A 75-year-old-man is admitted to hospice care for end-stage multiple myeloma. He has severe pain due to pathologic vertebral compression fractures and osteolytic rib lesions. The pain remains uncontrolled despite a continuous intravenous morphine infusion; the infusion rate has been increased several times, most recently 2 days ago. Temperature is 37 C (98.6 F), blood pressure is 140/75, pulse is 95/min, and respirations are 10/min. Pulse oximetry is 89% on room air. On examination, the patient is drowsy but constantly moans in pain and opens his eyes when his name is called. Which of the following is the most appropriate next step in the management of this patient?

Question

A 75-year-old-man is admitted to hospice care for end-stage multiple myeloma.  He has severe pain due to pathologic vertebral compression fractures and osteolytic rib lesions.  The pain remains uncontrolled despite a continuous intravenous morphine infusion; the infusion rate has been increased several times, most recently 2 days ago.  Temperature is 37 C (98.6 F), blood pressure is 140/75, pulse is 95/min, and respirations are 10/min.  Pulse oximetry is 89% on room air.  On examination, the patient is drowsy but constantly moans in pain and opens his eyes when his name is called.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

This patient with end-stage malignancy has transitioned to hospice care, in which the focus shifts toward maximizing comfort (eg, pain control) versus extending length of life. He has inadequate pain control despite his current morphine dosing and has evidence of sedation and respiratory depression (eg, respirations <12/min, hypoxemia). For patients with terminal illness (eg, advanced cancer), interventions that have adverse effects (eg, respiratory depression) are justified if they are given with the intention of promoting the patient's well-being or allowing for a comfortable death (ie, doctrine of double effect). Therefore, it is appropriate to increase this patient's morphine dose despite his sedation and respiratory status. This practice contrasts with management of chronic pain without terminal illnesses, in which serious adverse effects (eg, respiratory depression) require opioid dose reduction and pursuit of alternate pain control modalities (Choice B). (Choice A) A dose adjustment of continuous morphine infusion may be made as early as 8 hours after the last dose adjustment (ie, time to reach steady state). This patient's current dose has reached steady state; waiting another 48 hours would prolong unnecessary suffering. (Choice D) Although administering a reversal agent such as naloxone may be tempting due to the patient's respiratory depression and sedation, doing so would precipitate acute opioid withdrawal. This could cause needless suffering contradictory to the patient's goals of care. Educational objective: Opioids are the foundation of pain relief in end-of-life care. In hospice care, in which the goal is to maximize comfort, opioids may be used to promote comfort despite the potential of hastening the dying process. References: The use of opioids and sedatives at the end of life (http://www.ncbi.nlm.nih.gov/pubmed/12732169)

A 75-Year-Old-Man Is Admitted to Hospice Care for End-Stage Multiple