Dosages of morphine and other strong opioids can be safely increased by 50 percent every 24 hours until a satisfactory response is obtained. For most medications, dosage adjustments can be made every 24 to 48 hours. Medication dosages should be titrated promptly to achieve effective pain control. In general, only-as-needed prescribing should be avoided. (Both approaches result in a dosage of 60 mg per 24 hours.) If large amounts of breakthrough medications are required, consideration should be given to raising the dosage of the regularly scheduled analgesic. For example, if a patient is receiving 30 mg of sustained-release morphine (MS-Contin) every 12 hours, the breakthrough morphine dosage would be 10 mg administered every 4 hours. When opioids are used, the available daily breakthrough dosage should be equal to the regularly scheduled analgesic dosage. This allows attainment of a steady state of medication, which minimizes side effects and avoids periods of subtherapeutic treatment.Įpisodic or breakthrough pain should be anticipated and treated with as-needed pain relief in addition to the regularly scheduled analgesics. Patients with chronic or frequently recurring pain should receive medications around the clock according to the recommended dosing schedules. The choice of analgesic drug should be based on the type of pain ( Tables 1 through 4). Home visits can provide comfort and facilitate the doctor-patient relationship at the end of life. The physical, psychologic, social and spiritual needs of dying patients are best managed with a team approach. Side effects of pain medications should be anticipated and treated promptly, but good pain control should be maintained. Anticonvulsants can be especially useful in relieving neuropathic pain. Drugs such as corticosteroids, antidepressants and anticonvulsants can also help to alleviate pain. Physicians must overcome their own fears about using narcotics and allay similar fears in patients, families and communities. Starting with an appropriate assessment and following recommended guidelines on the use of analgesics, family physicians can achieve successful pain relief in nearly 90 percent of dying patients. Significant pain is common but is often undertreated despite available medications and technology. Such practices may not always be compliant with legal and professional regulations to promote transparency and patient-centred care at the end of life.End-of-life care can be a challenge requiring the full range of a family physician's skills. Occasionally, morphine is deliberately used in higher dosages than needed with the aim of hastening death. Physicians take more often than necessary into account that morphine potentially hastens death. Morphine is frequently used at the end of life. Possible hastening of death as a result of the administration of morphine was not always discussed with the patient, his family or other caregivers in 20% of the cases, it had not been discussed with anyone. In 2.1% of the patients, the physician indicated that the dosage was higher than needed to alleviate symptoms. Hastening of death had been part of the purpose of administering morphine in 2.9% of the patients and the explicit purpose in 1.2%. In 82%, the dosage was not or only gradually increased during the last 3 days of life. In 64% of the patients, the physician took into account that the use of morphine might hasten death. On the last day of life, 60% of all deceased patients received morphine. Physicians were asked to fill out a questionnaire on medical decisions and care that had preceded death. We explored the most important characteristics of use of morphine at the end of life.Ī stratified sample was drawn of death cases that occurred in the Netherlands in 2010. Intensive use of morphine at the end of life sometimes seems to represent a grey area between active ending of life and regular alleviation of symptoms.
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