Does Morphine Hasten Death?

Q. My mother is 82 and has dementia. Her condition has gotten worse and hospice has been suggested. I have heard that hospice often involves administering morphine to the patient to make them more comfortable. Does morphine hasten death? I want my mother to be comfortable, but I have heard stories about it from friends in similar situations and I’m concerned about making the wrong decision. Can I indicate in my own Advance Directive whether or not to use morphine if I decide it’s a bad idea for my mother? Thanks for your help!

A. Pain management is a key issue in increasing the quality of life of patients with a terminal illness, and it is one of the most important goals of both palliative and hospice care. Opioids, especially morphine, remain the treatment of choice for relieving severe pain, and high-dose morphine is sometimes used in end-of-life care. The question is… is pain worse as we near death and does the administration of morphine in any way hasten death?

Will Pain Worsen as Death Nears?

Pain is one of the more common symptoms experienced by those living with serious illness. Understandably, it is common to be concerned that pain will steadily worsen and be poorly controlled as death nears. While it is true that pain is a common symptom in advanced illness and merits the full attention and expertise of health care providers, for many, it tends to behave consistently throughout an illness. If pain has not been present, it is unlikely to develop near end-of-life. If pain has been present but manageable, it will most likely continue to be manageable rather than escalate out of control in the final days.

One study of patients with advanced cancer showed that the prevalence of pain actually decreased from 52% about 6 weeks before death to 30% in the last week of life. Perhaps this decrease in pain is because the dying process is one of shutting down, not escalation. Our energy decreases, our alertness decreases, and we tend to rest and sleep more.

Sometimes, however, an individual may be in chronic pain and unique circumstances may result in increasing pain in the last weeks of life. In such situations, especially when hospice or palliative care is involved, health care workers will aggressively pursue comfort with all of the urgency and expertise possible, and this could involve administering morphine.

Does Morphine Make Death Happen Sooner?

Morphine may be used to control pain or shortness of breath throughout an illness or at the end of life. Patients and families sometimes worry that opioids such as morphine will speed up the dying process.

Although studies show that terminally ill patients typically decline because of the illness with or without the morphine, some people still believe that morphine hastens death due to respiratory depression.

Here are some reasons hospice and palliative care doctors believe morphine and other opioids are not a factor in the death of a person with advanced illness:

• There is no evidence that opioids such as morphine hasten the dying process when a person receives the right dose to control the symptoms he or she is experiencing.
• Research suggests that using opioids to treat pain or shortness of breath near the end of life may even help a person live a bit longer. Pain and shortness of breath are exhausting, and people nearing the end of life have limited strength and energy. So, it makes sense that treating these symptoms might slow down the rate of decline, if only for a few hours.
• If a person has never received morphine, the initial doses given are very low. Dosage is gradually increased, if necessary, to relieve the person’s level of pain or shortness of breath.
• After a few days of regular doses, the body adjusts to the morphine. The patient becomes less likely to be affected by morphine’s most serious side effect — the slowing of breathing.
• It would take a large dose increase over a short time to harm someone. Morphine doses are increased gradually and only as needed to maintain comfort.
• The last dose is the same as the doses the patient has previously received and tolerated. The way the medication is given might change when someone can’t swallow any longer. If the medication needs to be given by a different route, the dose is calculated to equal the amount previously given by mouth.

Why Some People Object to Using Morphine

Opioid-induced respiratory depression (OIRD) is a side effect of opioid analgesics, and it can cause death, but the incidence of it is very low in those at the end of their life who have been suffering from terminal illness. In drug addicts, respiratory depression is the major cause of death, but not when the drugs are administered properly by medical professionals.

Unfortunately, medical fear of respiratory depression means that pain is often under-treated and patients experience unnecessary suffering. Other objections include the fact that people are afraid that if they use medications now, the medications will fail to work later “when they really need them.” In these cases, if medication tolerance develops, a stronger medication or a different medication may be used. People who are dying, family members, and healthcare professionals alike also often carry a concern about addiction. But this should not be a concern at the end of life.

The Difference Between Natural Dying and Dying from Too Much Morphine

There’s a difference between natural dying and dying from too much morphine, which helps clarify how morphine (even too much of it) does not hasten death. For instance, when someone has received too much morphine, he or she usually can’t be woken up. The person’s breathing becomes very slow and regular. Sometimes only one or two breaths are taken in a minute. The person also appears calm and comfortable.

In the last few hours of the natural dying process, a person’s breathing becomes shallower and faster than normal. The breathing muscles become weak like all the other body muscles. When the breathing muscles are weak, extra muscles help out. It may look like the person is working hard to breathe, but does not always mean that they feel short of breath. The person’s breathing pattern often becomes irregular with pauses. These pauses are often followed by a few fast and deep breaths. These changes in breathing are a sign that the control center for breathing is failing. The person may seem to be working hard to breathe, but this is a natural and normal response, and not due to morphine.

An excellent article entitled, Morphine: A Misunderstood Medication was just published in Next Avenue. It explains how physicians and caregivers are working to clear up myths about powerful end-of-life drugs, such as morphine.

Advance Medical Directives in Northern Virginia

An increasing number of people have views about the care they would want if dementia were to occur, including whether or not to enter hospice or palliative care and whether or not to administer morphine. Every effort should be made to honor those wishes. The best way to do so is to complete a dementia directive, such as the one included in our 4-Needs Advance Medical Directive®, before you develop signs of dementia. This is because even with early cognitive impairment, patients may lose the ability to complete complex planning about medical decisions.

If you or any of your loved ones have not done Incapacity Planning, Long-Term Care Planning, or Estate Planning (or had your Planning documents reviewed in the past several years), now is a good time to plan and get prepared. Call us to make an appointment for an initial consultation: