Empowering Old Women via Fashion Models?
INTERESTING STUFF – 25 June 2016

Easing End-of-Life Pain

Ask pretty much any old person and he or she will tell you that dying quietly in their sleep is the way they want to go. It's sure true for me.

Unfortunately, dying isn't always that easy. Sometimes it is painful and some of those times it is excruciatingly so or, equally terrible, it involves constant breathlessness. In fact, Joseph Andrews, a physician at a Connecticut hospice, says that breathlessness is the worst thing.

But there is a drug, a strong, often misused drug we have all heard of that can alleviate much of this kind of suffering at the end of life. It's called morphine:

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,” reports STAT.

“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.”

End-of-life patients can also be denied this drug because, according to Dr. Andrews, there is a myth that hospice care uses the drug to send the terminally ill on their way a bit faster than nature intended.

That doesn't happen in hospice, Andrews says, but the myth keeps physicians from prescribing morphine or family members from allowing it.

Fortunately, that was not true of my mother's physician when I was caring for her during her final months of life in 1992. We had a good-sized bottle of liquid morphine he had prescribed and I don't recall any warnings from him about how lethal it can be. For a long time she only chose the other pain pills that, although I couldn't be sure, did not seem to alleviate the pain as much as the morphine might.

When I finally had the wit to ask her why she refused to use it, she said she might become addicted and do something illegal.

This, from a woman who perfectly well knew she was dying and who was no longer ambulatory. “Ma, I said, I really don't see you running down the road to rob the candy store; you can't even get out of bed. And who cares if you become addicted.”

No dummy, my mother, she thought this over for a moment and switched to liquid morphine.

Dr. Andrews says he has seen a small amount of morphine completely change the last days or weeks of life for his patients when they or their family agree to it use.

In the case of one of his hospice patients, a man who could barely breathe and had been told his heart would fail within three days, decided to try the drug. Soon after he began using a small dose,

”...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.'”

You can tell your physician, family members, medical proxy or, better, all of them what your wishes are about such drugs for pain at the end of life. I'm doing that and if circumstances make morphine usable in my case and if it works as Dr. Andrews describes, I have a better chance of dying in my sleep.

It's worth your time to read the short report on this at STAT.

Comments

This is such an important issue for families to be aware of. My mom is the longest term resident in her dementia wing at the nursing home, having been there 9 1/2 yrs. In that time, I've seen hundreds of the other residents who are actively dying and morphine has made the difference between a difficult painful struggle or a peaceful one. Sometimes the trade-off is that the dying person is no longer able to communicate because they are so near the end of life but it's peaceful, their breathing is calm and for the family watching this dying process, much less traumatizing. It's hard to understand why we have such helpful medicines yet there is a reluctance to use them when the time comes.

I was not aware that the breathlessness was such a large part of death and dying. I thought everything slowed together enabling the person to use less and less functions in conjunction with all. This was until I watched my mother struggle to breathe and that is an image that is permanent and terrifying to me. The thought of smothering is the most dreaded thing to me. I insisted that they put oxygen on my mom but I don't know if that was the right thing to do. It was explained to me that as the process proceeds, the person requires less and less oxygen. I don't know what to think of that when the image of my mother gasping is so clear to me these many years later. I am completely for whatever makes the end of life easier and peaceful. The idea about morphine makes sense in that it seems to slow the body systems so they can synchronize better and function at similar levels. I am sorry if this is confusing or depressing. I wanted to make the point that I am all for comfort measures toward end of life.

My late husband was terminal with malignant brain tumors and I had to fight with his doctor to get him to prescribe morphine. After I convinced his doctor to write the prescription Wayne slept away his last days and that was so far superior to the way he had been living before having this drug. I am sure he was very grateful to be free of the pain and suffering.

Addiction should be the least of the worries at the end of life. I can't imagine why sensible people would even consider that to be an obstacle.

Valuable topic, Ronni. Seems intuitive to give end of life morphine if needed, but palliative care still needs advances. My father spent his last days in hospital in 2010 after a fall and broken hip. His last couple days he was being treated for pain and was pretty much unaware of his surroundings. Even so he had uncontrollable twitching and seemed pained. Upon asking his nurses if they couldn't do something, they said he probably needed a relaxant, however, the doctors wouldn't give it if the nurses asked. The family had to ask. I practically snapped at them. We had already discussed he wasn't a candidate for further surgery. In retrospect I should have asked for a dose myself.


I've had a Living Will in place for at least 10 years. I fear the dying more than the death. I wish I could be certain the transition will be peaceful and pain-free, but there are no guarantees. Family members can get so distraught, they think more of easing their own anguish, guilt, or whatever than they do the feelings of the dying. Colorado is not a right-to-die state, but we have a referendum on the November ballot. Maybe this time we'll succeed (similar referenda have been defeated twice in the past), but I'm not counting on it.

