August 7th, 2017

The “double effect” of morphine at end of life: reality or myth?

The Netherlands euthanasia thread on Saturday generated a fascinating discussion in the comments section about the use of morphine at end of life, so I thought I’d highlight it here and expand on my remarks.

First, a personal note. In the last few years, I’ve seen a few people die who have had their way eased by morphine. Like many and maybe even most people, I’ve long assumed that morphine is given to reduce pain and make it less laborious to breathe, and that it may hasten death as a sort of side-effect but that a quicker demise is not the goal. But a few months ago, when I looked up what medical experts on the subject had to say, I was extremely surprised to learn that my assumption wasn’t true.

The discussion on the euthanasia thread begins around here, with a commenter who wrote about the death of several loved ones, “It was the morphine that suppressed her breathing reflex, not the liver failure that killed her… in both cases, it was morphine that led to respiratory failure.”

I referred that commenter (and anyone else who’s curious about the subject) to this site, one of many that discuss the issue:

When a patient is receiving regular pain medication such as morphine in the final hours or days of life, there is always a “last dose”. To family at the bedside, it may seem like the drug caused or contributed to the death, especially if death occurs within a few minutes. However, this dose does not actually cause the person’s dying. It is simply the last medication given in the minutes or hours before the death naturally occurs…

…[R]esearch suggests that using opioids to treat pain or shortness of breath near the end of life may help a person live a bit longer. Pain and shortness of breath are exhausting, and people nearing the end of life have limited strength and energy…

If a person has never received morphine, the initial doses given are low. They are gradually increased to relieve the person’s level of pain or shortness of breath. After a few days of regular doses, the body adjusts to the morphine. The patient becomes less likely to be affected by morphine’s most serious side effect—the slowing of breathing. It would take a large dose increase over a short time to harm someone. Morphine doses are increased gradually and only as needed to maintain comfort.

The following is especially important to note:

When someone has received too much morphine,…the person’s breathing becomes very slow and regular. Sometimes only one or two breaths are taken in a minute…

In the last few hours of the natural dying process, a person’s breathing becomes shallower and faster than normal.

So, one way to distinguish between the two phenomena is the rate of breathing. When someone is dying of an overdose, the breathing rate slows, and this happens not just in the last few minutes or seconds but over a longer amount of time prior to death. The opposite is true for someone dying naturally. Even with the administration of morphine, breathing is typically shallow and fast, and then towards the very end will often switch to what’s called Cheyne-Stokes respiration that has a different and characteristic pattern (see also this).

It’s understandable that families and other observers often perceive that morphine hastens death in hospitals. But as far as we can tell it is not actually happening that way in the vast vast majority of cases, unless an error has been made in dosage. An even fuller discussion of the subject can be found here. It talks in particular about the myth of this “double effect” of morphine hastening death when administered at end of life. Of particular interest is how that perception relates to the euthanasia debate:

A troubling result of the mistaken belief in the double effect of pain medication is its effect on discussions of euthanasia and physician-assisted suicide. Giving pain medications is even referred to as indirect euthanasia, “double effect euthanasia,” or “accidental euthanasia.” For example, in one article, the authors stated that “a common example of indirect euthanasia is the administration of large doses of narcotics to a terminally ill patient in unbearable pain” And although the AMA’s Council on Ethical and judicial Affairs, in its “Decisions Near the End of Life,” rejected euthanasia and physician-assisted suicide and endorsed palliative care, the Council stated that the “ethical distinction between palliative care that may have fatal side effects and providing euthanasia is subtle. . . .”

In the past, the underlying theme of most discussions of the double effect of pain medication, even when referred to as indirect euthanasia, was that the administration of pain medications was ethical. Recently there has been renewed interest in “double effect euthanasia,” equating it to, and using it to support, legalized physician-assisted suicide or euthanasia. The argument usually takes one of two forms or some combination of the two. First, because hastening death by drugs is already being done and is ethical, perhaps we should extend medical practice to allow physician-assisted suicide. The second argument is that because physicians are already hastening death, we should legalize it to provide safeguards.

It appears that even many of the doctors who don’t specialize in end of life issues believe—incorrectly—in the “double effect” as a given. This belief in the double effect is also used by people who advocate physician-assisted euthanasia, who bolster their arguments by saying doctor-assisted euthanasia is already happening regularly anyway, just in hidden form.

Much food for thought.

8 Responses to “The “double effect” of morphine at end of life: reality or myth?”

  1. K2 Says:

    Years ago, as our hospital’s oncology pharmacist, I helped design treatment regimens for many terminal cancer patients. In addition to other treatments, a morphine drip (continuous infusion) was usually very helpful. Using a drip, with the morphine or dilaudid infused at a constant rate, eliminated the need for bolus injections, which resulted in peaks and valleys in coverage.

    The down side of continuous infusion is the need for a pump, compounding the drug into an IV bag safely and accurately, and the need for fairly constant monitoring. I think fewer folks are treated this way these days, primarily d/t those issues. But it really worked well.

  2. Gringo Says:

    IIRC, my mother died not long after a dose of a pain reducer- may have been morphine. I was present at her deathbed, but as it was 3 decades ago, my memory is hazy about whether it was an increase or not in medication. She was wasted away from leukemia, so there was no possibility of recovery.

    I am reminded of my father’s experience with pain reducers- or should I say lack of. After he was diagnosed with terminal lung cancer, he went home from the hospital. Aspirin was the only pain medication the doctors prescribed for him for his stay at home. I don’t now what pain medication he got in the hospital- I suspect he was given something stronger than aspirin in the hospital. He was in excruciating pain very soon after coming home. (It turned out the tumor had wrapped around his spinal cord. )

    My mother’s irate call to the hospital soon changed my father’s medication. The doctors gave him some very strong pain reducer. My mother asked why he hadn’t been prescribed a strong pain reducer when the hospital discharged him. “We didn’t want him to get addicted.”
    Terminal cancer, and they are worrying about addiction?

