ABCD Exchange : October 1998 : Research - Opiophobia and Respiratory Disease

Opiophobia and Respiratory Disease: Dispelling the Fears
by Margaret L. Campbell, RN, MSN, CS

Cohen, et al¹ described eight patients with terminal lung cancer who required continuous morphine infusions to reduce terminal dyspnea. Careful titration achieved satisfactory results for six patients, moderate relief for one, and no relief for one. The disease process itself led to changes in respiratory function. Seven of the eight patients died during the study interval; the authors were uncertain whether morphine shortened survival.

Citron, et al² studied the efficacy and safety of continuous morphine for severe cancer pain, including some patients with borderline pulmonary status. Despite increases in morphine dose, when titrated to patient responses, blood gas values remained at or returned to baseline values. Bradypnea (slowed breathing) which occurred without hypersomnolence (excessive sleepiness) was well tolerated. Bradypnea with marked somnolence was a cause for dose reduction.

Campbell, et al³ studied patient responses during terminal weaning from mechanical ventilation. They found no correlation between the amount of sedation/analgesia and duration of survival after removal from ventilators. This suggests that doses were titrated according to patient responses, excessive dosing did not occur, and patients’ deaths were not hastened.

In the patient near death, there is no way to prove whether the opioid hastens death. At the end of life, whether patients have opioids or not, the same hemodynamic and pulmonary changes that indicate imminent death are signs of opioid toxicity. When the opioid is titrated to the patient’s responses, and the patient is awake, hypersomnolence will precede significant respiratory depression and signal the clinician to adjust the opioid dose.

The following anecdotes demonstrate that the opioid did not hasten death, in fact, it may have prolonged the patients’ survival with improved quality of symptom control.

• A 73-year old man with end-stage chronic obstructive pulmonary disease (COPD) presented at the time of consult with severe symptoms. He was very near death. With the administration of Ativan (1 mg every six hours around-the-clock) and short-acting morphine (15 mg prn by mouth), 1) his anxiety disappeared, 2) his hypoxemia resolved and he only required nasal oxygen at 4 min, and 3) he became alert and oriented and interacted with his family. He lived for five more days before dying.

• An 80-year old woman with a new stroke, end-stage COPD, and congestive heart failure presented with similar symptoms. Improved consciousness, oxygenation, decreased supplemental oxygen need, and improved vital signs were achieved with a continuous morphine infusion at 3 mg/hr. She lived for five additional days after palliation for terminal dyspnea began.

References

1. Cohen MH, Anderson AJ, Krasnow SH, Spagnolo SV, Citron ML, Payne M, Fossieck BE. Continuous intravenous infusion of morphine for severe dyspnea. Southern Medical Journal 1991;84:229-234.
2. Citron ML, Jonston-Early A, Fossieck BE, et al. Safety and efficacy of continuous intravenous morphine for severe cancer pain. Am J Med, 1984;77: 199-204.
3. Campbell ML, Bizek KS, Thill M. Patient responses during rapid terminal weaning from mechanical ventilation: A prospective study. Crit Care Med, in press.

<<< Previous Next >>> [ Go Up ]