Use of morphine and CPAP in hospice patient

[Elizabeth Hanes, BSN, RN]

Hi all,

My dad has been living with me for six months due to dementia. Last week, we admitted him to hospice due to spiraling debility secondary to not only the dementia but congestive heart failure.

Because I'm not a hospice nurse, I have a few questions about his current regimen. I appreciate any advice.

1. Because of various co-morbidities, my dad has been on high-dose morphine therapy (75mg of extended-release PO morphine BID) for a few years. However, the hospice's DON expressed a negative reaction to morphine in the hospice setting. She wants to switch Dad over to a fentanyl patch with methadone and hydromorphone for breakthrough pain. Does this sound typical? I thought morphine therapy was common in the hospice setting, so I'm confused about why Dad can't remain on morphine with adjunctive therapies for pain.

2. Dad has used a CPAP for OSA for several years. However, I'm wondering whether it now provides comfort or discomfort for him. In short, if I don't place the CPAP mask on him, am I harming him?

I realize no one can give me specific advice. I'm just trying to navigate the hospice process as best I can while I simultaneously grieve, and I greatly appreciate any insight.

Kind regards,

Elizabeth, RN

[tewdles, RN]

It is important to remember that hospice goals always center on comfort and quality of life. Sometimes folks come to use with opiate therapy which is in need of adjustment...their doses or agents need to be re-evaluated, sometimes the patients benefit from a rotation of medication or changes in the doses or schedule to accomplish the desired effects. 75mg BID of Morphine SR is not a huge dose...and he should have adjuvant therapy available. If the morphine works well for him he would not be required to change that in my neck of the woods.

If your dad is not appreciating the CPAP he is not obligated to use it...bottom line...he gets to choose.

It is wonderful that your dad has you to advocate for him...good luck.

[mariannern]

Hi,

I do have lots of hospice and dementia experience. Making significant changes with your Dad and what sounds like his MS contin is quetionable. At some point it may become difficult for him to take pills by mouth and this med is not crushable. roxanol (concentrated morphine is one option, an iv drip morphine is another option, along with ativan intensol. The ativan intensol can help with his breathing / use of a CPAP. It is not uncommon for pt. to spike high fevers and if they wear a fentanyl patch it can be absorbed at a dangerous rate. We stay away from these. You didn't state if dad is inpatient or routine hospice because the plan of care is at times, quite different. If Dad is showing signs of being uncomfortable with the CPAP, going to a nasal cannula will not work as effectively BUT it is about his comfort and life for your Dad. God Bless both you and your father during this difficult time. I hope this helped . Just remember that the MD has a final say over hospice recommendations and if you are in ? , call him up, and express your concerns :)

[tewdles, RN]

Not to nit pick...but the hospice team makes recommendations and the patient or family have "final say"...hospice care is directed by the patient/POA

also...hospice works best if the patient/POA contact the case nurse when they have questions or concerns...that is the nurse's job in hospice...to be the advocate for the patient

[ErinS, BSN, RN]

I would certainly question a switch like that, but understand that there may be some other issues here. Methadone and dilaudid are cheap, and fentanyl patches can be reasonable. It may be a money issue (hate to point that out). We usually do not change medication regimens if someone is comfortable, but if there is not great symptom control we actually use methadone and fentanyl patches a lot, although not usually together. I always worry about fentanyl in the elderly with dementia- I have seen this drug cause more confusion and agitation more often than other drugs.

Also the above advice about the cpap was right on. This is you and your dad's plan of care. I often tell patients to try a night without their cpap and see how they feel. Often at the end of life people can no longer tell the difference between a night with it and without it. Good luck and may god bless you.