It was mid-October 2008 when the medics rolled the elderly man through the glass-enclosed lobby.

To his left was a sweeping view of the Long Island Sound and bright orange and crimson trees, but the view was nothing to him.

Before making the 15-minute ride from Yale-New Haven Hospital to Connecticut Hospice, the man was told he had maybe three days before his heart would fail completely. He couldn’t catch his breath. His eyes were wide, his fingertips dusky from lack of oxygen.

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His hospice doctor, Joseph Andrews, was desperate to ease the man’s breathlessness. “For patients, that’s more terrifying than pain, paralysis, or the inability to get around,” Andrews said. “It’s the worst thing.”

Another doctor suggested morphine might help.

The drug relaxes the muscle walls of blood vessels, Andrews said, increasing capacity and reducing the lungs’ urgency. Coronary arteries can also more efficiently carry oxygen-rich blood away from the heart.

The man’s doctors knew well that too much morphine can stop the lungs completely, so they tried just a tiny amount: one-quarter of a milligram.

Morphine is seen by many physicians and laypeople as a sort of single-purpose, liquified grim reaper, and understandably so: It is dangerous and addictive. Older physicians in particular were typically not trained to use it, Andrews said, and can resist recommendations to use morphine even for cancer patients with severe bone pain, for fear of killing them.

Morphine’s reputation as a killer underscores one of the more persistent myths surrounding hospice care, namely, that it serves as a grey market euthanasia service for the terminally ill, where the drug is given in generous doses to every patient — even those who do not want it.

Talk to any experienced hospice nurse or physician and they’ll tell you that such notions can lead to significant complications: family doctors refusing to prescribe morphine for dying patients who are in extreme pain; relatives refusing to give a dying family member prescribed morphine, or exhorting them to reject hospice care completely and opt for the ICU.

Hospice clinicians get it. People don’t want to risk killing someone, even if it means seeing their loved ones suffer. Clinicians also understand that they share some of the blame, for failing to clearly communicate the methods, goals and expectations of using  morphine. Because the medication is often prescribed during a patient’s final decline, family members are sometimes left to wonder if, in agreeing to the treatment plan, they have helped bring about their loved one’s death.

Morphine can have other less lethal side effects that require vigilance, and doctors and nurses are not always clear about those potential complications either. Still, clinicians say, it can be frustrating to encounter people whose misconceptions lead to unnecessary suffering for patients.

The elderly man was tall, slightly heavy-set. He’d been a teacher. He was quiet, loved to read books. His wife was alive but he’d lost her to dementia and a nursing home. His three children were nearby, though, and the grandkids. He was well-loved.

And now his children came in, looking like they were going to a funeral. They asked if they should call people to come say goodbye, and Andrews told them it was probably a good idea.

He asked them to consider morphine. It was worth a try, they said. They made their calls. They braced.

Their dad went to sleep, which was something.

He woke later to smiling faces. His breathing had eased dramatically, his skin color had returned to normal; he was fully alert, wide awake. He chatted with visitors. He told his life story.

He got six more weeks like this.

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Andrews said he remembers countless stories about how morphine had helped patients with respiratory distress, as well as patients with severe pain. Most recently, a patient had been immobilized by her cancer pain until she received small doses of morphine. She promptly flew to South America to spend time with family members.

Control and mobility, Andrews said, are among the most important factors in improving a dying patient’s quality of life.

Soon after the man’s breathing eased, he started a new routine. Twice a day he’d ask his children or grandchildren or nurses to bring his cap and his overcoat and they’d wheel him to the waterfront with his oxygen tank.

He’d stay as long as the gathering cold and darkness allowed. He saw the tides flow and the leaves fall and gulls and boats pass. In early December he began sleeping more, and then he slept entire days away, and then he died.

But that November reprieve.

“It was one of the best morphine stories I can remember,” Andrews said. “He had a great run.”

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  • My Mother at 89 just passed away on hospice care. My wife, a hospice nurse of 15 years was helping care for mom at home. Mom became agitated and restless, off her baseline for sure. I suspected either a UTI or pneumonia, she got like that with either. We had the specimens taken to check for UTI and c chest xray for pneumonia, before either results got back moms respiration went to 34. My wife gave mom the proscribed .25ml of morphine to slow her breathing, it worked, 20 minuets later she was dead! How did this happen, 30 minuets before getting the morphine she was up on her own using the potty and walking.

  • Upon reading some of these comments, I do not believe everyone has true concept of what hospice can do for a dying patient. I’m a healthcare worker, CNA and I have worked in nursing homes, assisted living as well as in home hospice care. Hospice is here to assure the person can die comfortable. As pain free and quietly as possible. Morphine not only helps with pain but it helps with breathing and calming too. I have seen alot of deaths in my 20 years in this field and I have always felt that when people use hospice and agree the end is near, death can be a beautiful thing.

  • T12lL1,paraplegic for 59 yrs.
    Uncontrollable shoulders pain.
    Weaker by the month.
    I’m not nursing home material!!

