Opioid use in dying patients in hospice and hospital, with and without specialist palliative care team involvement

Abstract

Newspapers claim that patients in hospices have their opioid doses increased to a point at which doctors know that they will die. However, research has produced conflicting results about whether hospice patients receive higher doses of opioids. This study investigated the differences in opioid prescribing between cancer patients dying in hospice and hospital with and without hospital palliative care team (HPCT) involvement and non-cancer patients dying in hospital, in Dundee, UK. The only statistically significant difference in the mean dose of opioids was that the cancer patients were prescribed and received higher doses of opioids than non-cancer patients. There was no statistically significant difference in the mean dose of opioids prescribed to and given to the different groups of cancer patients dying in different settings, indicating that the claims of the press are untrue. The cancer patients dying in hospital who were not on the HPCT records more commonly received Tramadol, which may indicate a reluctance of hospital doctors to move from weak opioids to strong opioids.

Clinical Experience With Strong Opioids in Pain Control of Terminally ill Cancer Patients in Palliative Care Settings in Taiwan

“…This is in accordance with previous studies reporting that elderly patients required lower doses to control pain than did young patients, because of a lower volume of drug distribution, reduced hepatic and renal function, and lower protein-binding capacity, and a difference in pain perception to that of younger patients. 20,22 In addition to interindividual variation, opioid doses have often been reported to increase markedly as death approaches, 23,24 which was also observed in this study.…”

“…Therefore, it is not surprising that patients referred to palliative care in hospices required higher doses than those cared for at home. 24,25 However, our data did not show a significant difference in analgesic dose between patients at home and those in hospice. This result was attributed to the limitations of the retrospective review process, which could not confirm the amount of "as required" medication that patients at home actually consumed.…”

Benchmarking opioids in the last 24 hours of life

“…There appears to be consistency in the dosages of opioids used across hospice teams within NZ, with no significant differences detected. The lesser requirement for opioids in non‐malignant disease has been previously described 35 . Although there is considerable overlap in symptomatology, cancer has the highest prevalence of severe pain 37,38 .…”

“…The lesser requirement for opioids in non-malignant disease has been previously described. 35 Although there is considerable overlap in symptomatology, cancer has the highest prevalence of severe pain. 37,38 Analgesic needs have been rated against diagnosis in cancer, 30,39 but we are not aware of similar studies in non-malignant disease.…”

Variable Patterns of Continuous Morphine Infusions at End of Life

“…1 There is sparse literature on EOL pain management. 2,3 Both the public and health care professionals often mistakenly believe opioid use will hasten death, when in fact appropriately dosed opioids can significantly improve pain and extend time until death. 4 According to the World Health Organization, properly dosed and titrated opioids are the medication of choice for pain management at the EOL.…”