Intense pain is a common feature of terminal disease near the end of life. Fortunately, hospice is very good at pain management. Hospice can manage symptoms effectively for most patients. Sedatives and high-dosage opioids are common in hospice treatment. Without them, hospice’s ability to manage pain so effectively could be compromised, but doctors have raised questions about the appropriateness of high-dosage opioids for patients already weakened by advanced disease.[Here we review the scientific evidence, which discusses people in general. This cannot be construed as individual medical advice. Hospice medications should only be taken under the prescription of a doctor, physician’s assistant, or nurse practitioner.]
The Opioid Crisis
In October 2017, the White House declared the opioid crisis a national Public Health Emergency. Doctors are heeding the call to be mindful of over-prescription. This includes looking for alternatives before prescribing opioids. However, hospice patients are different. Long-term addiction is not a likelihood among these patients. End of life is a very important time of life, and the quality of that time becomes an imperative.
Do Opioids Shorten Life for Hospice Patients?
With long-term addiction not being a prevailing concern in hospice, focus has moved to the trade-off between length of life and quality of life. Since the 90s, authorities have reasoned that opioid side-effects would hasten death.1-5 However, direct studies measuring this were largely not available to these authors. The concerns were theoretical.
Hospice Lengthens Life
Counteracting those concerns somewhat was the well-established fact that hospice does not shorten life. In fact, hospice lengthens life by days to months.6-14 Since hospice relies on opioids for pain control, could that medicine really be shortening life?
Opioids Can Lengthen Life for Hospice Patients
It turns out that the theories were wrong. Over the past twenty years, a conclusive body of scientific evidence has emerged. High-dosage opioids do not shorten life for hospice patients.16-18 Researchers have measured the amount prescribed, the timing, and several other factors. The high-dosages of opioids often seen in hospice did not shorten life. In fact, in one way, the opioids lengthened life. When patients had their dosages increased to the amount needed to control pain during hospice, their survival improved 54% (14 days versus 9.1 days).
Do Opioids Plus Sedatives Shorten Life for Hospice Patients?
With the debate about opioids in hospice settled, a more recent, theoretical concern arose.19 Hospice often uses opioids in combination with sedatives and anti-anxiety meds. Each of these categories of drugs have the side-effect of reducing breathing. It occurs more often at night. The prescriptions are generally safe in this regard, but could their combination shorten life for patients already weakened by advance disease?
Opioids Combined with Sedatives Lengthen Life for Hospice Patients
A study recently published in the Journal of Pain and Symptom Management finds that the opposite is true.18 They studied prescriptions of these drug categories: opioids, antipsychotics, and anxiolytics. In hospice, these drugs alone or in combination did not increase the percentage of nighttime deaths. In fact, the combination of opioids and sedatives correlates with survival improving more than 100% (5-day average survival to 11-day average survival).
The exact reason that hospice correlates with survival improving by days to months has not been established. Hospice does not try to lengthen life or shorten life. Hospice only works to improve quality of life for patients and families during a very important time. Concerns over opioids and their combination with other symptom-relieving drugs have been addressed. In fact, the improved survival associated with these drugs may shed light on part of the reason people in hospice live longer. Effective symptom management may be part of how hospice lengthens life.
- Wilson W, Smedira N, Fink C, et al. Ordering and administration of sedatives and analgesics during the withholding and withdrawal of life support from critically ill patients. JAMA. 1992; 267: 949-953.
- Cavanaugh T. The ethics of death-hastening or death-causing palliative analgesic administration to the terminally ill. J Pain Symptom Manage. 1996; 12: 248-254.
- Cantor N, Thomas G. Pain relief, acceleration of death, and criminal law. Kennedy Inst Ethics J. 1996; 6: 107-127.
- Krakauer E, Penson R, Truog R, et al. Sedation for intractable distress of a dying patient: acute palliative care and the principle of double effect. Oncologist. 2000; 5 (1): 53-62.
- Kaldjian L, Jekel J, Bernene J, et al. Internists’ attitudes towards terminal sedation in end of life care. J Med Ethics. 2004; 30 (5): 499-503.
- Huo J, Lairson D, Du X, et al. Survival and cost-effectiveness of hospice care for metastatic melanoma patients. The American Journal of Managed Care. 2014; 20 (5): 366-373.
- Keyser E, Reed B, Lowery W, et al. Hospice enrollment for terminally ill patients with gynecologic malignancies: impact on outcomes and interventions. Gynecol Oncol. 2010: 118 (3): 274-7.
- Saito A, Landrum M, Neville B, et al. Hospice care and survival among elderly patients with lung cancer. J Palliat Med. 2011; 14 (8): 929-939.
- Connor S, Pyenson B, Fitch K, et al. Comparing hospice and nonhospice patient survival among patients who die within a three-year window. J Pain Symptom Manage. 2007 Mar; 33(3): 238-46.
- Pyenson B, Connor S, Fitch K. Medicare cost in matched hospice and non-hospice cohorts. J Pain Symptom Manage. 2004; 28: 200-210.
- Christakis N, Iwashyna T, Zhang J. Care after the onset of serious illness: a novel claims-based dataset exploiting substantial cross-set linkages to study end-of-life care. J Palliat Med. 2002; 5: 515-529.
- Christakis N. Predicting patient survival before and after hospice enrollment. Hosp J. 1998; 13: 71-87.
- Connor S. Hospice: Practice, pitfalls, and promise. Philadelphia, PA: Taylor and Francis, 1998. 118-119.
- Forster L, Lynn J. The use of physiologic measures and demographic variables to predict longevity among inpatient hospice applicants. Am J Hosp Care. 1989; 6: 31-34.
- Portney R, Sibirceba B, Smout R, et al. Opioid use and survival at the end of life: a survey of a hospice population. Journal of Pain and Symptom Management. 2006; 32 (6): 532-540.
- Azoulay D, Jacobs J, Cialic R, et al. Opioids, survival, and advanced cancer in the hospice setting. Journal of the American Medical Directors Association. October 16, 2010; (available online ahead of print publication at http://www.jamda.com/article/S1525-8610(10)00242-2/abstract )
- Bercovitch M, Adunsky A. Patterns of high-dose morphine use in a home-care hospice service: should we be afraid of it? Cancer. 2004; 101: 1473-1477.
- Bercovitch M, Waller A, Adunsky A. High dose morphine use in the hospice setting. A database survey of patient characteristics and effect on life expectancy. Cancer. 1999; 86: 871-877.
- Golčić M, Dobrila-Dintinjana R, Golčić G, Čubranić A. The Impact of Combined Use of Opioids, Antipsychotics, and Anxiolytics on Survival in the Hospice Setting. Journal of Pain and Symptom Management. 2018 Jan 1;55(1):22-30.