  • This story is a fairy story.
    Hospice do not even share info on amounts of morphine being given to the patient.
    Hospices do not even check patient every so many hours to see how they are doing.
    Hospices do not even reposition patient every 4 hours maximum as the law says to avoid sores.
    I am taking notes as much as i can to prove it as I try to keep my mother alive who was brought to this hospice with not even a pathology dx of ca ! While my siblings that never gave any care to her wants her dead I, who has given that loving care for 2 years in spite of my own ailments, wants to keep her alive but a 3 to 1 factor makes ME the loser.
    07302018

    • Your situation is not that unusual. Family situations get really ugly at times like this. The very worst behavior can manifest, and it appears that the system encourages it. It detracts from what they are doing. A lot of patients outlive Hospice, because there is not much incentive to provide accurate diagnosis. There are a lot of good Hospice employees, but lie everything else the system selects for incompetence.
      After going through a similar situation, and listening to stories online, ad among friends and acquaintances, the media coverage of this topic is distorted and misleading. These end of life horrors are an opportunity for profit, from lawyers, to nursing homes. The system is designed to use every aspect of it to profit. Unfortunately it is not ethical to document any of it in pictures, which the system has used to it’s benefit.
      From the providers to the hospitals, Hospice and nursing homes, it is all about profit. I found it hard to reconcile how any of the people participating, could be so inhumane, but it is the business model. I realized that no one would speak up because it was benefiting the local healthcare economy financially. Physicians saw nothing, even though they entered the nursing home to treat patients, the local hospital was using a nursing home to dump patients so the Physicians were not allowed to notice anything. It is not hard to tell that a dying patient has not been turned for days, when a bedsore goes to the bone. Court appointed Guardians, did not smell the urine and feces, it was not their job. The state agencies are compromised, concerned over industry profits not benefit to the patients.
      The real stories have been suppressed by corporate media, and none of this end of life treatment makes sense. The “treatments” depend on the patients insurance. They prey on family members pushing unnecessary surgeries, procedures, and false hope.

    • If you truly believe that your mother has been forced into this situation, against her will, make your feelings known. Contact the hospice director, or your mother’s doctor and tell them that you don’t understand why your mother is in hospice at this time. You can suggest that you will involve law enforcement if explanations are not swift and completely illuminating to you.

  • I’m sure it would help if only my patient-my father-wasn’t aspirating every drop. He’s been in horrible fear and agony for days, and hospice does nothing. You can tell them exactly what happens, you can request injectables so he won’t keep choking, but they don’t care. Their attitude is, oh well, why bother. This seems to be common.

    • No, there is no plot on the part of doctors, hospice workers and so on to deprive your loved ones of those last precious days, hours or minutes.

      Let me tell you what it was like when I was in training in the late ‘70’s and early ‘80’s. Hospices were a relatively new concept. ICU beds were expensive and remain so.

      The black joke was “nobody dies in a University hospital.” And certainly dying was dragged out to ridiculous lengths even when the patient and or relatives were screaming “Uncle.”

      Critical cases who might survive couldn’t be treated if the ICU was full with people on life support. But to “kill” a dying person by taking him off a respirator was against the law.

      I remember this one old guy who had apparently been an abusive and mean man, by report. He had also been convicted of pedophilia. His kids hated him, as some could admit. The others had a “love conversion” because their hateful old man was lying in an ICU bed stroked out beyond hope or repair with minimal brain functioning as documented by EEG. But some earnest ER intern had intubated him and put him on a RESPIRATOR, which put his death at a remote distance. 30 days in fact.

      30 days, when other critical patients were shunted from this trauma hospital to other area hospitals that had less trauma expertise, because a less than expert opinion in the ER put him on a machine that was “breathing” him. If he had been put on oxygen (delivered via nasal cannula) he would have stopped breathing,sooner or later, undoubtedly in a time period well short of 30 days.

      I was too far down the totem pole to be involved in decision making. The “We love our misunderstood Daddy” side was threatening a lawsuit against not only the hospital but against the entire university system.

      I believe a judge ultimately made the decision and he was moved from the ICU to the general medicine floor, “extubated” from the respirator, given oxygen and supplemented water via nasogastric tube, and where he died of his own devices 3 days later. This was not before nurses had been summoned frequently to assess his reflex responses to a daughter’s singing or to the prayer meetings held in the corridor.

      There was nothing left of this man except his spinal cord. The spinal cord gives reflex neuronal responses that do not involve the brain and the cortex—those parts that make us who we are. That’s what the doctor is assessing when she taps below your kneecap with a rubber hammer. She’s eliciting a reflex and testing your lower motor nerve function.

      The abused relatives (reacting internally to their guilt over the many times they had undoubtedly wished him dead) were the loudest singers. The man’s reflex twitches signalled to them that he was alive in there, and a miracle would bring him back into his evil self so they could begin hating him anew.

      It took a judge to say, “Enough.”

      Yes, to some I sound cruel, and I’ll grant you that far more difficult dilemmas exist. But when the doctors have tried everything feasible and further attempts would only prolong suffering, it is time to let your loved one go. Death by morphine is a dreamy,seductive surrender to forces beyond any human’s control. Much better than exiting the planet in screaming agony.

      And yes, I’ve been through this w/ the deaths of both of my parents from “complications of Alzheimers.” They died in peace, God bless them.

      My advice: Discuss w/ concerned relatives well before the illness or death. Better yet, everyone make their wishes known via a “living will” on file w/ a lawyer or the hospital. Even if one ends up at the wrong hospital, the living will info can be faxed or e-mailed to the treating hospital.

      And remember, no one gets out of this alive.

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