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Morphine May 7, 2012

Posted by ijwoods in Blog+.
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Taking time to understand the process of dying may help you avoid going into full panic mode as your loved one moves through unfamiliar behavior patterns. But doing some research about the use of morphine during palliative care may save you from potential grief, guilt and long lasting personal trauma.

In the first meetings with our hospice representative we learned about palliative care including the use of narcotics to relieve pain. We learned that if the pain became greater than what the lower grade pain-releivers could manage we might have to escalate all the way up to morphine. Our representative wanted to make sure we understood and were okay with this.

My initial reaction was that I wanted K to be as conscious as possible during her final days and I wasn’t sure if morphine would allow her that privilege. On the other hand I most certainly didn’t want her to suffer with extreme pain. I wasn’t settled, but rather than impose my thoughts I waited for K’s reaction. She agreed that the morphine would be preferable, if ever needed. I went along knowing K didn’t make decisions like this lightly. It was obvious to me afterwards that she had already thought this through.

As important as that conversation with our rep was, I didn’t really understand what it meant when played out in real life. My thinking was lazy because I was in a state of denial; I didn’t believe that K would be leaving us any time soon. What I didn’t realize was that in reality she would pass away about two months later.

During those remaining months, K experienced some pain off and on but the pain killer oxycontin was sufficient. K took it as little as possible because oxy has some side affects she found uncomfortable. Still, she seemed to manage the narcotic and the pain pretty well.

One day the pain went up several notches to the point where it was severe. Again the oxy was good enough to relieve it, although we had to increase the dosage. Some days later the severe pain returned to the point she was in agony. This time the oxy was not working, even with the greater dosage. I immediately called the hospice for help. Our nurse told me it was time to escalate to the morphine. Liquid morphine was part of an emergency kit given to us when we began hospice care. This form of morphine is put into the mouth, where it is absorbed into the body. The morphine worked very well and in a short period of time K went to sleep for quite a number of hours.

I’m not going to elaborate on our morphine tale except to say that for me it was intense. I was, and still am, very happy that K was able spend her final days peacefully and pain free. Nonetheless the use of morphine was not an easy one for me and I came out of the experience beaten up. I wrestled with questions like “Did we start too soon? Did it impact her ability to be conscious during those last days? If it did, was it better than the alternative? Was I killing her?”  I can’t begin to describe the anguish I went through.

As I struggled with this I shared my doubts with our nurse. The nurse was patient but firm with me. She helped me remember what the alternative would be. The alternative, which I had already witnessed, would be K living through excruciating pain and over the top restlessness. I didn’t want to see her go back to that and so trusted the process and accepted the treatment.

Now, after half a year later with plenty of time to reflect and read, I have come to understand better and accept the benefits of having had K medicated with morphine. This was a time that the cancer was killing her in a most brutal and painful way and we had to do something. The more I learned the more my concerns were put to rest. I wish I had known all that earlier.  As the Australian department of Health and Aging so simply points out, “Some people fear that being prescribed opioid medicines means that they’re closer to the end. However, relieving your pain changes your quality of your life — not its length.”

I discovered afterwards that the use of morphine in hospice care is a contentious issue for some people. The hospice nurses I’ve met, or have read commentary from, are all very clear about the compassionate nature of using morphine should it becomes necessary. I believe them.  When I hear them speak I hear them talking from a depth of experience working with many patients and experiencing firsthand how things play out for the ones they are caring for. And, now having read quite a bit about it, I know that in K’s case it was the best thing we could do to make her comfortable. But there are some outspoken people who believe the use of morphine is being abused and at times unnecessary.

If you are in, or entering, a palliative care situation I urge you to understand this subject as well as you can. When you meet with the hospice representatives have your questions ready. Speak to your designated nurse about it. Speak to the hospice doctor about it. Read about the experiences other people have had with it. Know what your loved one wants to do. Make sure others in your family, who may be around to help, are on the same page. When you are well informed and clear it will be much easier to make decisions and to manage what’s going on. Without taking time to be informed and clear, the potential trauma over the practice of using morphine can be high.

Here are links to some helpful articles on the subject:

“A Ban on Morphine is Reconsidered”: this is a very personal essay in the New York Times a few years ago by someone who brought her mother home to die at a time that the FDA was looking at imposing a ban on morphine use.

http://newoldage.blogs.nytimes.com/2009/04/27/a-ban-on-morphine-is-reconsidered/

“Pain Control: Dispelling the Myths by Dr. Joel Potash, MD”.  From Hospicenet.org. Good clear run through of myths regarding pain control and use of morphine.

http://www.hospicenet.org/html/pain_myths.html

“Facts about morphine and other opioid medicines in palliative care.” This is a brochure put out by the Australian Government department of Health and Aging. Nice, simple overview.

http://www.palliativecare.org.au/portals/46/resources/FactsAboutMorphine.pdf

“From CA: A Cancer Journal for Clinicians: Common Misunderstandings about The Use of Morphine for Chronic Pain in Advanced Cancer.” This paper addresses many of the myths and misconceptions about the use of morphine. This may be bit harder to read but has some very good clinical information.

http://onlinelibrary.wiley.com/doi/10.3322/canjclin.35.3.164/pdf

Comments»

1. frangipani - May 7, 2012

I received pethidine (related to morphine) injections for labour pains. My experience was that the pain didn’t completely go away, but it ceased to bother me, and I could rest and sleep awhile.
Cancer pain certainly lasts longer than childbirth. I fully support the use of morphine to relieve suffering.

2. Chris de Boinville - May 7, 2012

Dear Ira,
I read with great interest your beautifully written account of the hesitantcy you felt and experienced over giving liquid morphine
to K. Your courage and your heart guided you: and the support
and encouragement of your hospice Team was perfect. Thank
you for sharing your experience as caregiver in such a
beautiful way.
–In peace,
Chris de Boinville
Montgomery Hospice
Rockville, MD

3. blessedbebeth - May 13, 2012

Thank you for this. I have been caring for my mom who is a 90 year old vet for three years. We have recently entered the hospice side of our journey. Having assisted in end of life care of others, I am a big fan of the comfort morphine can bring. Of course, I was still unprepared for a brief period of wrestling with the timing of this with my own mother for all the same reasons you mention. You have brought another level of clarity to our process, and I am most grateful. Blessings and peace to you. Beth Zwecher from Middlescapes.com

ijwoods - May 13, 2012

Thanks Beth. The use of morphine turned out to be a very emotional experience for me. Subsequent to posting the article I’ve spoken to some people for whom it was very clear to provide their loved ones with the treatment, but that’s not always the case. Learn all you can about it and, as I mentioned in the article, speak to professionals and ask as many questions as you can. If I had to do this again I would be asking things like; how exactly will the morphine be affecting the person; Will it stop them from eating and drinking; how will it inhibit their ability to communicate? Will it hasten their death or simply enable them to continue to live more comfortably? — and so on.

blessedbebeth - May 13, 2012

sound advice Ira. Thanks, will follow up this week. live well.

4. Laurie Samsel Olson - November 11, 2014

You really hit the nail on the head. Deciding when and how much morphine to give my mother at the end was agonizing. No one tells you how difficult that is going to be. Yes, we consulted the hospice nurses when Mom started to get very restless. But did we give her too much? Would she rather have been a bit more aware than she was the last several days. We’ll never know.

ijwoods - November 11, 2014

I can really relate to the difficulty you faced. I still wonder about it myself. But, over time I remembered that Kris had expressly told me that if it came down to it to make sure she was on morphine rather than going through intense pain. That’s one bit of direction that helps save my sanity.


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