Morphine for Hospice Patients: What Nurses Need to Know

Morphine, when used in hospice care, is different than in the acute care setting. When making the transition to the role of hospice RN, it is important for nurses to understand the differences in use in order to provide education, quell myths and ensure comfort in an individual's final days.

Updated:  

Morphine for Hospice Patients: What Nurses Need to Know

When moving from acute, inpatient nursing to home hospice, nurses have to reshape how they think about morphine. In acute care, there is an emphasis on minimizing narcotics, fear of creating addiction and adverse outcomes for patients after their hospital stay, and nerves around over-sedation and respiratory depression from narcotic use.

It is important for nurses to not let this bias transfer to in-home hospice care. Here, morphine and similar narcotics are commonly used to treat pain and shortness of breath during end of life. As patients, families and caregivers often have their own fears around morphine, the hospice nurse must provide education and support in using morphine in the home in order to maximize patient comfort during his or her final days. 

Why Morphine is Different in Hospice

Families report three primary fears around morphine used for at-home hospice: decreased communication, hastening death, and worries around addiction.

Morphine has a positive effect on communication in hospice patients

Try to imagine a time when you were in moderate to severe pain. Did you want to enjoy pleasant moments with loved ones, or withdraw into a ball on the floor? Were you your most open and kind self, or perhaps you became a bit snippy and mean? One of the common symptoms experienced near the end of life is moderate to often severe pain. 

Not managing an individual's pain at end-of-life can cause a person to feel angry and short-tempered, making it difficult for meaningful communication to take place, according to the National Institutes of Health. Ensuring someone is comfortable by using morphine, as prescribed by a physician, allows for improved communication between loved ones during final days. When we all think of our final moments, don't we wish for pain-free, love-filled final days or weeks, with shared memories and special moments. For hospice patients, appropriate use of morphine is often the ticket to just that.

In fact, in a study of 4,037 hospice patients using morphine for end-of-life symptoms, 85% saw little to no decline in communication. 

Morphine will not hasten death

We as nurses know that morphine can have terminal side effects like respiratory depression that can quicken an individual's death. However, multiple studies done with patients in at-home hospice care have shown no correlation between morphine use in the home and a quicker death. For one, the dosage is often lower in comparison to acute care settings, and the administration route is oral or intramucosal as opposed to intravenous. In-home dosing has low risk for respiratory harm, and in fact, often eases shortness of breath symptoms. 

In fact, a 2022 study showed that when an individual's pain was well controlled it benefitted sleep and appetite, improving quality of life and even extending survival. 

Hospice nurses can share this information with patients, families and caregivers to assure them they are not harming their loved ones, but rather improving their quality of life and allowing them more enjoyment in final days. When we are not in pain, doesn't food taste better, music sound better, and the voices of loved ones sweeter? And aren't these the things we hold onto life for?

Morphine will not cause addiction in end-of-life care

This one may seem straightforward, but it is still a common fear among individuals providing at-home hospice care. When receiving morphine for end-of-life symptoms, there is simply not enough time to become addicted.

One doctor stated, "at this point the most important thing is comfort.”

Nurse Responsibility

Nurses have a responsibility when providing end-of-life care to educate patients on morphine, quell fears and expel myths to ensure that patients are as comfortable as possible. As there is a lot of contradictory information about morphine use, the nurse must be well educated and confident to share this information with patients, families and caregivers to ensure optimal pain management and comfort during an individual's final days.

References

U.S. Department of Health and Human Services National Institute on Aging. Providing Care and Comfort at the End of Life.

Opiophobia in Palliative Care: Conquering the Last hill by Mamak Tahmasebi

Toward Evidence-Based Prescribing at End of Life: A Comparative Analysis of Sustained-Release Morphine, Oxycodone, and Transdermal Fentanyl, with Pain, Constipation, and Caregiver Interaction Outcomes in Hospice Patients 

5
Up Vote Up Vote ×
KyleStaarmannRN

About KyleStaarmannRN

Education is power. Kyle Staarmann, RN BSN became a nurse to help educate individuals on how to best care for themselves and their loved ones.

1 Article   1 Post

Share this post

Share on other sites
Specializes in CRNA, Finally retired.

MSO4 is probably the variable that keeps patients in hospice living longer than if they weren't.  Hard to believe that anyone still uses the old addiction argument anymore; I could understand it in the 80's but not now.  Education can so excruciatingly slow:(

3
Up Vote Up Vote ×
Specializes in Critical Care/Vascular Access.

It may be a little inaccurately broad to say "Morphine will not hasten death". In the hospital setting when a patient transitions to Comfort Care it is not uncommon to see orders like "Morphine 1-2mg IV push q5min PRN shortness of breath" or something similar. Then it is up to the nurse's judgement how far to push that, because that dose is certainly enough to cause respiratory depression and "hasten death", especially for a fragile elderly person. Comfort care involves some of the tougher decisions nurses have to make, I think, because none of us want the patient to suffer, but where is the line between hastening death and simply easing suffering? I have certainly seen nurses caring for comfort care patients that I questioned their decision of how much pain medication to give......too much and too little. But maybe the author was referring exclusively to home hospice settings and the like.