I'm in 110% agreement with the use of morphine or whatever else will ensure a peaceful departure--if it's a few days or weeks "ahead of schedule", that's O.K. by me. If I'm comfortable and can breathe (for Pete's sake, why NOT help a patient breathe?), that's the important thing. If I develop some nasty, painful terminal condition, I sincerely hope I'll be eligible for assistance in dying, which is legal in my state.

I have a Living Will, a POLST, a signed personal statement specifying what I want and do not want, PLUS a letter to my family. Problem is, will my wishes be honored at the end by the medical-industrial complex? That's a good question especially now that the DEA and FDA seem to be dictating where, when and to whom certain medications can be prescribed.

As a retired RN (35 yrs. in clinical nsg) I can attest completely to the fact that MS is the drug of choice as Ronni has posted. On only rare occasions did the drs. balk at using MS. And all RNs agreed, asked & pushed for (if need be) a patient to be given MS. It is a miracle drug to alleviate suffering especially at the end. I suggest it be put in your living will. :) Dee

Great advice, Dee. Morphine use will be included in the next revision of my living will docs.

I took care of my 93-year-old grandmother the last year of her life. She had Alzheimer's, didn't know who my husband and I were, didn't know where she lived, but she was generally in good spirits. She had suffered for many years from sciatica and used a walker to ambulate throughout the house and a wheelchair for longer treks, to the doctor's office or to the stores, etc. She received one tab of Tylenol #3 (Tylenol with codeine) every afternoon for pain. Once when I called the pharmacy to get a refill of the prescription I was told I must call the doctor's office first, so I did. The nurse I talked to mentioned that the doctor should see my grandmother to make sure she wasn't becoming addicted to the drug. Something in me snapped, and the conversation went something like this:

"You do know how hard it is for Grandma to get in and out of the car and to make it all the way up to your office on the tenth floor?" Well, yes, the nurse replied. "And you do know that I administer the pill to her every afternoon -- she can't even get the pill bottle open on her own?" Well, yes, the nurse admitted. But, the nurse said, "what if she is becoming addicted to the meds?" I said, "So what? It's not like she's going to go out and rob a convenience store to get the medication. She doesn't know where she is, not even what town she's in, she can't drive a car, she wouldn't know how to rob a store even if she could formulate such an idea." No, the nurse admitted. "Then why do you make her go through hell so the doctor can speak with her for three minutes to verify that nothing has changed in Grandma's life?" The nurse agreed and said she would renew the prescription automatically and in future, all I had to do was to call their office and they would continue to do the same. And so that's what happened and Grandma got her meds on a continual basis in future without all the unnecessary hassle she had had to endure in the past. She died peacefully at home without a lot of hoopla and trouble, exactly as she had wanted before the Alzheimer's took over her mind.

Unfortunately for terminally ill people nowadays, with or without senility, the law makes everyone jump through hoops, no matter how ridiculous, to ensure that old people do not become addicts, meaning that they sometimes have to go days before they can get a doctor's appointment and must do without their meds during that time so that all the bureaucratic paperwork is properly filled in. So idiotic.

I was so happy that I was able to talk like and adult with a nurse who had common sense and was willing to forego the requisite paperwork to see that her patient was kept comfortable and happy for the remainder of her life.

Nodding along vigorously here. Years ago I was very surprised to learn that morphine--a narcotic, after all, should slow everything way down, right?--was helpful in making breathing easier. My mother had congestive heart failure and her nurses used morphine to make her breathing easier, as well. (As an aside, I can tell you that when I take the hydrocodone I need for my generalized osteoarthritis, it actually energizes me to get more done than I'd feel up to without it.) The evil poppy is like the evil pen--all depends on how you use it. Thanks for this good piece, Ronni!

I was surprised to learn that there is so much resistance to giving morphine to the terminally ill. When I was primary caregiver for my in-laws and hospice was called in at the very end of each of their lives, that was the primary purpose of everything -- to keep them comfortable, and there did not seem to be a reluctance to prescribing morphine. However, this was very late in the game with both of them. My 90 year old father-in-law received morphine, during three days of hospice care after suffering a second head injury due to falls within less than a year. He did not want to stay in the hospital, and had had a terrible time ten months earlier while hospitalized after his first head trauma and neurosurgery for a subdural hematoma. He was in a wheelchair after that and in assisted living when he fell from the wheelchair and hit his head again. We brought him back from the hospital to AL under hospice care. I cannot imagine the pain he would have endured without the morphine. It was a very difficult time even with it, though he slipped peacefully away on the third day.

