Medications

Difficulty breathing is also called shortness of breath or dyspnea. It’s a common symptom in many diseases, especially in advanced stages. Many people describe it as feeling "hungry for air."

Opioid medications are commonly used to help control shortness of breath. In advanced stages of an illness, the treatment approach is similar to that for pain. That is, the goal is to have a constant level of medication in the body, to prevent dyspnea from occurring, rather than to wait for it to appear then treat it and wait for relief. This approach requires regular, around-the-clock doses of an opioid.

The regularly scheduled medication may do a good job controlling the shortness of breath, but the health care team can prescribe what’s called a breakthrough dose or rescue dose in case the dyspnea occasionally flares up or “breaks through” the level of regular control. It’s a good idea to keep track of how many breakthrough doses are used and when. This gives the health care team a sense of how the patient is doing, and whether the regular dosage is effective. If there are many flare-ups, the regular dosage may need to be increased.

Dyspnea can cause anxiety or increase existing anxiety. In this case, medications for anxiety may be given. Other medications may be used to treat other causes of dyspnea. For example, an antibiotic may be given in the hopes of treating a pneumonia.

The health care team, the patient and the family together need to consider several factors before making any change in medications. All these questions need to be answered:

What are the patient’s or family’s goals for care?

This may be the most important question. The goals must be realistic and achievable. For example, it may not be realistic to give medications to increase appetite when the patient isn’t hungry and eating won’t change the course of the illness.

What is the patient’s condition?

For example, often oral medications are stopped if the patient has trouble swallowing or is no longer alert.

What is the benefit of the medication?

In late stages of an illness, when maintaining comfort is a goal, it’s common to stop any medications that are not essential for comfort.

What will the patient feel if the medication is stopped or decreased?

If the person is still feeling pain, then medications that relieve pain are still helpful. If the person can’t swallow, then medications can be administered some other way.

There usually comes a time when medications that are not directly needed for comfort are discontinued. This happens when a person is no longer able to swallow or becomes unconscious. At this point discussions with the health care team will include which medications to continue and how those medications will be administered. Often medications to treat symptoms such as pain can be administered in other ways.

Many people worry about the use of morphine in palliative care. Morphine and other medications in the morphine family, such as hydromorphone, codeine and fentanyl, are called opioids. These medications may be used to control pain or shortness of breath throughout an illness or at the end of life.  Patients and families sometimes worry that opioids will speed up the dying process.

Morphine is sometimes used when a person is in the advanced stages of illness, and his or her overall condition is declining. If the person is experiencing moderate to severe pain or shortness of breath, his or her doctor will often prescribe morphine. This opioid helps maintain the person’s comfort throughout the illness and up to the time of death. The person declines because of the illness with or without the morphine.

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.

We know that morphine and other opioids are not a factor in the death of a person with advanced illness. The following information explains why:

• There is no evidence that opioids such as morphine hasten the dying process when a person receives the right dose to control the symptoms he or she is experiencing. In fact, research 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. So, it makes sense that treating these symptoms might slow down the rate of decline, if only for a few hours.
   
• 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 last dose is the same as the doses the patient has previously received and tolerated. The way the medication is given might change when someone can't swallow any longer. If the medication needs to be given by a different route, the dose is calculated to equal  the amount  previously given by mouth.
   
• There’s a difference between natural dying and dying from too much morphine. When someone has received too much morphine, he or she usually can’t be woken up. The person’s breathing becomes very slow and regular. Sometimes only one or two breaths are taken in a minute. The person also appears calm and comfortable.

In the last few hours of the natural dying process, a person’s breathing becomes shallower and faster than normal.  The breathing muscles become weak like all the other body muscles.  When the breathing muscles are weak, extra muscles help out. It may look like the person is working hard to breathe, but does not always mean that they feel short of breath. The person’s breathing pattern often becomes irregular with pauses. These pauses are often followed by a few fast and deep breaths. The person dies when he or she does not draw a breath again after a pause.

These changes in breathing are a sign that the control centre for breathing is failing. The person may seem to be working hard to breathe, but this is a natural and normal response.

If there are concerns about increased rate and work of breathing, gasping for air, and that the person is distressed, we know that morphine is not a factor in the dying process. Instead, this suggests an ongoing need for giving the person additional regular doses of morphine to relieve distress.

Morphine and other medications in the morphine family, often play an important role in maintaining the person’s comfort throughout an illness and the dying process.

See also:
Pain
Assessing comfort at end of life (1 min 51 second video)
Tips for Talking with Someone Who is Dying
When Death is Near