Morphine Use in Hospice – When is it appropriate?


There is a universal principle in hospice care.  All people have the right to a dignified death, free from pain and suffering.

 Pain management is an incredibly broad subject,  because there are different types of pain.  There are some people that suffer from chronic pain, maybe with cancer or arthritis.   Pain can also be short term, secondary to an injury or an infection, and improves as healing occurs.  Diabetic patients will frequently report nerve pain to their feet and lower extremities, and this type pain not treated with a typical “pain pill”.

A simplified definition of pain is…..”physical discomfort and suffering related to an injury or an illness.”  Pain is not measurable, and it is unfair to try to assess someone else’s pain level based on their demeanor or their expression of pain.  Often times, a patient will apparently be in some pain with suffering, and a caregiver will have difficulty in accepting it, or even recognizing the pain.

Your hospice physician will order a variety of medications to manage difficult symptoms like pain, anxiety, nausea, and shortness of breath.  A common medication that is usually ordered at the onset of admission to hospice is Morphine. I always discuss this topic as a priority, whenever I have a new patient.  You would be shocked at how many people are resistant and anxious about this medication Morphine in specific.

My hope is to provide a little clarity on this subject.  When we talk about “pain pills”, this is usually a reference to an Opioid medication.   This is a very broad category of pain medications, and the term Opioid includes both synthetic drugs and opiates. Examples of synthetic Opioids would be Tramadol, Hydrocodone, Oxycodone, Methadone, and Dilaudid.   Codeine on the other hand is a true opiate,  meaning that it is produced naturally by the Opium Poppy flower. Most people recognize medications like Hydrocodone and  Codeine because they have been widely used by primary care physicians and specialists in treating pain.

Morphine is simply another opiate, also found naturally in the Opium Poppy.  It has been used as a pain reliever for over 200 years. It is rock solid known to be effective, and also has another quality that sets it apart from synthetic opioids.  Morphine-like opiates are known to have “no ceiling”.  In medicine we refer to this concept as the “ceiling effect”, and all of the synthetic opioid medications have a maximum dose recommendation also referred to as a ceiling.  This basically means  that a Morphine dose  can be safely increased slowly according to the patient’s need.  The medication can be increased slowly until a patient is no longer experiencing pain or suffering.  Your hospice team will closely supervise these medications to ensure that they are are safely administered.

It is a common misconception that Morphine in hospice is utilized for the purpose of ending someone’s life or hastening their death.

Family members caring for the their loved one often need a little reassurance when it come to administering Morphine.  This  medication is only intended to provide relief from pain and suffering. I can assure that there is no malicious intent by hospice when the use of  Morphine is deemed appropriate.

Pain can be a deal breaker, and must be addressed. In Hospice, we value the quality of life and freedom from pain over chemical dependence.  In this scenario,  the benefits of comfort far  outweigh any risk of chemical dependence on a pain medication.

If you or your loved has been admitted to hospice,  most likely the medication ordered is called Roxanol, which is a liquid form of Morphine.  This medication works very quickly by simply applying under the tongue with the absorption occurring in the mouth. Usually Roxanol aka Morphine comes in a concentration of 20mg/mL and the starting dose is 5-10mg or 0.25-0.5mL .  Your Hospice Nurse will guide you on how frequently to take the medication, and how to gradually increase the dose as needed to get adequate pain relief.  There will be a small 1mL syringe with the medication to allow for accurate measuring.

If I may give you a frame of reference on how appropriate and safe Morphine is for you to give to your loved one. I have had patients with cancer-related pain that were taking 400-500 mg of Morphine per day, and they were talking, walking, and very capable of having meaningful interactions with their loved ones.  In comparison,  10mg of Morphine seems pretty reasonable,  if it will provide comfort and relief for you or your loved one.

At the end of life Morphine  becomes even more important in honoring your loved one, by allowing them to be comfortable.  It is an understanding in Hospice that a patient will have difficulty passing over peacefully if they are in a pain crisis.

Morphine has another very important use at the end of life,  it is a medication that is used to ease breathing and relax the chest.  One of known side effects is a slowed down breathing rate. In hospice, that is the intent and it is referred to as respiratory depression.

This is really a key component to ensuring someone is comfortable at the end of life.

Managing pain for the hospice patient is a priority, and the hospice team will need to look at the full picture to decide how best to treat it.  We do not only prescribe medications for pain management, but we also utilize  alternative methods as well.  Music and Massage Therapists are often an addition to the team and are very effective in providing a lot of comfort.  Hypnosis and Guided imagery techniques is another suggestion, and can be used in conjunction with traditional pain medication.

