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Subcutaneous morphine infusion by syringe driver for terminally ill patients.

Introduction

In 17.5% of deaths an important medical decision relates to the adequate relief of pain and distress at the cost of a possible shortening of survival [1]. In striking the balance between minimizing pain and possibly hastening death, pain relief should have priority [2]. Although complete eradication of pain can be obtained in about 85% of terminal patients at home, general practitioners frequently have problems in achieving this [3].

To maximize patient autonomy, analgesic medication should be given orally, but in the terminal state a parenteral and continuous route of administration may be needed. In the United Kingdom and the Republic of Ireland hospices with a medical director or consultant in palliative care often use invasive procedures [4]. Dutch nursing homes (DNH) with psychogeriatric and geriatric wards, also have a hospice function; they all have a medical director and a full-time specialized DNH physician per 100 inpatients. Many DNH patients suffer a terminal distress syndrome, characterized by severe functional disability, progressive impairment of digestive, urinary and respiratory systems, pressure sores, cachexia and dehydration [5-7]. Oral therapy commonly becomes difficult.

In general, patients near death are usually directly cared for by family and nurses, rather than a physician [2]. It is clearly necessary for family and nurses to have an adequate influence in the schedule of administration of medication to relieve pain. Since 1992, terminally ill patients in DNH De Bieslandhof, Delft, The Netherlands, can be given morphine by continuous subcutaneous infusion by syringe driver for the relief of pain and distress. Daily dose increments and interim driver shots are possible. The purpose of this study was to investigate if morphine administration by this means led to higher morphine dose and possible shortening of survival compared with routine morphine administration.

Methods

Setting: DNH De Bieslandhof has 355 beds of which 58% are in psychogeriatric wards, 30 outpatient treatment places and an outreach service to 11 residential homes for elderly people. The aims of admission can be geriatric rehabilitation (15 beds), long-term palliative and nursing care (315 beds) or hospice care (25 beds). Hospice care is not provided in a special ward but in single or double rooms.

Patients and Methods

All patients dying over the 2 years from 1 April 1992 had their files retrieved. In the nursing home all records of physical examinations, treatments and observations of all staff including paramedical, nursing and psychosocial carers are recorded in a multidisciplinary compound personal patient file. Family members and carers are involved in decisions over morphine administration. In the nursing home, morphine may be administered orally as 10mg or 30mg morphine sulphate tablets, 20mg morphine suppositories or as 10mg ampoules. Kits are available, each including a syringe driver (Graseby Medical Limited, England, type MS26), necessary materials and a manual describing installation, control of the system and a means of assessing pain relief.

Statistical analysis of data was by [chi square], Mann-Whitney U test and t test where appropriate, using SPSS.

Outcomes

Over the study period 297 inpatients had died. Sixtysix per cent were women and the mean age was 85 years (range 40-102). The median length of stay had been 173 days (range 1-6741). There were no differences between patients admitted to the geriatric and psychogeriatric wards in terms of length of admission or morphine administration. There was, however, a significant difference in the cause of death, with more patients on the geriatric wards dying of cancer, heart failure or stroke and more patients on psychogeriatric wards dying with progressive dementia (Table I).
Table I. Length of stay, cause of death and morphine administration by ward

                  Somatic ward  Psychogeriatric   Total
                                       ward
                   (n = 154)          (n = 143)   (n=297)
                       %                  %           %       p

Length of stay:                                             0.52
  < 100 days           46                37           42
  100 days-1 year      22                22           22
  1-2 years             9                14           11
  2-3 years            10                11           11
  3-4 years             7                 6            6
  > 4 years             6                10            8
Cause of death:                                              0.001
  cancer               12                 2            8
  dementia             18                27           22
  heart failure        23                13           18
  stroke                8                 3            5
  pneumonia            17                22           19
  wound infection       8                11           10
  sudden death          6                10            8
  others                8                12           10
Morphine administration:                                      0.10
  no                   59                65           62
  by syringe driver    29                30           30
  by other means       12                 5            8




During their terminal illness, 113 (38%) patients were given morphine 86 (29%) by syringe driver. The two groups did not differ significantly in mean age, sex distribution, length of admission or cause of death. Morphine was administered by syringe driver more often on account of painful distress during personal care (Table II). Dose increments were used, mainly on account of insufficient pain relief, for 54 patients, 85% of whom were on syringe driver (32 patients one increment, 12 two or three times and two four times.). Interim driver booster doses were given to 36 (41%) patients, ten for incidental severe pain and 26 half an hour before getting personal care. During the last 24 h of life morphine dose ranged from 10mg to 100 mg. There were no statistically significant differences in dosage or in length of survival between the two groups (Table II).

