Morphine and comfort medicines in hospice: what’s true

Few words worry families more than morphine. Many people have heard that it means the end is near, that it makes death come sooner, or that it leads to addiction. The research says something different.¹ This note covers what comfort medicines do, what’s true about breathing and timing, the side effects and how they’re handled, how medicines are given when swallowing gets hard, who pays, and how to keep them safe at home.

The short answer

• Opioids like morphine work very well to relieve pain and are commonly used at the end of life.¹
• Studies have shown no link between opioid use and dying sooner.¹
• Opioids can also ease shortness of breath in people near death.¹
• Drowsiness and nausea are most common in the first days of an opioid and usually get better within a few days. Constipation needs a plan from the start.²
• When swallowing gets hard, opioids can be given under the tongue, as a patch, as a suppository or with a small needle under the skin.²
• With Medicare, the family pays a copayment of up to $5 per prescription for medicines for pain and symptom control.³
• When a controlled medicine like morphine is first ordered, the hospice must give you its written policy for managing and disposing of it, and talk it through with you.⁴

Why hospice uses morphine

Morphine is an opioid pain medicine. Opioids work very well to relieve pain and are commonly used at the end of life.¹

Pain isn’t the only reason. Feeling short of breath is common near the end of life and can get worse in the final days or weeks. Opioids and other measures can help the person breathe more easily.¹ So a hospice may order morphine for someone who has little pain but struggles to breathe.

Does morphine make death come sooner?

Many families wonder whether morphine will shorten the time they have left. The National Cancer Institute’s answer is plain: studies have shown no link between opioid use and early death.¹

What families sometimes see is the breathing of the last days. Breathing may become irregular, with very shallow breaths, short pauses, or deep, fast breaths.¹ Those changes are common in the last days. If you’re not sure what you’re seeing, call the hospice line and a nurse will talk you through it.

Is it addictive?

Two words often get mixed up. Tolerance means that, over a long time, the same dose gives less relief. It’s a physical dependence, and it isn’t the same as addiction, which is a psychological dependence.² Most people who are prescribed opioids for serious pain use them safely, though some can become addicted.²

If anyone in the home has struggled with opioids or other drugs, tell the nurse at the first visit, so the plan for storing and counting medicines fits your home.

Side effects, and what helps

• Sleepiness and nausea. These are most common when an opioid is first started, and they usually get better within a few days.² Call the hospice line if they don’t, or if the person is hard to wake.
• Constipation. Opioids slow the bowel, which can cause hard stools. The care plan should include steps to prevent it.²
• Anything new. Write down what you notice and when, and tell the nurse. Changing the dose, the timing or the medicine is often possible.

On a schedule, with extra doses for breakthrough pain

Pain medicine works best when it’s given on a schedule, so the level in the body stays steady and pain doesn’t get ahead of it.² The doctor may also order extra doses for pain that comes between scheduled doses, called breakthrough pain.²

Keep a simple log: the medicine, the dose and the time. If extra doses are needed often, call the hospice line so the nurse can look at the plan.

When swallowing gets hard

In the last days of life, a person may not be able to swallow pills.¹ Opioids can be given other ways: placed under the tongue, as a patch on the skin, as a suppository, or with a small needle into the tissue just under the skin.² The nurse will show you how to give each one and what to watch for.

The comfort kit

Many hospices leave a comfort kit in the home: small amounts of medicine that a caregiver can give for sudden, distressing symptoms like severe anxiety, agitation, delirium or nausea.⁵ Use it only as the nurse directs, and call the hospice line first, any hour. Keep it where you can find it fast and where children and visitors can’t.

Who pays

With Medicare, the hospice must provide the medicines related to the terminal illness and its symptoms.⁴ The family pays a copayment of up to $5 per prescription for outpatient medicines for pain and symptom control.³

Medicines for health problems that aren’t related to the terminal illness aren’t part of the hospice benefit. Medicare still covers care for those problems the usual way.³ Who pays for hospice has the rest.

Keeping medicines safe, and getting rid of them

When a controlled medicine like morphine is first ordered, the hospice must give you a copy of its written policy on managing and disposing of these drugs, discuss it with you in a language and manner you understand, and note in the record that it did.⁴

Keep opioids out of sight and out of reach, and never share them. When they’re no longer needed, follow the hospice’s policy. For unused medicines, the FDA’s first choice is a drug take-back program, such as a collection site or a prepaid mail-back envelope.⁶ If there’s no take-back option, a few medicines, like fentanyl patches, are on the FDA’s flush list. Most others can be mixed with something unappealing, like used coffee grounds, sealed in a container and put in the household trash.⁶

Questions to ask the nurse

• What is each medicine for, and when do I give it?
• What should I write down after each dose?
• Which side effects are expected, and which ones should I call about?
• What’s in the comfort kit, and when would we use it?
• How do we store these safely, and what happens to them later?