I'm an RN with limited palliative care and hospice experience. My terminally ill patient who was previously taking hydromorphone is now using morphine. What factors are involved when choosing morphine for end-of-life care?—TF, ILL.
Karen M. Kuebler, BSN, RN, replies: When patients enter hospice care, clinicians make great efforts to provide appropriate analgesia on a day-to-day, and sometimes hour-to-hour, basis. When patients are experiencing significant adverse reactions to one opioid, another one may be substituted to ensure pain control.
For example, consider a patient with end-stage lung cancer and a life expectancy of less than 1 month. Since being admitted to the hospice facility on oral hydromorphone, he's reported increasing pain; in addition, he's agitated and dyspneic. His hospice team collaborates and decides to discontinue hydromorphone and give an equianalgesic dose of morphine. Round-the-clock slow-release oral morphine and p.r.n. sublingual morphine for breakthrough pain are prescribed.
Why the change? Morphine is an opioid that can help alleviate chronic dyspnea, especially when administered in a long-acting formula.1 Hydromorphone is an effective opioid, but it doesn't offer the same benefit.
After the patient is switched to morphine, the team will evaluate the patient's response, monitoring closely for verbal and nonverbal signs of pain and adverse drug reactions such as agitation, confusion, nausea, or seizures. If the patient's dyspnea diminishes or subsides with morphine, it could easily replace hydromorphone.
Morphine is commonly used in hospice facilities. The World Health Organization has endorsed it as the gold standard of opioids and it's considered the first-line treatment for moderate-to-severe pain.2 Morphine is inexpensive and readily available. Because of its short half-life, it can be titrated quickly based on patient response.3 With virtually no ceiling to its analgesic effect, morphine is limited only by adverse reactions, most of which usually diminish as the patient develops tolerance.
Morphine may be combined with adjuvant therapies such as corticosteroids, antidepressants, antiepileptic drugs, topical treatments, and over-the-counter medications, such as acetaminophen and nonsteroidal anti-inflammatory drugs. Analgesia is often obtained with a combination of medications to keep the patient as comfortable and connected to the world as possible.4
Educating patients and their families is very important when morphine is prescribed. Some people erroneously believe that morphine is administered only when death is imminent. Because it's an opioid receptor agonist that produces analgesia, morphine can be a very effective pain reliever and is part of many palliative care therapies.
Many patients and families are concerned about addiction and the need for increasing morphine dosages to manage pain. All opioids are prescribed at dosages that relieve pain. If patients have pain, the dose is titrated until they're comfortable. This doesn't mean they're addicted; their need for larger doses may simply be a sign of disease progression or a tolerance to the current opioid. Tolerance is an expected physical response occurring with drug exposure that results in diminished drug effects over time.5Addiction is often characterized by a physical and psychological need for an opioid, which may lead to self-destructive behaviors.6
Used appropriately, morphine can effectively maintain analgesia without producing unacceptable adverse reactions. Although it's a consistent standard in the treatment of many types of pain in end-of-life care, many professionals, patients, and families need more education about its use.
1. Heigener DF, Rabe KF. Palliative care concepts in respiratory disease. Respiration
2. Ensor BR, Middlemiss TP. Benchmarking opioids in the last 24 hours of life. Intern Med J
3. Caraceni A, Pigni A, Brunelli C. Is oral morphine still the first choice opioid for moderate to severe cancer pain? A systematic review within the European Palliative Care Research Collaborative guidelines project. Palliat Med
4. Christo PJ, Mazloomdoost D. Cancer pain and analgesia. Ann N Y Acad Sci