A Family’s Decision and Questions They Ask: Are Opioids Necessary and Do They Hastened Death for Patient Receiving Hospice Care? a Literature Review

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But fear of addiction and tolerance are the two main barriers to their use among most people who are hospice eligible. Teno et al. (2008) “the use of satisfaction measures that rely on ratings or the level of satisfaction with pain management is problematic because of the paradox that high-level satisfaction is reported despite unacceptable levels of pain.” (p.580).

Potenoy et al. (2006) stated that “the critical balance between the need to reduce suffering through aggressive pharmacotherapy and the potential to do harm has been discussed extensively in both the medical and ethics literature” (p.533). Questions like: How long does it take to reach its affects? And how long it takes to clear a person’s system? Are critical questions that require the clinician to answer when administering opioids to the elderly. Once therapy with an opioid is initiated, renal function is critical. This is especially so in the elderly. It was stated by Potenoy et al. (2006) “clinician concern about the potential for serious toxicity in medically frail patient may contribute to under treatment.” (p.538). Family’s and patient need to be informed that oral morphine is not as strong as I.V morphine. In fact, I.V morphine is three times stronger than oral morphine. And Portenoy et al. (2016) “the interval in days between the time of last opioid dose change and death, the maximum opioid dose prior to death, and the percentage by which the dose had been changed to achieve this final dose. For the entire sample, the mean number of days between final dose change and death was 12.46-23.11.” (p.534)

Myths continue to limit the use of opioids. Patients and their families may delay the use of opioids fearing that they cause imminent death. Untreated pain results in impaired mobility, depression, and a diminished quality of life. As Potenoy et al. (2006) stated “although pain is highly prevalent in populations with advanced illness and the need for aggressive therapy is widely accepted, under treatment is common” (p.533). Addressing these fears early in the education of end of life process may help. But initiation of education on opioid use during end of life may not be enough to alleviate the concerns of some families. But for others, fear can be the hardest emotion to overcome.

However, opioids are the medication of choice for end-of-life pain. They can be used safely and effectively for the treatment of patients with moderate to severe pain during end of life. As stated by Potenoy et al. (2006) “under treatment of pain is a far more pressing concern than is the risk of hastened death in those with advanced disease and physicians should be encouraged to opioids effectively to relieve suffering at the end of life” (p.539)

In challenging and unique cases, aggressive opioid therapy may be used for uncontrolled pain. Strand et al. (2014) stated “despite meticulous attention to symptom management, some patients still may not achieve acceptable levels of comfort and symptom control due to their advanced disease.” (p.363). The uninformed person may have fear and think of palliative sedation when any opioid is recommended for pain management at end of life. Opioids are safe and effective for the treatment of moderate to severe pain. Strand et al. (2014) “when a gap is identified between the desired level of comfort and a patient’s experience of suffering, clinicians must seek means of mitigating the suffering while weighing factors such as survival and potential risks and benefits of therapies” (p.363) Opioids are often the medication of choice for end-of-life pain.

Study

Purpose

Sample and Source

Findings

Notes

Baumrucker et al.

(2015)

Analyzed the use of aggressive treatment at end of life

A case study of a female below the age of 40 and her care team viewpoints on the family’s choice of care.

Families desire for a cure can lead to unnecessarily treating a terminal illness

Decisions for end of life are very difficult for care givers but the patients suffer when wrong decisions are made and aggressive treatment is chosen

Carrion, I., Park, N., & Lee, B. (2011).

Research done to explore the association of race and hospice use

A study sample

of a total of 22,936 hospice patients in central Florida

Over a four-year time span

The associations of the 4 groups the hospice stay duration

Data was analyzed using SPSS software

An examination of the main four racial groups. African American, Asians, Hispanics, and whites and their statistical use of hospice

And if race is associated with using hospice during end of life.

The results were that whites are more likely to use hospice than any other group. And the results may be due to lack of referral, education about hospice, seeking aggressive treatment, absence of caregivers, or surrogate decision makers in the non-white groups

Carson et al.

(2016)

Research done to explain how palliative care meeting impacted a chronically ill family

A multicenter randomized clinical trial of 256 individuals over a four-year span in four intensive care units. Adult Patients on mechanical ventilation and the primary outcome measure was (HADS)

Hospital anxiety and depression scale

Secondary outcomes included PTSD symptoms of the surrogate decision maker

At least 116 (86%) included the patients and family meetings. Meetings with families and the decision makers in the family and palliative care did not alleviate the caregivers anxiety and depression related to the outcome for the patient

Families feel overwhelmed with guilt when caring for a chronically ill patient and have difficulty deciding end of life care.

The findings do not support

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