Why give more morphine to a dying patient?

Nursing, Nov 1999 by Kettelman, Karen P

If you're worried about hastening death, consider these facts.

"I KNOW IT'S MY TIME and I'm ready to go. I just need help with this terrible pain."

Margaret Matthews, 76, has been admitted to your unit with terminal breast cancer and severe, intractable pain. When you perform your nursing assessment, Mrs. Matthews tells you she's used 100 mg of oral morphine every 4 hours for pain control at home, but it doesn't relieve her pain and suffering. When she arrived at the hospital, the physician ordered a continuous intravenous (IN.) morphine infusion at 10 mg/hour.

An hour after you start the infusion, Mrs. Matthews reports, "The pain is a little better but still bad." You call the physician, but he doesn't want to increase the dose, feeling that more morphine would hasten Mrs. Matthews' death.

Would it? Or might she die a more peaceful death if her pain is relieved? Read on for answers to this common debate.

Resolving a dilemma

Like Mrs. Matthews' physician, members of the health care team sometimes struggle with the concept of pain relief versus an overdose that could cause death. To help resolve the dilemma, the Agency for Health Care Policy and Research says in its Cancer Pain Guidelines, "The person dying of cancer should not be allowed to live out life with unrelieved pain because of fear of side effects; rather, appropriate, aggressive palliative support should be given." So if the intent is to relieve pain and provide comfort, administering more morphine to Mrs. Matthews is appropriate.

Why morphine?

When a patient has severe, intractable pain, morphine is the drug of choice. Administered IN., it has a rapid onset, peaks in about 20 minutes, and controls pain for 4 to 5 hours. Like other opioids, it works by interrupting the transmission of pain impulses in the central nervous system to alter the patient's pain perception. Effective and easily titrated, morphine has more benefits than adverse effects.

Morphine's main advantage for cancer patients is that it has no maximum recommended dose and no ceiling on its pain-relieving effects; the dose can increase as the need for pain control increases. So, although a patient like Mrs. Matthews may require more morphine for pain relief as her disease progresses, increasing her dose by 25% to 50% should restore her comfort. Even if she eventually requires more than 10 times the amount of a typical postoperative dose, the large doses are unlikely to kill her.

Breathing easy about morphine's effects

Now I'll help ease your mind regarding adverse responses to morphine in a dying patient:

* depressed respirations. Although morphine can depress respiratory drive, most patients who have pain quickly adjust to this effect. The reason is that pain stimulates respiration and antagonizes the drug's respiratory depressant effects. Mrs. Matthews will probably tolerate morphine's respiratory effects within a few days. Meanwhile, monitor her for sedation while titrating her dose.

A word of caution: Don't rely on naloxone (Narcan), the antidote to opioids, to combat respiratory depression in a patient who's been taking large amounts of morphine or other opioids over a long period: It can precipitate withdrawal and cause your patient severe discomfort. Instead, slow titration of an opioid is preferred.

* addiction. Addiction is a psychological dependence, but addiction to opioids shouldn't be a concern for patients with pain. Although Mrs. Matthews may develop morphine tolerance and physical dependence, getting off the drug isn't a concern for a terminal patient.

* sedation and mental clouding. Although these responses are common with morphine, most patients adjust to them within days of a dosage increase. And don't confuse the effects of sleep deprivation with excess sedation: Your patient may simply need to catch up on sleep once she gets pain relief.

* sensitivity in the elderly. Like younger patients with pain, Mrs. Matthews needs aggressive pain management and assessment, but the elderly are especially sensitive to morphine's effects. Use caution by starting your elderly patient on low doses and carefully observe for adverse reactions as you titrate the dose.

Gauging pain responses

Your patient's report is the single best indicator of pain intensity. (See Debunking myths acout pain assessments for what not to believe.) But don't be surprised if her complaints of severe pain seem at odds with her behavior. Different people use different strategies to deal with pain, so behavior is a poor indicator of pain intensity.

For example, some patients, sleep to escape pain, so a sleeping patient isn't necessarily pain-free. Ask your patient to rate her pain on a scale of 0 (no pain) to 10 (worst possible pain), then titrate the opioid dose according to her serial responses.

Becoming a pain control advocate

In its revised standards on pain control, the Joint Commission on Accreditation of Healthcare Organizations states that all patients have the right to pain relief. But although you're obligated to relieve your patient's pain and suffering, when the means to pain relief is seen as life-threatening, you may need to advocate for her right.