Conscious Departures

Morphine May 7, 2012

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