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.

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 Dad has advanced dementia. He fell and broke his hip, had surgery to repair his hip mainly to reduce his pain. He is now at home, and we have hospice care. Everyone has been incredibly kind and caring. Morphine has been prescribed for him, but my brothers only give it to him when he’s already in pain demonstrated by moaning and restlessness. He’s not going to get well, and I want the easiest, most painless death he could possibly have..
    Hospice has not only helped my Dad, they’ve helped me and my family. I’m very grateful for them and their services.

  • About 10 years ago, my mother (then age 86) was suffering from dementia and was comatose, and was in pain. She was definitely “end stage”, and was in a hospital based hospice (which was excellent, BTW).

    My brother was the executor, and both he and my brother-in-law were adamant that she be fed via a nasogastric tube—she had been getting only water, which is standard procedure in end stage patients for whom recovery is impossible. I asked the internist if the amt. of morphine being given (2 mg/4 hrs.) was sufficient. The doctor said no—if she was free to choose, my mother would be getting 6 mg/4 hrs. The she said something odd—“your brother won’t let me give her anymore.”

    Turned out that both my brother (the exec) and my brother-in-law had barely accepted the idea she was dying. They wanted her fed and given fluids so that she could be transferred back to the nursing home. She had lived in that nursing home for 8 years—and they had some notion that she would want to die among friends. Since my mother’s mental status had been poor for at least the 4 years since my father’s death, I wondered if she really had friends there, at least in the way they were talking about friends. Perhaps they imagined a “Kum-byah” moment of group cohesiveness as she eased off the planet. I asked my brother if he would go along w/ the internist’s recommendation, and he shouted at me, “So you want me to kill her?” Clearly reason had left the room. I also found it odd that my non-medical brother could countermand a doctor’s order. But context applies here—if she was awake and alert, it would be her choice to get more morphine or not—so, I guess, as executor, he could make that judgement for her.

    I went back to the internist and discussed some thorny family problems which were not help ing the situation. I also told her that I was an MD, and they were not. They meant well, but they didn’t comprehend the amt. of pain my mother was in and IMHO that there was no way in hell, she was going to walk (or be carried out on a stretcher) out of there. I told the dr. that I was not licensed in the CO, but had an active license in two other states. If she wanted my opinion, I thought she should be giving the 6 mg/4 hrs.

    I was not familiar with the law regarding end of life issues in that state (CO). I was licensed in CA and OH, and as far as I knew in those states, there were two executors—a medical one and an estate one. It puzzled me that the dr. was constricted from doing her job by someone who wasn’t a dr.

    She asked me to follow her to the nurses’ station, as she drew up 6 mg.of morphine. Then we went back to my mother’s bedside, and to my surprise, she gave me the syringe so I could give it to her. So I did. My brother was none the wiser. She was still unconscious, but seemed calmer, and responded to stimuli. I asked if she could be given only water by the N-G tube, which she was. I sat by her bedside for some hours, and she remained calm. Her pain had obviously improved. I played her Irish music, and she gripped by finger more tightly.

    I went back to the hotel for a break and was called a few hours later by a nurse who told me she had died. I went back over, met w/ the group, and we asked a Christian chaplain to say a prayer for her and us, and he did.

    I wasn’t angry at my mother, nor did I want her to die. I wanted her to be as free of as much pain as possible.

    This taught me that one must be very specific about one’s end of life wishes. I don’t think my mother would have lived many more days even w/ the small amt of morphine. But she was suffering and I didn’t want her to suffer. That was my main motivation.

    Also, family tensions and anger had been historically high. There was lots of guilt on the part of my brother.

    I’ve thought about this a lot, and I am as sure as I will ever be that my motivation was to ease her pain, so the dying process would be as peaceful as it could be. I have thought the Irish music might have given her a clue that she was in familiar surroundings—maybe it contributed to a sense of safety. I’ll never know, of course.

    • Hi Sheila. As someone who recently lost my father, I wanted to clarify your brother’s role. I’m thinking he likely was both your mother’s designated POA (power of attorney) and executor – two separate roles. The POA can be enacted when a doctor designates the patient is not of sound mind to make their own medical decisions. The POA can then make decisions in the best interest of the patient. The POA ends at the time of death. After death, the executorship of the estate (all monies and assets) needs to be presented before a court to be enacted. This usually takes a few weeks or more.
      Hope this helps.

  • I came across this site looking for information on the effects of morphine.
    My mother in law is 93 yrs old, suffers from dementia, has stage 4 bed sores; second bout of them, she is bed ridden. Everything she eats is blended and spoon feed. She is at a very nice facility where they treat her with great care and dignity. Because she can’t move, her muscles have atrophied. Any movement is painful along with the stage 4 sores. They have been treating the sores, over the last 2 months with very little progress. The family is at a crossroads, do they ask for morphine to ease her pain. She has been battling dementia for 8 years, she has moments of clarity, occasionally. I hope they choose morphine so she can be pain free for the remainder of her days or weeks or months.

    • To Mike,

      I guess some questions, I would have are: 1) Does your mother in law have a durable power of attorney, a last will and testament? Has she made all of the final arrangements that a person should make? In her durable POA she would indicate how she wants to be treated in her final days. Unless she says in that document, that she wants morphine to be dropped into her bloodstream at the end, just ask her what she wants. Ask her if she would accept taking some hemp oil to relieve her pain, because it might work. It has worked for me and countless other people, relieving pain! It can’t hurt her. And there are other hemp creams and products you can get that they can put on her bed sores that might help too. The medical staff are not in charge, she is and always has been. We are all in charge of our health, not the doctors and medical people. Another thing: I have heard that after people lay in bed for a long time, they develop breathing problems. Most people, especially those in the Western Hemisphere don’t breathe right. Probably half of the people in Western hospitals, if they were taught how to breathe right would get well and could leave the hospital. The Chinese know how to breathe and it is a big part of their medicine and has been for thousands of years. Western medicine has a lot to learn from the Chinese.

  • If a person is going to die soon it doesn’t matter? But who is to say he/she is going to die and the question is, can morphine cause death to come sooner than it would otherwise? And yes hemp oil has been found to relieve pain. It did it for me and for many other people. So I would rather use morphine only as a last resort if the hemp oil doesn’t help. It is my body even at the end so I should be able to do what I want with it, right?

  • Yes, I think it’s all above having the facts about the various treatments that are avaiable, discusing the pros and cons and then coming to an informed decision. When my time comes I don’t think I’ll rule anything out; at least that’s how I feel now!

    • Mike,

      I am a hospice nurse and I would ask for a hospice referral from the attending physician at the facility your mother is residing. Hospice won’t take the place of her every day care but will enhance the care. The hospice nurse and team can assess your mom’s condition and get her the proper medication plan to make her comfortable. The hospice team is a great resource to help advocate for your mom on your behalf so you can spend more time together without having to worry about her comfort. It sounds like your mom is appropriate for hospice from your description and I think you would be surprised at the high level of care that is given at the end of life.
      Whatever you choose is really your choice. I just try to give as much education as possible. Many blessings to you, your family and your precious mom.

  • If I am ever in a hospice and having any pain I don’t want to be given morphine, I would rather they give me hemp oil (intravenously or however) and see how it does to ease the pain, because it is non-addictive and is not even a drug!

    • If a person is going to die soon, it doesn’t matter whether he’s addicted to a drug that comforts him and relieves his pain.

      Also, hemp oil hasn’t been shown to work to reduce pain, especially the pain associated with terminal illness.

      Morphine is the gold standard drug when it comes to treating end-of-life pain relief and discomfort.

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