Families often tell Dr. Christine Schwartz-Peterson, JourneyCare Medical Director, that they are amazed at how comfortable their loved ones become once they are on hospice. That is because hospice care strives to alleviate pain and symptoms for those facing the end of life, so that they can enjoy each moment with their families and friends.
But to make this happen, clinicians may use a prescription that commonly faces misconceptions: morphine. Below, Dr. Schwartz-Peterson explains what patients and families who choose hospice need to know about this opioid, so that they can understand its benefits in end-of-life care.
Q. Why is morphine so prevalently used in hospice care?
A. When people are nearing their last stage of life, some may experience significant symptoms related to their medical conditions including pain, anxiety and dyspnea (difficulty breathing-sometimes referred to as “air hunger”). Morphine can help alleviate all of these potentially distressing symptoms and provide what people most desire during this stage of life – comfort and quality of life.
Q. Does this medication change how my loved one acts?
A. It is rare to see a serious alteration in a patient’s mental status with the initial low doses of oral morphine that we recommend. Part of what our hospice physicians and nurses do includes supporting our patients through their first doses of morphine and monitoring for side effects, as well as teaching how to manage these side effects through the first days.
But there is a potential for side effects including sedation, dry mouth, nausea and mild itching. These are short lived, however, and typically subside three to four hours after receiving the medication. If a person needs ongoing doses, these side effects typically resolve after two to three days as one’s body gets “used” to the medication. Constipation is the one expected, ongoing side effect; because of this, each patient prescribed morphine or a similar drug will also receive medication to help prevent constipation.
Q. Can my loved one become addicted to morphine given by hospice clinicians? How can you safely manage pain with morphine?
A. The concern of addiction as well as side effects are common reasons why people are hesitant taking morphine. But under the direction of our hospice physicians and support from our hospice nurses and team, we can provide these medications safely while mitigating any serious risks.
We always start with a low dose, then adjust the dose as needed to maximize the benefit without adverse effects, based on the person’s individual needs. Morphine is also administered in hospice mostly as a pill or liquid that is swallowed, which is typically gentler and with less risk of side effects than what is sometimes seen with intravenous (IV) morphine in a hospital or emergency department setting.
Q. Is morphine given only when death is imminent?
A. No. Morphine is administered when our patients have distressing symptoms such as pain, shortness of breath or anxiety. If a patient is dying and is not in any distress, there is no need for us to give morphine.
Q. Can morphine use cause premature death?
A. Morphine does not hasten death if administered properly under the direction of our hospice physicians and support of the patient’s hospice team.
Q. Are there other opioids that families should know about before their loved one enters hospice care? What is the difference between these meds?
A. Hydrocodone (one of the medications in Norco/Vicodin), hydromorphone (Dilaudid), oxycodone and fentanyl are other opioids that may be used in hospice with similar effectiveness in symptom relief as morphine. With the exception of fentanyl – which is a longer acting opioid and administered as a transdermal patch – the others are typically taken by mouth. And, like morphine, these pharmaceuticals will not alter mental status or hasten death when administered properly by professional hospice physicians and supporting clinicians.
Q. What else do I need to understand about morphine in hospice?
A. As a physician, I respect morphine and its cousin opioids. It is our most valuable therapeutic tool for meeting our hospice patient’s goals of comfort and quality.
I have had many of our patients who arrived at our inpatient hospice CareCenters for unmanaged shortness of breath, requiring high oxygen therapy and still in distress – arriving essentially describing “air hunger”. After receiving one or two doses of morphine with us, their breathing was no longer labored, they were no longer reporting “breathlessness” and we are often able to change their oxygen therapy from a harsh, high-flow oxygen to a gentler oxygen delivery. Sometimes, they could even discontinue oxygen therapy all together without any discomfort or distress.
Families have shared with me that they could not believe their loved one could be so comfortable off oxygen therapy and wonder why morphine was not offered to them before they came onto hospice. One of our hospice nurses referred to this as the “miracle of morphine” and I could not agree with her more.