    Less than 3 months later, my father was dead. At least his death was relatively painless, as best we could tell.

  3. arfldgrs Says:

    assumptoins not correct?

    finally find that out WHEN YOU LOOK

    and so, thats how soeone changes

    they discover that what they joined due to some ad copy was not doing or representing waht they actually thought once they actually took a look…

    the best example no one will look at is the history of willi munzenberg… as he got hollywood and lots of the world to fight against fascism..

    but who where they fighting FOR?
    so big on the fight for revolution or for this or that
    they never asked whose army did they join?

    funny how people are like that
    and even more funny if you show it
    as they dont want to know others notice i guess

    whose army?
    its hidden in wrong assumptions…

    just as its a wrong assumption to think marx and the game is about some valid idea. its not. its just a invalid idea once pretended to is so dysfunctional it gives means to power when there wasnt any.

    At bottom Marxism is a strategy behind which stands a pathological desire for absolute power and global destruction.

    The outward phenomenon of Marxism is merely the intellectual camouflage of the politically self-actualized psychopath. Here is the outward expression of his rationalization for murder, for seizing power.

    This outward expression has changed time and time again, but its spiritual essence is always the same.

    And we always seem to miss the point of it. We always seem to address the inner thoughts and intentions of people who are assumed to believe or not believe in a set of “principles.”

    But this is an error.

    We do not understand these people at all! The communist does not take ideas seriously. He is serious only about power and strategy.

    A mask is not an idea. A strategy is not a principle. These are tools, weapons, methods.

    Marx did not believe in his tools. He used them, and his followers used them, until the tools of the hour no longer served their purpose.

    Then the old tools, the old weapons, were discarded for a new set of weapons – “new lies for old.”

    Those who talk about belief or disbelief are only talking about the superficial shell of the thing, which can be replaced with a new shell – a new outward appearance.

    If Marx did not believe in Marxism, then the true Marxist should not believe in it either. It is a sorry swindler who believes in his own swindle. Nyquist…

    -=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-=-

    and while you waste time trying to understand what was never meant to be understood but to confound and get you to waste your time… (cause that is your critical comodity, wait to long and nothing you do is possible)

    you look for escape where there is none, because you think the ideas are valid…

    and i have watched for 10 years as people try to make sense of someting the leaders and movers provide that is nonsense… and they watch you stupidly fumble over it trying to integrate nonsense, understand nonsense, try to show nonsense is invalid do to contradiciton (irrelevent if its nonsense which is why doing that dont work), you try to debate it to change mionds, but they wouldnt believe unless they didnt have the mind in the first place

    you work at a combination lock that is not connceted to a lock at all… its there to keep you busy, distracted, to apply rules that dont work… keep you holding still while they dont.

    like a large portion of street light buttons, they dont work, they nver worked and never were intended to work!!!

    they were put there to make people feel they were doing something to hurry things along, like pressing a elevator button several times to move it along, or lean over a track to get the train faster, or watching water boil..

    even if you show that this is not uncommon to the political, or even to us who know to give chew toys to pets to keep their minds busy. dont realize we are the pets and we are HAPPY with the chew toys…

    so much so, we dont do much but chew on them

  4. lelu Says:

    A friend of mine years ago told me that, from her observations, the relief the painkillers give the patient allows them the focus to pass on.

  5. John Guilfoyle Says:

    lelu…I have nothing but anecdotal/observational evidence and a lot of bedside conversations with Drs and nurses (I haven’t probed the science like Neo provides for us), but I’d accept your theory…

    Maybe what happens is that pain relief allows the dying to quit fighting to stay alive (the body’s inherent drive) and let go in peace?

    But until it’s me…I won’t know for sure.

  6. DNW Says:

    “The “double effect” of morphine at end of life: reality or myth?”

    You sound like a Roman Catholic social critic about half of the time; even though we all know that not only are you not, you are, by your own pronouncement, not even a Christian.

    Huh …

    “Thomas Aquinas is credited with introducing the principle of double effect in his discussion of the permissibility of self-defense in the Summa Theologica (II-II, Qu. 64, Art.7) …”

    https://plato.stanford.edu/entries/double-effect/

  7. Ed Bonderenka Says:

    When my dad was on his death bed, I did not give him his scheduled dose when we were all gathered around him.
    He opened his eyes, looked around, we said goodbye, and he left.
    I look forward to asking him about that.

  8. BrianE Says:

    My mother died of pancreatic cancer in 1996. Since I was self-employed, to honor her wishes to die at home, The last few months, I stayed with her during the day and my sister and brother-in-law stayed with her at night.

    She was never fully lucid, and seldom fully conscious the last few weeks, except for Thanksgiving, when all the family gathered. It was amazing that she had a good day thou obviously hallucinating from the morphine.

    She was on heavy doses of morphine, and a drip had been installed a few weeks before she died. I’m not sure the morphine was blocking all the pain, and my sister wasn’t getting much sleep.

    She asked the doctor for something to help my mother sleep, and after taking that medication, she died shortly thereafter.

    The family never talked about it, I’m not sure what she was given, and can’t say for sure the additional medicine had anything to do with her death, but I’ve always speculated to myself that it did. And if it did, I have no regret. Her discomfort was constant.

    That was a week after Thanksgiving.

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Previously a lifelong Democrat, born in New York and living in New England, surrounded by liberals on all sides, I've found myself slowly but surely leaving the fold and becoming that dread thing: a neocon.
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