1
Up Vote Up Vote ×

"At home, patients are taking 0.25-0.5mg oral or intramucosal." Did the writer mistake "mg" with "mL"? I've worked with Hospice patients for 20 years and the standard order has always been Morphine Sulfate 20mg/ml , give 0.25mL which is 5mg every ___ hour PRN. If the patient is in extreme distress, we will increase it to 0.5mL. 

1
Up Vote Up Vote ×
Specializes in Have done it all!.

When someone is in the active dying stages morphine is used to help ease the transition. Like a hospice nurse once told me we can drag the patient's death out 1 to 2 weeks or we can give it around the clock and help this person to die with dignity and how they wanted to die.

I am exhausting in alf nursing as to how patients & families are educated about end of life care. 

We are still so focused on keeping people alive that we refuse to acknowledge that people get old and die....there time is coming and we can help them.

Up Vote Up Vote ×
Specializes in Critical Care/Vascular Access.
On 7/11/2022 at 11:06 AM, ShayNeq65 said:

We are still so focused on keeping people alive that we refuse to acknowledge that people get old and die….there time is coming and we can help them.

You have a valid point, but where's the line that separates "helping" a person with the process of dying and euthanasia? It's vague at best.

Up Vote Up Vote ×
Specializes in Hospice, Palliative Care.

It’s frustrating do you have anyone who is a healthcare professional think that hospice uses morphine for euthanasia. Prior to becoming a hospice nurse I worked on the cardiac floor where are they increasingly gave me more and more hospice patients. I still remember the one that was on a morphine drip via IV where the doctors orders or to monitor four respirations above 20 for every 30 minutes and to increase the dose until such a time the respirations were 24 or less. During my eight hour evening shift I remember doing 16 increases where the respirations were in the low 50s upon the start of the shift and we’re in the mid 40s towards the end of the shift. This was my first nursing job no not my first patient. This was my first IV morphine drip. I still remember looking like a deer in the headlights to my fellow workers as I was doing my end of the evening Jordan were they were asking me what was troubling me and I shared with them did over the past eight hours I increase the dose 16 times. They looked at me as if I was a child stating how many licks does it take to get to the end of the tootsie roll. They Said Peter, Night Shift is probably going to increase another 16 times. And when I looked amazed they said if he’s still around come dayshift they said they’re gonna increase get another 16 times and none of that’s going to kill the man!

as A hospice nurse I have had cases of severe terminal restlessness and agitation we’re under doctors orders I gave 180 mg of morphine in less than an hour along with 50 mg of haloperidol, 10 mg of lorazepam for a 72 year old town man skinny as a stick it took more meds just have him sedated but not yet euthanized because that wasn’t the goal nets never the goal at least for our state. Let alone my faith. 

It’s a significant amount of morphine do you have a potential and I used to work potential for a reason to kill somebody. Please do not be among those who continue to believe false things when it comes to morphine.

1
Up Vote Up Vote ×
Specializes in Critical Care/Vascular Access.
2 hours ago, pmabraham said:

It’s a significant amount of morphine do you have a potential and I used to work potential for a reason to kill somebody. Please do not be among those who continue to believe false things when it comes to morphine.

First of all, I'm not accusing anyone of euthanasia. I'm saying there is a thin line between "making someone comfortable" and accelerating their death, and it is most certainly not clear cut or precise.

I assume that I don't even have to tell you this, but everyone's response and tolerance to pretty much any kind of medication can be drastically different......especially pain meds. I've given enough pain medication to some non-comfort care patients that I'm quite certain would have killed many other people, because that's what they needed to control their pain and that's what their body could handle for whatever reason. So just because you gave a ton of Morphine to one patient, that doesn't mean that exact same amount would not have killed another.

It is not at all a false belief that Morphine can kill people, or at the very least accelerate their death. I've seen people get Narcan for too much Morphine, and they quite possibly would have died without it. Again, I'm not accusing anyone of anything. At all. I'm just saying there is a lot of gray area and subjectivity when it comes to this topic.

Up Vote Up Vote ×
Specializes in CRNA, Finally retired.
Mr. Murse said:

First of all, I'm not accusing anyone of euthanasia. I'm saying there is a thin line between "making someone comfortable" and accelerating their death, and it is most certainly not clear cut or precise.

I assume that I don't even have to tell you this, but everyone's response and tolerance to pretty much any kind of medication can be drastically different......especially pain meds. I've given enough pain medication to some non-comfort care patients that I'm quite certain would have killed many other people, because that's what they needed to control their pain and that's what their body could handle for whatever reason. So just because you gave a ton of Morphine to one patient, that doesn't mean that exact same amount would not have killed another.

