morphine reduction in dying

[joannotrealname]

http://www.nursingcenter.com/lnc/static?pageid=1255264

I wanted to get your input on what you think of this article, and how many of you encounter situations where reducing morphine in the dying, hospice patient might be in order to prevent more pain and discomfort, as mentioned here. Is this actively considered in the hospice environment?

Also, have any of you encountered conditions in which morphine in the hospice patient with dyspnea might be contraindicated? e.g., brain swelling in stroke, with or without adequate hydration?

[MunoRN, RN]

Thanks for the article. I deal with typically very short term end-of-life care, so the build-up of metabolites that can't be cleared is not typically an issue. We do typically use fentanyl rather than morphine for patients with known severe renal impairment to try and avoid metabolite build up issues.

I'm not sure what you mean by patients for whom morphine is contraindicated due to brain swelling in stroke. Morphine isn't a contraindication for cerebral edema in general, so I wouldn't consider it to be contraindicated in the dying patient with cerebral edema.

[nurseprnRN, BSN, RN]

"Adequate hydration" is also not a concept that means the same in hospice as it does in acute care. People who are dying naturally want to take in less by mouth. The resulting dehydration decreases the incidence of nausea and vomiting (fewer stomach contents and GI secretions), respiratory distress (lungs don't get so wet), and urinary management issues (less urine). Oral care for comfort is always nice, but IV hydration when PO intake fails isn't an issue most of the time. So I'm not sure what your reference is to brain swelling in stroke-- if someone has (presumably terminal) cerebral edema in hospice, that's not something that would be being treated (other than symptomatic symptom relief as possible).

[joannotrealname]

Thanks for the responses! This is very helpful.

Sorry for the confusion in my questions.

The crux of my questions was whether or not morphine could exacerbate brain swelling in a dying stroke patient who has both 1) brain swelling, and 2) signs of renal failure (reduced, black urine) that might enhance the drug's effects.

I'd read several technical sources that said morphine can increase intracranial pressure (ICP), but others that say untreated pain can raise ICP as well--hence my confusion.

[MunoRN, RN]

Morphine can contribute to cerebral edema, but it's effect isn't typically all that clinically significant even in patients that already have swelling. Morphine and other prn opiates are part of recommended medical management of cerebral edema because the effects of pain and distress can worsen to swelling much more than the opiate itself does (increased metabolism, cortisol, etc).

In a post-stroke comfort care/hospice patient we try not to speed up the dying process (at least we're not supposed to), but we don't necessarily avoid that either if it would mean sacrificing comfort (if we assume that morphine would actually worsen edema more than it would help it).

Medscape: Management of cerebral edema

(Medscape links don't always work, if it doesn't you can usually get to it by a google search using the above title).

[joannotrealname]

Thanks, MunoRN--very helpful! Expanding my knowledge and understanding!