Working Caregiver- Caregiver Articles
Medicine, a Palliative Care Strategy at End-of-Life, is part science and part art with a lot of unknowns in the mix
When Hospice Started the Morphine - End of Life & Palliative Care
What happened? Do you think hospice started it too soon? Did they use too much? Did your loved one seem so sleepy you could not talk to him anymore? Did he seem to lose interest in things he enjoyed before? Did he die quickly afterward? Some people react negatively to morphine and some people have been given too much. Palliative Care and Medicine is part science and part art with a lot of unknowns in the mix and we can really never know how a person's body will be affected by the combination of his disease, treatments and medications. (*There are other drugs being used for the same purposes as morphine, methadone for example, but I am only going to focus on morphine. Also, issues of pain that will not subside with traditional methods is not being addressed here either.)
This topic, palliative care strategy at end-of-life, is very controversial and let me start out by apologizing in advance if I offend anyone reading this. Also, I am far from an expert; I am just sharing my training and experience in caring for people who received morphine as part of controlling their symptoms of pain and breathlessness. Keep in mind that medical professionals strongly disagree on this topic. It’s been interesting to see excellent nurses and doctors come into hospice work, bringing with them varying opinions. After they have worked in hospice awhile their beliefs change because of their experience..
What I hope to convey is that morphine, when administered appropriately, will minimize the distress of pain and breathlessness. Coping with these unrelieved symptoms robs a person of energy. It takes a lot of energy and focus to live with symptoms that are not well controlled. The person doesn't eat and loses more energy. He is too tired to visit with family and friends becoming more isolated. Anxiety is high when a person can't breathe well or is in a lot of pain. Anxiety robs him of energy. All this shortens life, it does not extend it. When a person is comfortable, he is not struggling to cope. He is eating, visiting, and using his energy in the way he wants.
These are just a few experiences of mine to illustrate what I am saying.
..........I was called to the home of Mr. A because the family was very scared about the significant decline in his level of consciousness. He was afraid of morphine because he thought he'd become addicted to it. He had it in the house but was not using it because he said his mild to moderate pain was being handled by vicodin. Just by common sense alone, you’d think that morphine would be the last drug you'd use for any reason. After a thorough assessment and history of the last few days, it became clear to me that pain could be a reason for his decline. I received orders to begin the morphine. By the next day Mr. A had 'woken up', was eating more than he had in days, was visiting with his family and sleeping less than half of his waking hours. He had 'turned around' according to his family. He had been coping with severe pain that had 'snuck up' on him and he didn't want to complain.
...........Mr. B was in the hospital on the oncology floor I worked on. He was a pain management doctor with an implanted morphine pump due to the severe pain that he was trying to control. He had the reputation for being short tempered and somewhat abusive to the staff and it was difficult to care for him. I did my best to be of service to him. Over the day, I had the strong feeling he was really in pain although he always reported very little (we are taught to believe whatever a person reports their pain to be…usually in relation to not doubt that a patient is over reporting). When a person is dealing with high level chronic pain, often they do not have the presentation or vital signs that we expect to see. In one encounter, I asked him if he really had no pain and he barked that he didn’t. I stayed in the room and he began to talk about non-illness things. I told him again that I really had a strong feeling he was in a lot of pain. We just stared at each other for some seconds and then he burst into tears and reported that he was. The doctors got his pain under control within a few hours. In 'supercoping' with pain, it is understandable that irritability would be high. His demeanor changed. I think about the irritability I have even when I’m dealing with moderate pain of a chronic condition that I know will eventually end (like after surgery).
...........Mr. C came onto service with congestive heart failure and said he had not been breathing comfortably for 10 years. He had no pain. He face was grayish, not pink and "…had a hard time breathing…" He said this was normal for him. He hadn't had the energy to get out of his wheelchair in months. I received orders from the doctor to begin morphine to handle his breathlessness. When I returned to check on him the next day, his skin was pinkish, his perceived breathlessness was significantly reduced and he told me he slept through the night and it was the first time in years since he'd done that. His wife told me that he walked from the bedroom to the living room to visit with friends and that he ate 'like a horse'.
I cannot describe the relief and gratitude people express who have had the experience of relief of distressing symptoms. When I first started doing hospice work, I was constantly amazed at how morphine appeared to be a miracle drug. I would not have believed it had I not seen it for myself. These stories are common. How often have you heard one like this? Ask any hospice doctor and nurse and they will have many, many more.
There are other things to consider. When morphine is begun in the hospice setting, it is being started in response to changes (i.e. pain/breathing issues) in the person’s condition due to progression of his disease and his present regimen is no longer effective. When someone is admitted to hospice service, he usually comes on within the last month of life. The last month of life is when decreased intake, fatigue, withdrawal into self (in preparation for transition), and confusion become very noticeable and do not reverse. This would be happening if morphine were used or not. The difference is that with appropriately administered morphine there is more comfort, less pain and less breathing difficulties. The decline that is normal in a dying person is happening concurrently with morphine administration. This is a point that is often overlooked and it is easy to understand why.
My hope is that this information has given you more insight into the complexities of morphine administration, as a palliative care strategy at the end of life. For more information on morphine, please visit St. Christopher's House website. Their information page on morphine is www.stchristophers.org.uk/page.cfm/link=280. St. Christopher's House is the pioneer of the modern hospice movement and has earned a reputation for excellence in clinical practice, research and education.
In peace,
Deanna Cochran, RN
Quality of Life Care, LLC