It is not at all a false belief that Morphine can kill people, or at the very least accelerate their death. I've seen people get Narcan for too much Morphine, and they quite possibly would have died without it. Again, I'm not accusing anyone of anything. At all. I'm just saying there is a lot of gray area and subjectivity when it comes to this topic.

For someone who claims to not be accusatory, you certainly are throwing a lot of shade into the arena.  Of COURSE there is a grey area when it comes to end of life MSO4.  That's why this thread was started.  But to assume that people are using MSO4 in a situation that COULD hasten death, disregards the needs and wants of the patient.  The question arises when the respiratory rate falls while the patient is relatively comfortable.  Would you prefer that people die with a respiratory rate between 12 and 16 or die without pain?

1
Up Vote Up Vote ×
Specializes in Critical Care/Vascular Access.
5 minutes ago, subee said:

For someone who claims to not be accusatory, you certainly are throwing a lot of shade into the arena.  Of COURSE there is a grey area when it comes to end of life MSO4.  That's why this thread was started.  But to assume that people are using MSO4 in a situation that COULD hasten death, disregards the needs and wants of the patient.  The question arises when the respiratory rate falls while the patient is relatively comfortable.  Would you prefer that people die with a respiratory rate between 12 and 16 or die without pain?

I was responding specifically to pmabraham, and I'm not sure how my tone or words could be interpreted as accusatory or throwing shade, but if they came across that way to you or anyone else then I apologize.

I'm 100% in favor of a patient dying with comfort and dignity. It's just very subjective and situationally specific with few clear cut lines. Even objective criteria like respiratory rate is still very subject to the patient's over all clinical picture.

Up Vote Up Vote ×
Specializes in Hospice, Palliative Care.

Let's start off with just a little background of how hospice is supposed to work with families. What I'm sharing is per Medicare guidelines and that means every hospice nurse and provider should be following what I'm about to share but I'll put it out there that there are people who may not keep up with the guidelines or try to remember them etc. with that stated when I first meet a family whether their loved one is at home or in a facility I let the family know hospice is not in charge. Hospice is supportive. The power of attorney is the one who is in charge. We will give recommendations for how to best keep the loved one comfortable, but the power of attorney including any and all doctors were involved in the case can toss those recommendations to the wind without offending anybody.

When I assess the patient for the benefit of using something like roxanol which is liquid morphine, Included in the assessment is were they ever on any type of opioid, type, dose m, drug allergies, drug interactions... And if they're what is considered opioid naïve I will start them off on the lowest dose as approved and ordered by the doctor keeping in mind that nurses do not write prescriptions orders. And the one thing that everyone reading this thread must keep in mind it's all orders come from the doctor and not the nurse.

And if they're what is considered opioid naïve I will start them off on the lowest dose as approved and ordered by the doctor keeping in mind that nurses do not write prescriptions or orders. And the one thing that everyone reading this thread must keep in mind it's all orders come from the doctor and not the nurse.

From there we monitor for side effects and we educate everyone involved in the patient's care as to what side effects to monitor and we keep it simple and smile approach.

Four years is not a long time to be involved in a specialty but in those years I've had extreme cases ranging from loss of airway Requiring palliative sedation under the orders of a doctor, extreme terminal agitation requiring temporary palliative sedation under the orders of a doctor and cases where it was a complete when were the oncologist could not manage the pain for the loved one that they were completely bed and chair bound due to the pain or thanks to the expertise involved by hospice got to pain so will manage that the patient was able to have one last vacation to the beach with his wife and his rescue dogs before passing.

Requiring palliative sedation under the orders of a doctor, extreme terminal agitation requiring temporary palliative sedation under the orders of a doctor and cases where it was a complete when were the oncologist could not manage the pain for the loved ones that they were completely bed and chair bound due to the pain or thanks to the expertise involved by hospice got the pain so well-managed that the patient was able to have one last vacation to the beach with his wife and his rescue dogs before passing.

I will continue to maintain that morphine, methadone and the other medication is used by hospice do not lead to euthanasia under Doctors orders with hospice involved.

1
Up Vote Up Vote ×
Specializes in Critical Care/Vascular Access.
pmabraham said:

I will continue to maintain that morphine, methadone and the other medication is used by hospice do not lead to euthanasia under Doctors orders with hospice involved.

?Never said that it did, my friend.

I also work at a hospital, where "1-2mg Morphine q5min PRN shortness of breath" is completely up to the nurse's discretion and it most certainly could hasten death with certain patients. You are in a different setting using different forms of the drug. As I said multiple times.......subjective.

I'm not disagreeing with you or accusing you, and I'm not even sure why this discussion has taken any kind of argumentative tone. My only point in chiming in at all was to point out that the issue is not as clean cut and simple as some of the post (including the OP) seemed to imply.

I'm sure you do your job well, and please believe I'm not accusing you and I understand quite well how it is "supposed" to work.

Up Vote Up Vote ×
+ Add a Comment