Does Morphine Hasten Death?

Morphine is a frequently prescribed medication for the treatment of end-of-life symptoms for terminally ill patients, has not been shown to hasten death when used appropriately. A comprehensive review of its use in research reports: “No studies have shown that patients’ lives have been shortened through the administration of appropriate pain medication.” Another study published in the Journal of the American Geriatrics Society shows that opioid use can increase quality of life, and possibly even extend it for some patients.

Nevertheless, the myth that morphine hastens death persists, both in the lay public and among healthcare providers. The reason for this is clear. Morphine and other opiates, when given in large doses, can cause respiratory depression, especially when therapy is first initiated.. Known in healthcare circles as the “double effect,” this forces physicians and prescribers into an ethical quagmire. “If I give the patient enough medicine to ease their pain, I may unintentionally cause side effects that shorten their life.” Further, despite the fact that ethicists agree that the foreseeable but unintended shortening of life is not a reason to withhold needed pain relief, it often results in the undertreatment of pain at the end of life. 

With that being said, research shows that patients in pain react differently to morphine than healthy people or people who use opioids to “get high.” Pain itself acts as an antagonist to respiratory depression; in other words, patients in severe pain are unlikely to experience morphine’s respiratory effects. Further, if morphine is initiated at a low dose and titrated according to patient symptoms, it has rarely been shown to affect respiration in a significant way. 

The Benefits of Morphine at End of Life

There is no “one size fits all” approach to the use of morphine for terminally ill patients. Patient safety is a concern when prescribing any pain reliever, as much as comfort or relief. This means physicians generally start patients on a low dose to minimize side effects while attempting to achieve a therapeutic goal. Depending on the person’s ability to swallow or severity of decline, morphine can be prescribed in tablet, capsule, liquid, suppository, or intravenous infusion forms. Dosage is continually reassessed by the hospice or palliative clinical team, and modifications are made according to patient outcomes or feedback.

Although morphine is not the only drug that can help reduce end-of-life symptoms such as pain and shortness of breath, it is preferred for a number of reasons. Some of these include: 

• It alleviates or lessens all types of moderate to severe pain effectively
• It is an effective treatment for shortness of breath, which can be both terrifying and debilitating
• It is inexpensive compared to other similar pain relievers
• The dosage can be easily adjusted to achieve adequate pain control
• Side effects such as itching, nausea, sedation and constipation usually can be easily managed 

Morphine, like all pain relievers, is most effective if therapy is initiated before pain becomes unbearable. In most cases, providers will order a maintenance dose to be administered every 2 to 4 hours “around-the-clock” and an additional dose in between for “breakthrough” pain.  

Side Effects Associated with Morphine

Like any medication, morphine can cause adverse effects. The most common side effects are constipation and nausea. Often additional medications are prescribed to relieve these symptoms if pain is otherwise managed well. In rare instances, someone may have an allergic reaction like hives, rash or swelling of hands, face, or mouth. In this case, alternative medication options are available.

Sedation is another potential side effect and one of the main reasons why patients or families refuse to utilize morphine when recommended. While the risk for sedation is inherent for all pain medications, starting the patient on a low dose with gradual increase can greatly reduce its sedative effects. It is important to alert the hospice or palliative team if sedation becomes apparent while taking the medication. The physician can lower the dosage and monitor the patient more closely. 

Other Fears About Morphine

Medical providers know that unwarranted fears about morphine can have a direct, negative impact on patient care. It is natural for patients or families to hesitate or ask questions when confronted with so many end-of-life care options. But irrational resistance can cause unnecessary pain for the patient. Struggling with severe pain or shortness of breath can cause adverse effects like elevated blood pressure, increased agitation or trouble sleeping. It can also result in severely diminished quality of life and a difficult death. 

While opioids are known to be addictive, they are considered a safe and effective treatment option when taken as prescribed by a doctor. Further, the risk of addiction is not an issue when a person is in the final stages of a terminal illness and actively dying. 

Cultural, ethical, or religious beliefs regarding palliative care may also cause aversions to symptom management. It is important to openly express concerns about the use of medications like morphine with family, trusted healthcare providers, or spiritual advisors.  

Sources

“Drug Fact Sheet: Morphine”. Get Smart About Drugs. https://www.dea.gov/sites/default/files/2020-06/Morphine-2020.pdf 

“Essays on Euthanasia and Physician Assisted Suicide”. International Association for Hospice and Pallative Care. https://iahpc.org/resources/publications/euthanasia-and-physician-assisted-suicide/essays-on-euthanasia-and-physician-assisted-suicide/ 

“Increasing opioid therapy and survival in a hospice.” Journal of the American Geriatrics Society. https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/j.1532-5415.2007.01536.x 

“Respiratory Depression (Hypoventilation)”. Healthline. https://www.healthline.com/health/respiratory-depression 

“Opioid complications and side effects”. PubMed. https://pubmed.ncbi.nlm.nih.gov/18443635/ 

“Can pain cause high blood pressure?” Very Well Health. https://www.verywellhealth.com/can-pain-cause-high-blood-pressure-5208139 

“Agitation”. MedlinePlus. https://medlineplus.gov/ency/article/003212.htm 

“When pain interrupts your sleep”. WebMD. https://www.webmd.com/sleep-disorders/features/pain-and-sleep 

“How opioid use disorder occurs.” Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/prescription-drug-abuse/in-depth/how-opioid-addiction-occurs/art-20360372 

“The importance of cultural competence in pain and palliative care”. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK493154/