Being in a position of caring for a loved one at the end of life is very stressful, and hospice nurses don’t underestimate what you are experiencing.  I hope you find this reassuring that Morphine is the Hero, certainly not the Villain.  You are not alone in this journey, and hospice will walk with you every step of the way.

I hope that you found this information useful.  Please free to ask a questio or leave a comment.





20 Comments

  • Jennifer March 23, 2017 at 9:40 pm

    Very interesting to know the multitude of ways morphine can be used to ease the pain of the ill and dying. I had no idea that doses varied so much and how many ways the medicine can ease discomfort. I definitely think that morphine is a hero in this situation. There is no need for physical pain to amplify an already difficult situation. Thank you!

    Reply
    • Heather Williams RN CHPN March 24, 2017 at 12:23 pm

      Hi Jennifer,
      Thank you for taking the time to review the article. This is a subject I am very passionate about and believe we as Hospice Caregivers have a moral obligation to advocate for our patients. This is a topic that I engage regularly in my practice and ultimately understanding, education, and a little compromise can go a long way.
      Best Wishes,
      Heather

      Reply
    • CK Mama April 6, 2017 at 1:16 am

      My first experience with Morphine was when my 4 year old was diagnosed with cancer. We found out at the same time that he was also very allergic to codeine. When he was in a lot of pain with mucositis, the morphine was the only thing that would help. I was very thankful that they were able to make him comfortable -sometimes he would even perk up and start telling jokes!

      Since they seemed to have really cracked down on pain management. Even the mention of morphine to a medical professional seems enough to get labeled as a ‘drug-seeker’, so a lot of people probably wouldn’t even ask. I’m glad to know that in a hospice setting patients wouldn’t be shamed for needing help with pain.

      Reply
      • Heather Williams RN CHPN April 6, 2017 at 2:05 am

        Thank you for sharing. Amen! May God Bless you, your son, and all your family.
        Take Care, Heather

        Reply
  • Helen March 27, 2017 at 2:02 am

    Heather, the belief that the use of Morphine is a only a means of euthanasia isn’t that common over here in Australia. Yes people know it can be used for that, where legal. However it is well known as a pain relief and either it or a synthesised replacement are fairly common.

    Morphine itself isn’t a dirty little product. It is only the people who misuse it who have created that myth.

    After all the poppy doesn’t pick itself and then isolate the morphine component. It takes people to do that. And morphine doesn’t decide to apply itself to people. People do that too!

    As with many things morphine used correctly is a boon to the many people in chronic or acute pain. And, as you say, it begins as a natural product which is a good thing.

    I believe used in a holistic pain management plan morphine is a wonderful drug that many people would miss if it became unavailable due to misconceptions and misuse.

    Great article and I hope many visit your site to read all about it.

    Ciao
    Helen

    Reply
    • Heather Williams RN CHPN March 27, 2017 at 3:11 am

      Hi Helen,
      Thank you so much for taking the time to review my post, and I appreciate your feedback. Euthanasia is not legal here in Texas, but I do know that it is a concept that is gaining momentum in here in the US. I have no personal knowledge of the particular medications used in euthanizing, but I would imagine that they are much stronger than morphine. I will have to look into this. 🙂
      Take Care,
      Heather

      Reply
      • Helen March 27, 2017 at 4:37 am

        It isn’t legal in Australia yet but I am really for it as long as there are safety checks set in place.

        My mum had Pict’s Disease and spent the last two years as a vegetable. She always said she wanted to go quickly. She would have embraced the idea of euthanasia.

        Reply
        • Heather Williams RN CHPN March 27, 2017 at 1:25 pm

          That must be very difficult to watch your mom go through that. Frontal lobe dementias can be very aggressive, and affect younger people too. There is a lot of hands care involved too, assuming the primary caregiver role in that situation can be very challenging as well. Let me know if I can assist or support you. Take Care, Heather

          Reply
  • Stisse April 5, 2017 at 4:28 am

    Hi Heather,
    thanks for this great informational article on Morphine! I vote for this medication, it saved me from excruciating pain when my appendix burst and I had to wait for hours at the hospital for a surgery room. Omg, I’m telling you, what would I have done without it?!! The pain was still intense even on Morphine (maybe they didn’t dare to give me enough), but I could at least survive those dreadful hours.

    I think people are a bit scared for Morphine and opioids in general. The fear of becoming addicted and so forth. It’s great that you’re educating people on how it really works and how it’s administrated in doses totally safe for the respective patient.

