How To Start Morphine For Your Loved One and Quell the Accompanying Fear

I have a nurse friend who urgently took some time off work to be with her mother who had recently signed on to hospice. Her mother was born and bred in Minnesota and has the accompanying midwestern grit and strength as illustrated by her ability to survive multiple health knocks and severe weather.

The day her mom signed onto hospice she received a pharmaceutical “comfort kit” that included highly concentrated morphine. The admitting hospice nurse went to my friend’s mother’s home and recommended starting with five milligrams of morphine for shortness of breath and left the house. My friend felt the enormous responsibility to begin dosing her mother with morphine and called me right away: “They want me to start morphine, and I am terrified. I can't believe they make families do this.” I coached her through it.

Hospice prescribes many different types of opioids depending on the disease process, kidney function, age, and type or severity of pain. I recently wrote about pain management and a broader approach to opioids in hospice. I specifically address morphine in this blogpost because so many families are afraid to administer it.

The focus of hospice care is comfort and quality of life — whatever that means to the patient.

The word morphine puts many people on high alert because of the opioid crisis in America as well as the myths that have accompanied this drug for decades. Patients and their family members fear the hospice patient will get addicted to morphine or that it will hasten their death. These myths provide significant barriers to adequate pain relief. When my dad was taking care of my mom while she was on hospice, he stated out loud that he would not give my mom the morphine because he did not want to be responsible for killing her. Take a breath and know your fear is a common experience. It is important to remember that any opioid when used for the intended purpose such as pain or shortness of breath and when titrated appropriately will not cause death or lead to addiction. 

Pain prevention is one of the cornerstones of hospice care. When a patient’s pain is well managed, their quality of life significantly improves. They can sit longer, sleep better, move easily, laugh deeply, converse with their loved ones, and breathe deeper. We want their pain well managed so they can enjoy and savor their last days, weeks, or months of life.

Roxanol (highly concentrated liquid morphine) is hospice’s drug of choice for alleviating pain and shortness of breath because it is easy to administer, easy to increase the dose, inexpensive, effective, and the doses are so small the patient does not have to swallow it. Before administering any of the drugs in the comfort kit, you will need to call the hospice for guidance.

Unless there is a pain crisis or debilitating respiratory event, we always start with the lowest dose of Roxanol and increase slowly. Roxanol’s concentration is 20 milligrams of morphine in one milliliter. The typical starting dose is five milligrams which is .25 milliliters, literally drops. You are not blasting your loved one with an opioid when you start with this amount. Five milligrams of morphine is equivalent to one Vicodin which most people have no problem popping after a tooth extraction.

My friend’s mother had never used an opioid in her life — again, shout out to the hearty midwestern folks — and my nurse friend refused to start with five milligrams. She wanted to start with three milligrams or less. Although five is the normal starting therapeutic dose, a smaller trial of three would not harm her mom, so I told her it was a great idea to see if her mom tolerates it.

She trialed the small amount of morphine and her mom fell asleep. Ah, sweet relief. Often patients who have been struggling with pain or shortness of breath can finally rest. Her mom woke two hours later, alert. She appreciated the break but continued to struggle with shortness of breath. My friend administered three milligrams of morphine intermittently over the next 24 hours. The next evening my nurse friend was confident to increase the dose by two, and she found that the five milligrams brought her mom relief for longer. Her mom was still mentally clear and able to engage with longer periods of relief. 

Roxanol should start working within 30 minutes of taking it, will reach its maximum effectiveness after one hour, and will last about three to four hours. If it is not effective after an hour or if it does not last three to four hours, call the hospice team for guidance on increasing the morphine. Do not increase the doses on your own or without their instruction. You can always request a nurse visit if you want their physical support. When I visited patients in their homes, I would often administer the first dose from the comfort kit because I know how scary it is for families; this is why we have nurses on call. 

My friend’s mother is still living and living well in the midst of her terminal diagnosis because that is what midwesterners do. Her symptoms are well managed and her quality of life is significantly better. She is able to engage with her family without the accompanying shortness of breath. She can talk, eat, drink, walk, and not be completely worn out by the exhaustion that persists when one continually struggles with air hunger. She has had thoughtful conversations with her kids and grandbabies and hopes to live many more months or possibly years.

Blessings.

*Writer’s note: Because of privacy laws, the subject in this story is not an actual patient, but a story that includes a combination of many many patients and scenarios over the years.

For end-of-life guidance, buy my book, Some Light at the End.