In the last couple months of her life, my 93 year old mother-in-law who had lived with dementia for several years at that point, was in pain due to a fall that resulted in a pelvic fracture. For that. she was given only dermal patches and tylenol. The day that hospice felt it was appropriate to get involved turned out to be the last day of her life. That first day of care, having been bathed, placed in a new and very comfortable hospital bed in front of her living room window, and covered with her mother;'s quilt, she passed quietly away, never having had any of the medication hospice had delivered that same day. I only realized something had changed when it occurred t0 me that I wasn't hearing her usual snoring. The hospice nurse returned that evening and collected the drugs, whose seal had never even been broken. Along with others here, I would advocate for what ever alleviates suffering for those clearly near the end of life. As you said Ronni, who cares if someone becomes addicted at that point? It clearly seems the lesser of two evils.

My dad, who died last November of congestive heart failure at 97 1//2, got morphine in hospice. He didn't have pain, but it also eases the feeling of breathlessness. He also got Ativan for "terminal agitation" (which, in the case of my mild-mannered dad, mostly amounted to repeating with resolve, "Okay, let's go!"). Hospice makes routine use of morphine. When my husband Jacques was dying of Lewy body dementia plus the death blow of disseminated shingles, he had severe postherpetic neuralgia, and hospice encouraged us to use the morphine in the emergency kit you keep in the fridge. A younger friend of mine was convinced that hospice was trying to hasten his death and pressured me to reduce the morphine. The result was a spike in the pain and I felt terrible for having caved and tried the "experiment." What does "addicted" even mean when someone is dying? At that point comfort and calm and peace, as far as possible, are everything.

On a side note, I do NOT want to die in my sleep. I don't want to miss this big event! I want to see what happens! Or, as Jacques' mother said thoughtfully a few years before she died, "I am curious about this last great experience." Of course, one has to take what one gets. But to die in my sleep is not what I wish for. My favorite last words are those of the boxer Max Baer: "Oh god, here I go!"

My mother fell in assisted living at 96 --weeks in the hospital then a month in rehab to learn how to walk again. She was in a lot of pain, but her physical therapist felt the morphine she was on was "interfering with her ability to re-learn how to walk." My sister, who had Power of Attorney, had her taken off morphine as a result. When I got there, within a week, she had only mild, useless pain relief and was constantly moaning in a weak voice "No more, no more." I told my sister she was dying, but was told that since I hadn't been there over the earlier months, I didn't realize that Mother was "doing a lot better." I had no POA and no say in anything. My mother died groaning in pain and dehydration for the last week of her life while I sat there watching and my sister came and went. At the funeral there was the vague sub-text of my having somehow contributed to her death -- at 96 -- by my "negative attitude." My lesson is this: beware of the people who want you to keep living -- they are your worst enemy. Cassandra

Cassandra, what a horror story. I totally believe what you say about people who want you to keep living. I've made my wishes crystal clear to everyone I know, but I realize that's no guarantee, which is one of the reasons I prefer to die quietly in my sleep. IMO your sister was clearly in the wrong, as was the physical therapist, but neither would reconsider keeping your mother on morphine. Very SCARY!

Although I'm no longer useful to society in the generally-accepted sense of the word and have begun to have more physical "discomfort" (commonly used by the medical-industrial complex to describe pain) than I anticipated, I still find enjoyment and reward in living. However, when the time comes that illness/disability, pain and uselessness rule, I hope I still have the capacity to control my end of life care and final exit.

My husband dies of cancer. The doctor had given us morphine for "just in case". I had no knowledge of the drug, absolutely none at all, other than it was a pain killer. Neither of us were drug/medicine takers. Husband was in hospice for a few days but was deemed well enough to return home (good in part, because he was happier in familiar surroundings). Well, he died a few days later. I still haven't gotten over it. Just a few minutes before death, his voice calling me from another room was as hale and hearty as it had been at 40yrs. He had fallen out of bed and called for help. He died a few seconds after I came into the room, no deep sigh, no sign - nothing! This was a few years ago, and I'm crying as I write this. Does the pain ever end?

My mom died recently. She had been bedridden for many years. Towards the end, she was in pain and distress, and really wanted to die. The family took her to the hospital each time she was in bad shape, and they revived her. I thought it was unnecessary torture. I wanted her unnecessary suffering to end and for her to go. The family didn't want to be accused of failing in their "care" and a social stigma of not doing enough. Doctors seemed to be in it to earn for services rendered, or perhaps fear of possible persecution from state/family if they assisted in an easier death. She died while being taken to the hospital. I hear her last request for water was in a strong, healthy voice. She died shortly after and was declared DOA at hospital. My siblings grieve for her death. I don't - I'm glad she's out of her suffering.

Verify your Comment

Previewing your Comment

This is only a preview. Your comment has not yet been posted.

Working...
Your comment could not be posted. Error type:
Your comment has been posted. Post another comment

The letters and numbers you entered did not match the image. Please try again.

As a final step before posting your comment, enter the letters and numbers you see in the image below. This prevents automated programs from posting comments.

Having trouble reading this image? View an alternate.

Working...

Post a comment

Your Information

(Name and email address are required. Email address will not be displayed with the comment.)