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November/December 2021
End-of-Life Care — Misconceptions About Morphine Sandra was distraught. In addition to experiencing grief following her father’s death, she was haunted by fears that she had “killed him” by agreeing to use morphine to control his pain near the end of his life. “He never woke up after we started the morphine. It was only a couple days until he died.” Morphine is a standard, and often the best, medication for keeping terminally ill patients comfortable. According to Jared Lowe, MD, HMDC, medical director for University of North Carolina Hospice, morphine “works on receptors in the body to reduce pain and shortness of breath, which are two of the most common symptoms encountered at the end of life. Having a drug available to treat those symptoms is critical in keeping individuals comfortable.” For terminally ill patients, morphine has many advantages. In addition to its effectiveness and reliability, it can be administered easily in multiple ways (for example, through tablet, liquid, or injection). It has relatively fast onset of delivery, and doses can start low and be adjusted in small increments. Research is clear that, when morphine is used under proper medical guidance, such as that of a hospice team, it doesn’t cause or hasten death.1-5 Unfortunately, fears such as Sandra’s are common. Lowe says that “we often meet patients and family members who associate morphine with death or hastening death.” A Pervasive Problem For people taking care of a loved one at home and responsible for giving medications themselves, the idea of using morphine can cause distress and doubt. When a loved one is struggling with uncontrolled pain and the medical team is recommending morphine, a caregiver afraid of opioids may feel boxed into an impossible situation. Do I use morphine to ease my loved one’s suffering despite fear that it could cause harm? Do I refuse morphine knowing my loved one’s physical suffering may not be adequately alleviated? Such distress may be intensified by personal or cultural beliefs. For example, a caregiver who believes that God cures those who are genuinely prayerful may view using morphine as a lack of trust in God, which might undermine hope for a “miracle.” Those who believe it is their responsibility to encourage a life partner to remain hopeful may see using morphine as “giving up on” or even betraying the patient. A common origin of the belief that morphine causes death in terminally ill patients is that it’s often used in the last days and hours of life. By then, it may be scheduled every couple of hours ensuring that whenever death occurs it will be shortly after a dose is given. According to Lowe, this association between morphine and time of death can “sometimes be perceived as causation,” leaving some anxious that morphine caused or accelerated the timing of a loved one’s death. In a commentary in the journal Palliative Medicine, Rob George, MD, agrees that when death occurs shortly after starting or giving morphine, it can lead to the false assumption that morphine kills. Though this assumption may seem logical, George points out that it is actually based in emotion and defies what we know about morphine from years of research and clinical practice. “When reason and emotion are in conflict,” he concludes, “emotion usually wins, and an emotional link between morphine injection and death is common.”6 Lowe says when patients are referred for hospice care late in their illnesses, it can reinforce this misconception. “We have many patients who are only on hospice for a couple of days before they die. They may have been in pain or discomfort for weeks as their disease progressed, but hospice care is started very late, so the association between when they die and when they started symptom management medications like opioids seems even more pronounced.” Having the Conversation Such conversations may be left to a hospice or palliative care team recommending morphine because a patient can no longer swallow and needs a medication that can be delivered in liquid form. Thus, a death which actually occurs after a long, incremental decline may be experienced as sudden and as corresponding with the start of morphine. Another source of confusion is that signs of imminent death such as somnolence and/or alterations in respiration may be attributed to effects of morphine rather than to the underlying illness. A normal part of the dying process is to spend more time asleep, but caregivers may attribute this to the sedative effects of morphine. A patient may be having periods of apnea related to dying, but a caregiver who believes morphine depresses respiration may attribute this to the medication. Morphine does cause sedation, but this typically diminishes as patients gets used to it. When used properly, it doesn’t depress a patient’s respiration, and, for those struggling with shortness of breath, it can bring significant comfort.3 Since opioids affect the parts of the brain that deal with emotions such as fear and anxiety, it can also help dying patients relax, which provides additional comfort from disease-related changes in breathing. Some caregivers believe they have caused a loved one’s death when the death occurs shortly after raising the dose of morphine or under circumstances when, because of fatigue or nerves, they worry they drew up more than the correct dose. Did I draw too much into the dropper? Was it that extra 5 mg? Such caregivers would be reassured to learn that research focused on whether increasing opioid medication just prior to a patient’s death hastens the timing of death has shown that it doesn’t.8-10 Concerns about morphine hastening death often entangles with other fears, such as fear of addiction, sedation, alterations in cognition, and