[TABULAR DATA II OMITTED]

One hundred and thirteen (75%) of the patients were unable to communicate and family and carers were consulted over the decision on morphine administration. In these instances 24% were spouses, 53% children, 16% other family and 7% friends and guardians.

During morphine therapy by syringe driver six (7%) patients suffered local erythema and oedema around the needle insertion, requiring relocation of the needle. Short-term problems included unintended withdrawal of the infusion needle in ten (11%) patients and failure of the syringe driver due to flat battery or inadequate installation of the syringe affected six (7%) patients.

Discussion

At present one in six deaths in The Netherlands occurs in nursing homes and 38% of these within the first 6 months after admission [8]. Most such patients are in terminal stages of cancer, cerebrovascular or cerebral degenerative disease associated commonly with the terminal distress syndrome characterized by severe functional disability, progressive failure of digestive, urinary and respiratory systems, pressure sores, cachexia and dehydration [5-7]. Euthanasia (intentional termination of life by another person on request of the patient) is rare in Dutch nursing homes, affecting only 0.4% of deaths, whereas a phase of palliative care at the end of life is usual (85% of patients) [1].

The hospice function of the nursing home especially concerns short-term terminal care on geriatric wards for patients with cancer or heart failure and on psychogeriatric wards for patients with dementia. In contrast with the 14% deceased patients in the study by Black and Jolley [5], 42% of patients dying in Dutch nursing homes had been resident for less than 100 days. Length of stay over 4 years was 27% in the British study [5] compared with 8% in The Netherlands. There was no major difficulty in admitting acute patients to the nursing home studied which had a mean throughput of 0.83 deaths and discharges per bed per year.

There are advantages in the use of a syringe driver. These include the absence of frequency/dose problems caused by the short half-life of morphine, finer titration of the 24-hour morphine dose, easy administration at the request of the patient, nurse or relatives of booster doses in cases of fluctuations in pain and distress. The syringe requires filling only once in 24 h. Morphine administration by syringe driver is also cost-effective in terms of materials and time. Psychosocial advantages include the satisfaction of informal and professional carers for patients whose pain and distress are adequately relieved. Nurses who were able to give booster doses without increasing the mean dose by 24 hours thus had a direct involvement in the treatment and prevention of patient distress. Shortterm problems with the syringe driver system affected 10% of patients.

Availability and use of three syringe drivers (1 per 120 beds) did not lead to higher doses or longer administration of morphine. An average dose of 35 mg/ 24 h during the last week before death is not excessive.

Our findings suggest that the prevention of pain, distress and anxious dyspnoeic restlessness during the last week before death is possible with skilled care and continuously informed consent. Our findings do not suggest that morphine administration by syringe driver in comparison with routine administration leads to significantly higher morphine dose and so potentially to shortening survival. Morphine administration by syringe driver would also be practicable in residential homes for older people and in their own homes.

References

[1.] Mass PJ van der, Delden JJM van, Pijnenborg L, Looman COON. Euthanasia and other medical decisions concerning the end of life. Lancet 1991;338:669-74. [2.] Wanzer SH, Federman DD, Adelstein SJ, et al. The physician's responsibility toward hopelessly ill patients. N Engl J Med 1989;320:844-9. [3.] Haines A, Booroff A. Terminal care at home: perspective from general practice. Br Med J 1986;292:1051-3. [4.] Johnson IS, Rogers C, Biswas B, Ahmedzai S. What do hospices do? A survey of hospices in the United Kingdom and Republic of Ireland. Br Med J 1990;300:791-3. [5.] Black D, Jolley D. Slow euthanasia? The deaths of psychogeriatric patients. Br Med J 1990;300:1321-3. [6.] Bruning H, Klein Hessel J. Terminal care III (in Dutch). Leiden Zorn, 1986. [7.] Aangenendt-Siegers IP, Cools HJM. Causes of death in Dutch nursing homes (in Dutch). Ned Tijdschr Geneeskd 1992;136:2015-7. [8.] Cools HJM. The end of life in Dutch nursing homes (in Dutch). Ned Tijdschr Geneeskd 1992,136:2003-5. [9.] Bruera E, MacEachern T, Ripamonti C, et al. Subcutaneous morphine for dyspnea in cancer patients. Ann Int Med 1993;119:906-7.

Authors' addresses

H. J. M. Cools, G. H. de Bock Department of General Practice, University of Leiden, p.o. 2088, 2301 CB Leiden, The Netherlands

A. M. M. Berkhout De Bieslandhof Delft

Received in revised form 18 September 1995
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Author:Cools, H. J. M.; Berkhout, A. M. M.; De Bock, G. H.
Publication:Age and Ageing
Date:May 1, 1996
Words:1648
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