Dear Barbara, I have a man that regrets giving his father morphine for pain at the end. His father had cancer all over. What would you say to him to make him understand that he did not kill his father? After his father passed a family member made a comment that he gave morphine until his father died.
The use of Morphine is one of the most misunderstood practices I encounter with families and end of life issues. Our society is so drug conscious we tend to equate any use as misuse.
First, let’s understand end of life pain. Dying is not painful, disease causes pain. If pain has not been an issue in the person’s disease history then just because death is approaching does not mean the person is in pain. We do not need to use a narcotic for comfort. Ibuprofen is my drug of choice.
If pain has been an issue during the disease process then we certainly want to continue to provide adequate pain management until the last breath is taken. Just because a person is non-responsive (which most people are before death) does not mean that pain is not there. We also need to know that whatever was causing the pain is not removed by the narcotic. The narcotic just covers up the pain. We must keep the cover on. In end of life pain management we also need to know that the use of narcotics over time tends to require increasing the amount of the narcotic.
I am trying to put a lot of detailed information into a few words, but end of life pain management is really an all day or more workshop.
Now let’s address the major concern---hastening death with the administration of morphine (or any narcotic). When a person is days to hours before death their body is shutting down. Nothing works right. Circulation, the blood flowing through the body, is slower and less effective (this is what the bluish color to the hands and feet show. When you give any medication at that time it does not get absorbed and become effective in the same way it would in a body that’s functioning normally. This is why giving pain medicine to someone who is actively dying is rarely the cause of death.
This father had “cancer all over”. I believe that means he had the potential for pain, lots of pain, in his disease progression. Morphine given continually is a must to keep this man relaxed and relatively comfortable. The morphine did not kill him, it allowed him to leave this world more gently than if he were suffering physically.
Now let's explore a controversial thought. What if the morphine had killed his father? He had a terminal illness. In fact his father was actually in the dying process. There was no reversing what was physically happening. Death was coming. What if hours of life (a few hours) could be extended by withholding the pain medicine? The result would be physical pain causing agitation and extreme discomfort even though the body is non-responsive. By continuing to give the morphine the last hours could be relaxed and relatively comfortable. Either way the person, as death approaches, is non-responsive. The misconception is that by withholding the narcotic the person would be alert and interactive. That is not the case. Either way the person will be non-responsive. It is just that in one scenario the person is hurting and the other they are not. What would you want?
Something more about Does Morphine Hasten Death?...
There are so many questions and concerns about narcotics. In my booklet, Pain At End of Life, I address the issue of narcotics and how they are used in end of life care. My film NEW RULES for End of Life Care will also help educate families (and staff) on the use of narcotics with the dying.
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Mary, I am so sorry to hear of your horrible hospice experience. I hope you spoke to the hospice administrator explaining your beliefs. You can also report the hospice to medicare. Taking action will not change what has happened but it may prevent someone else having the same experience. My blessings are with you and your daughter. Barbara
I am not a perponent of morphine, I personally have seen it abused by hospice three out of three times, I have witnessed a death. They flat out killed the person within a few hours of their arrival. I begged my daughter when her husband was at the end of his life, not to allow hospice into her home. She listened to her doctor, hospice was ordered by her doctor, and her husband was literally killed within 4 hours of hospices arrival. Now with that being said, the unbelievable guilt my daughter feels for the rest of her life, because she was exhausted from caring for a patient with cancer and was to exhausted to think for herself. She allowed her doctor to make that decision for her and her husband. When she recovered from her exhaustion, and began to think for herself, the guilt set in because she realized what had happened. That was three years ago and she has become a recluse, and the guilt of what hospice did eats at her. She blames herself because she did not have the strength to say no to the doctor who ordered it. He told her it would just keep him comfortable.
My husband passed 26 years ago. It still haunts me. He was on home hospice. He had slipped into a comatose state briefly. Then he rallied and was alert, communicating, in fact he asked to sit outside to see the sunset. Hospice was with us 24/7 the final 3 days. He was conscious but in terrible pain. He received every form of morphine that existed constantly. I don’t understand. The hospice workers (2) held his shoulders down, while he called out and pushed extra crushed morphine and liquid morphine down his throat. I was there. It appeared he was fighting them, not wanting the extra drugs. He was already on push IV morphine and a patch. This continued for an hour. Until he quit breathing.
I carry that horrific struggle every day. He choked on the drugs. I didn’t tell them to stop.
I feel like I killed him.
Well, reading through the comments I see I am not alone in reliving the traumatic last days/months of a loved ones death.
My father was in hospice for 6 months and was often angry, agitated and depressed during that time. There was an unexpected death in our family during his time under hospice care and it broke my already anxious father. My father was always a proud and independent man and was resistant to any help even in his waning years. Looking back, he was much more confused and disorientated during his years than any of us realised. It was difficult to separate his character (strong willed, intelligent) from his illness (senilty) and we pretty much treated him as we’ve always treated him. We gave him space and argued with him without realise he really didn’t remember blocks of time.
In any case, after the unexpected death of another family member he was self medicating while drinking and asked hospice for valium. They gave it because he was obviously in a great deal of grief and pain.
It seems that once valium started, it was almost instantaeneously rapid downhill deterioration of his health. He fell a lot, slept a lot, was confused more until one hard fall in the middle of the night and then bedbound and not really concious for another 10 days. Do you think valium could have contributed to his death? We also stopped all his heart medications at that time, could that have contributed? Rationally I know, does it matter that much if he went slightly earlier if he were suffering so.
Anyway, I’m not being coherent. I guess once I start dwelling it all comes out again.
But thank you for all that you do. And this quote of yours means so much to me, “Family dynamics are very challenging in the best of times. The approaching death of someone we care about (or don’t care about) brings out the best or the worse in these fragile relationships.”
It helps me to understand why my relationship with my father was so fraught right until the end. I bitterly regret the way we related the last two years of his life. He was SO ANGRY at me for moving him into my home and blamed me for his woes. I wish I had been more patient and understanding. I so wanted those last years to be gentle. But they were not.
Hi Kim, Family dynamics are very challenging in the best of times. The approaching death of someone we care about (or don’t care about) brings out the best or the worse in these fragile relationships. I am sorry your mother had the difficult ending to her life. So often the last year of our old age life is one of medical issues, falls, helplessness, confusion. I also appreciate the frustration you must have felt in being excluded in the decision making regarding her end of life care. The question now is how do you live forward with these feelings? You might write your mother a letter. Put all your thoughts about your life with her and about how her life ended on paper. Let the tears, frustration, sorrow out and down on paper. Write from your heart everything you want to say to her. then burn the letter and scatter the ashes to the wind.
Being an end of life doula is a great goal but I would recommend you wait at least a year. Right now you are too fresh in your grief for your mother. Every interaction with someone who is dying will rub the wound of your own grief. Use this year as a study year. Prepare yourself with end of life knowledge, with communication techniques, maybe one of the end of life doula courses. Blessings! Barbara
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