Hospice: Algorithms for pain?

Nurses General Nursing


Here is the situation. A elderly person is dying and has pain,say from cancer.

MD orders morphine,either po or sc.but it doesnt control pain. So MD orders fentanyl patch,say 25mcg.,so the patient now gets both drugs but this doesnt control pain.

Now lets say for sake of discussion a PCA pump is not an option. Then which med should be increased,the Morphine or Fentanyl patch?

Is there some kind of "Algorithm" for pain control and the end of life care?

aimeee, BSN, RN

932 Posts

The fentanyl patch will take up to 12 hours to kick in, so you need to be increasing the morphine to a level where it covers the pain. Are you giving pills or sl roxanol? How frequently is the morphine ordered? We often give it as often as every 2 hours. Sometimes just giving it regularly will improve its effect. Once you get to the point where the morphine is bringing the pain down to a level 3 or less then you look at how much you needed over a 24 hour period. Then you can go to a conversion table to see what dose of duragesic will be needed to keep the pain under control round the clock and the morphine can just be used for breakthrough pain.

On cautionary note: up to 20% of the population lacks the proper enzymes to convert morphine well and will not get good relief from it and so may get better relief from one of the other narcotics.

Home Health Columnist / Guide


11 Articles; 18,069 Posts

Specializes in Vents, Telemetry, Home Care, Home infusion.

Web sites for pain mgmt Info:

Duragesic Patch Use



Narcotic Conversion Chart/Pain management algorithims from Hope Hospice


Pain Meds



New site with TONS pain links---

Pain Management for Nurses



386 Posts

Thank you aimee for the info on MS and Fentanyl and thank you NRSK for the pain web sites ,man this is a great site


104 Posts

When I worked oncology, we used to give SC Morphine hourly if needed... and with the Duragesic patch, he needs to have enough fatty tissue under his skin to properly absorb the medication, so make sure it's not placed over a boney prominence, such as the scapula. If he's terminal, and close to "that time" is a morphine pump an option if his pain isn't being controlled?

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