    Why would you want your elderly loved ones to suffer when there is help to get?! No one should have to suffer from pain.

    Thanks again for sharing valuable information!
    Best wishes,
    Stina

    Reply
    • Heather Williams RN CHPN April 5, 2017 at 1:08 pm

      Thank you for the comment. There is some psychology behind this. I don’t believe that anyone wants their love one to suffer, not at all. The problem is lack of information and lack of trust. The caregivers that are most resistant to using morphine really believe that are advocating for their loved one, and feel very strongly about the need to protect them from what they perceive as potential harm. Trust building is key.
      Take Care,
      Heather

      Reply
  • Joe April 5, 2017 at 5:30 am

    This is a powerful article. Robert Anton Wilson, who suffered from post polio syndrome in his later life, said that a life without pain should be one of the primary goals for improving quality of life.

    I think there is a lot of misinformation about morphine, which for some can be a wonder drug to make their lives bearable in the face of chronic pain. This is important for people to realise, it has nothing to do with bringing about an end to life because morphine is basically worthless for that (in a clinical setting at least)

    Reply
    • Heather Williams RN CHPN April 5, 2017 at 12:56 pm

      Thank you Joe. I completely agree with you, and I encounter resistance all the time in my day to day practice. So far my solution has been providing education, guidance, and reassurance one patient at a time. Take care, Heather

      Reply
  • This blog is needed April 28, 2017 at 10:29 am

    I knew morphine was a painkiller but we always made to believe that it is such a bad thing and you would use it only under dire circumstances. It reassuring to know that morphine is also not a synthetic drug and that there is no ceiling allowing the dose to be administered effectively there is no more pain for the patient. Hospice does an amazing job and I think it is very much undervalued all over the world in terms of the care. It takes a special person to be a caregiver. God Bless you.

    Reply
    • Heather Williams RN CHPN April 29, 2017 at 2:49 am

      Thank you for your comment. I am very happy that you found this article useful. I think that hospice is a hard topic to talk about, but the people that go through a hospice journey are able to find the value in what we do. If I can just impact one life, then I have succeeded. God Bless You my friend.
      Take Care,
      Heather

      Reply
  • Daniel April 28, 2017 at 4:38 pm

    Wow, a very interesting article. Thanks for that! It is very interesting to read how morphine is used. I do not really know about it. You can hear or read it again and again, but since I do not have any interest in such substances, I have never been concerned with it.

    It certainly gave me a little insight into how to work in a hospice. It is about giving people a dignified farewell to our planet.

    All the best,
    Daniel

    Reply
    • Heather Williams RN CHPN April 29, 2017 at 2:15 am

      Thank you for taking the time to read the article. People generally don’t have much familiarity with morphine outside of a hospital setting. I really think the “hospital experience” prompts the reaction that is often received when I propose giving someone Morphine at home. There is a difference between medication given through an IV versus given orally, but the fear overall is generally unwarranted.
      Take Care,
      Heather

      Reply
  • Farhan May 1, 2017 at 8:02 am

    Wow, I didn’t know that many people have this distorted idea that morphine is used to make old people reach the end of their lives faster. It is shame because people should be allowed to suffer.

    It is s a good thing that you have taken the time to clarify in detail, on how morphine is utilized in Hospice. This will surely put the minds of many family members at ease.

    Very informative article!

    Reply
    • Heather Williams RN CHPN May 3, 2017 at 11:30 am

      Thank you for taking the time. I agree with you that people should not have suffer, and it is my hope to spread awareness. If I have helped one person, then I have succeeded.
      Take Care,
      Heather

      Reply
  • Catheryn Murphy May 15, 2017 at 4:15 pm

    Thank you Heather for posting this article. I found it very informative. I wish I knew this information when my father was in hospice – it would have saved our family from fighting and arguing with each other on the “morals” of morphine. I don’t know why it is so taboo to some people.

    I especially appreciated the following paragraph: “At the end of life Morphine becomes even more important in honoring your loved one, by allowing them to be comfortable. It is an understanding in Hospice that a patient will have difficulty passing over peacefully if they are in a pain crisis.”

    My father had cancer that metastasized to his bones – the morphine eased his pain and relaxed him. Unfortunately, it became a huge fight among family members, to give him the morphine he needed from family who felt strongly against it.

    Reply
    • Heather Williams RN CHPN May 16, 2017 at 12:24 pm

      Thank you for your comment. It is a constant struggle with some caregivers, my hope it that we are able to minimnize the unwarranted fear.
      Take Care,
      Heather

      Reply

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