loss of effect due to increasing tolerance. Although these concerns are manageable in an end-of-life context and often exaggerated, they can reinforce a belief that morphine is dangerous. Unfortunately, there are also health care professionals who believe morphine hastens death.3,11 Although such fears are rare among end-of-life professionals, if a caregiver detects or senses hesitation in other health care providers, this can intensify their own doubts and second-guessing. As a clinical social worker, I’ve worked with many caregivers whose grief is complicated by recurring thoughts that they failed to protect a loved one and hastened their death. In some, this belief can even cause moral distress or injury, posttraumatic stress, and/or depression. Many end-of-life settings provide information about opioid medications including educational materials. This often includes “fact sheets” debunking some of the “myths” about morphine. Ideally, this kind of education should begin prior to initiating morphine. For professionals who use morphine routinely, it’s important to remember that opioid medications can feel morally charged and trigger intense emotions in caregivers, especially those responsible for giving the medication. It may be normal for professional staff, but it isn’t normal for those watching a loved one struggle with pain or respiratory distress. Professional staff should take time to assess for questions and concerns and be prepared to explain repeatedly over time why morphine is safe and effective. Continuing to Ask the Right Questions It’s important to remember that these fears don’t stem from irrationality or an inability to absorb information. There are many understandable reasons for confusion and second guessing. Often feelings of guilt or distress are rooted in love for the patient and wondering whether one made the right decision under great stress. In addition to educating about medical care, health care staff should respond with empathy, patience, and compassion. People with complicated grief may overfocus on troubling thoughts, beliefs, and emotions. Some may experience intrusive memories, nightmares, or ruminations about their perceived failures. It can help to reflect on the moment they decided to use morphine. What was happening? What was their hope? What was their intention? When I ask these questions, caregivers often recall that their intention was to alleviate a loved one’s pain. Sometimes they say they were feeling a sense of duty or responsibility to follow the recommendations of the medical team, to “do a good job.” A caregiver’s answers often reveal underlying positive values that can be acknowledged and affirmed. These may include things such as love, protectiveness, duty, trustworthiness, sacrifice, loyalty, mercy, reciprocity, or compassion. Taking time to identify ways a caregiver was able to express these values during a loved one’s illness and tying them into decisions about morphine can help broaden their perspective on events and engage self-compassion. Asked what he would say to someone worried they had hastened a loved one’s death, Lowe offers this: “Caregiving for someone at the end of life is incredibly difficult. It’s very natural to second guess every step along the way, and in some ways that ‘story-telling’ to ourselves can be part of the grieving process. But we can say confidently that the morphine or any other opioid medication did not hasten death. There have been several studies looking at the use of these symptom management medications at the end of life and they found no effects on how long someone lived. That was even true for the few patients who required much higher doses than average in order to remain comfortable. It’s normal to question the impact of our actions, but caregivers need not worry that, when used appropriately, they hastened the death of someone they love by using morphine.” — Scott Janssen, MA, MSW, LCSW, is a hospice social worker and member of the National Hospice and Palliative Care Organization’s Trauma-Informed Care Workgroup. His book Standing at Lemhi Pass: Archetypal Stories for the End of Life and Other Challenging Times explores the use of therapeutic storytelling with hospice patients and families.
References 2. Sykes H, Thorns A. The use of opioids and sedatives at the end of life. Lancet Oncol. 2003;4(5):312-318. 3. Gallagher R. Killing the symptom without killing the patient. Can Fam Physician. 2010;56(6):544-546. 4. Azoulay D, Jacobs J, Cialic R, Mor E, Stessman J. Opioids, survival and advanced cancer in the hospice setting. J Am Med Dir Assoc. 2011;12(2):129-134. 5. Lopez-Saca J, Guzman J, Centeno C. A systematic review of the influence of opioids on advanced cancer patient survival. Curr Opin Support Palliat Care. 2013;7(4):424-430. 6. George R. Lethal opioids or dangerous prescribers? Palliat Med. 2010;21:77-80. 7. Winemaker S. ‘Morphine is no substitute for the truth’: doctors must be honest about progressive illness. HealthyDebate website. https://healthydebate.ca/2018/01/topic/progressive-illness-palliative-care/. Published January 18, 2018. 8. Abraham DL, Hernandez I, Ayers GT, Pruskowski JA. Association between opioid dose escalation and time to death in a comfort measures only population. Am J Health Syst Pharm. 2021;78(3):203-209. 9. Good P, Ravenscroft P, Cavenagh J. Effects of opioids and sedatives on survival in an Australian inpatient palliative care population. Int Med J. 2005;35(9):512-517. 10. Thorns A, Sykes N. Opioid use in the last week of life and implications for end-of-life decision-making. Lancet. 2000;29(356):398-399. 11. Regnard C. Double effect is a myth leading a double life. BMJ. 2007;334(7591):440. 12. Janssen S. Honoring the moral concerns of caregivers afraid of giving morphine. Am J Nurs. 2019;119(8):64-65. |
