief?”

• “What signs should we watch for, and what do we do if we’re worried?”

• “Can you explain how comfort medications work at end of life in plain language?”

This restores agency without stepping into medical authority.

Step 5: Invite the interdisciplinary team appropriately

If the conflict is intense or ongoing, request social work support.

Say:

• “It might help to have the social worker join a family conversation too, so everyone feels heard and supported.”

If the family’s fear is spiritual and moral—“Am I causing death?”—you can support the soul-level distress while the nurse addresses clinical details.

Step 6: Offer brief spiritual care that matches the moment

If Diane is open, offer a short Scripture and prayer that addresses fear, not medical outcomes.

Optional Scripture (WEB):

• “Let your gentleness be known to all men. The Lord is at hand.” (Philippians 4:5)

• “Yahweh is near to those who have a broken heart.” (Psalm 34:18)

Optional prayer:
“Lord, bring calm and clarity. Give Diane wisdom and peace as she asks questions. Comfort Mrs. Harper and surround her with mercy. Guide the care team as they relieve suffering with gentleness. Amen.”

Keep it short. Do not turn prayer into persuasion.

What Not to Do (Required)

What Not to Do in This Situation

• Do not tell the nurse what to do or speak as if you are a clinical authority.

• Do not give opinions about morphine, dosing, or prognosis.

• Do not imply the nurse is trying to “hasten death.”

• Do not promise outcomes: “She’ll be fine,” “She won’t die,” or “She won’t be sedated.”

• Do not shame the family member for fear (“You’re being controlling”).

• Do not take sides against staff or against the family.

• Do not carry secret messages or become the mediator without team alignment.

Sample Phrases to SAY

• “I can hear how afraid you are.”

• “I can’t direct medications, but I can help you talk with the nurse and get clarity.”

• “Let’s ask the RN to explain the goal and how they monitor comfort.”

• “We can look for a balance between comfort and alertness; the nurse can guide that.”

• “Would you like a brief prayer for peace and wisdom?”

• “Mrs. Harper, I’m here with you.”

Sample Phrases NOT to Say

• “They shouldn’t be giving morphine.”

• “Morphine will kill her.”

• “You have to trust the system.”

• “You’re overreacting.”

• “This is God’s will, so don’t fight it.”

• “If you had enough faith, you wouldn’t be afraid.”

• “I’ll tell them to stop.”

Boundary Map Reminders (Limits + Consent + Documentation + Team Communication)

• Limits: Chaplains do not give medical advice or direct medication decisions.

• Consent: Ask permission before prayer, Scripture, touch, or sensitive questions.

• Documentation norms: If required, document the request and your action factually (support provided, referral made).

• Team communication: Notify RN/SW that family is distressed and needs clarification/support—briefly, respectfully.

• Safety: If you hear threats, abuse risk, or unsafe care concerns, follow agency policy immediately.

• Pace: Your goal is stabilization and clarity, not solving everything in one moment.

Likely Outcomes (What “Success” Looks Like)

A realistic win is not perfect agreement. A realistic win is:

• Diane feels heard and calmer.

• The RN is invited into a respectful conversation.

• The patient’s comfort is prioritized without conflict escalation.

• The team supports the family with clear education and care planning.

• You remain trustworthy and within scope.

Diane may still struggle. But she now has a safe path: questions go to the nurse, conflict support goes to social work, spiritual fear can be held with you—without you taking over.

Reflection + Application Questions

1. What fear was driving Diane’s request? Name at least three layers (emotional, ethical, spiritual, systemic).

2. How did you protect your scope of practice without abandoning Diane?

3. What are five questions you can help a family ask the RN when medication fears rise?

4. How did you protect the patient’s dignity when the conversation became tense?

5. When should the social worker be involved in a case like this?

6. What would you document (if documentation is required) and what would you avoid documenting?

7. What short Scripture and prayer could you offer that addresses fear without making medical promises?

References

Biblical (WEB):

• Psalm 34:18

• Philippians 4:5–7

• Proverbs 11:13

• 1 Peter 5:2–3

Hospice / Palliative Care and Ethics:

• National Hospice and Palliative Care Organization (NHPCO). Interdisciplinary hospice care and family support resources.

• World Health Organization (WHO). Palliative care definition and whole-person suffering framework.

• Ferrell, B. R., & Coyle, N. (Eds.). Oxford Textbook of Palliative Nursing (comfort goals, interdisciplinary care, family distress).

• Puchalski, C. M., & Ferrell, B. (Eds.). Making Health Care Whole: Integrating Spirituality into Patient Care(spiritual care within clinical systems).

Chaplaincy Practice, Boundaries, and Communication:

• Association of Professional Chaplains (APC). Standards of Practice and Code of Ethics (scope, confidentiality, documentation).

• VandeCreek, L., & Burton, L. (Eds.). Professional Chaplaincy: Its Role and Importance in Healthcare (role clarity, interdisciplinary communication).

• Fitchett, G., & Nolan, S. (Eds.). Spiritual Care in Practice: Case Studies in Healthcare Chaplaincy (case-based boundary formation).