From the Guidelines
The most appropriate factor to consider when deciding to increase this patient's current dose of morphine is D) Brain metastasis. In this hospice patient with end-stage metastatic melanoma, the presence of brain metastasis is critical to consider when evaluating pain control needs, as suggested by the European Association for Palliative Care recommendations 1. Brain metastases can cause significant headaches and neurological pain, which may explain why the patient is frequently touching her head with her left upper extremity. This behavior suggests localized discomfort that may not be adequately controlled with the current pain regimen. Some key points to consider when managing pain in terminal cancer patients include:
- The opioid of first choice for moderate to severe cancer pain is morphine, according to the EAPC recommendations 1.
- The optimal route of administration of morphine is by mouth, but in patients who are unable to take morphine orally, the preferred alternative route is subcutaneous, and intravenous infusion may be preferred in patients who already have an in-dwelling intravenous line 1.
- If pain returns consistently before the next regular dose is due, the regular dose should be increased, as stated in the EAPC recommendations 1. While the nursing staff and husband noted improved comfort after initiating the morphine drip, the patient's nonpurposeful movements and head-touching behavior indicate possible ongoing pain. The other factors listed (agitation, blood pressure, bowel sounds, constipation, and pupillary size) are important to monitor but are less directly relevant to determining the need for increased pain medication in this specific case. When managing pain in terminal cancer patients, especially those with brain metastases, ensuring adequate analgesia is a priority in hospice care, even if it requires careful titration of opioid medications, as the main continuing adverse effect from morphine is constipation, and the prophylactic use of a laxative is almost always required 1.
From the FDA Drug Label
If the level of pain increases after dosage stabilization, attempt to identify the source of increased pain before increasing the morphine sulfate tablets dosage
The most appropriate factor to consider when deciding to increase this patient's current dose of morphine is Agitation, as it may be a sign of uncontrolled pain or opioid-related adverse reactions. According to the drug label 2, 2, and 2, it is essential to identify the source of increased pain before increasing the dosage and to continually reevaluate patients receiving morphine sulfate tablets to assess the maintenance of pain control and the relative incidence of adverse reactions.
- Key considerations:
- Identify the source of increased pain
- Assess the maintenance of pain control
- Monitor for adverse reactions
- Adjust the dosage to obtain an appropriate balance between management of pain and opioid-related adverse reactions
From the Research
Assessment of the Patient's Condition
The patient is a 37-year-old woman with end-stage metastatic melanoma, experiencing bone pain and constipation, and is currently on transdermal fentanyl and intravenous morphine. Her father requests an increase in the morphine dose due to concerns about her pain level.
Factors to Consider for Morphine Dose Increase
When deciding to increase the patient's morphine dose, the following factors should be considered:
- The patient's current level of pain and comfort, as reported by nursing staff and her husband, who noted an improvement after the initiation of continuous morphine drip 3, 4.
- The patient's inability to answer questions and her non-purposeful movements, which may indicate discomfort or pain.
- The potential side effects of morphine, such as constipation, respiratory depression, and tolerance, which are common complications of opioid use 5, 6.
Most Appropriate Factor to Consider
The most appropriate factor to consider when deciding to increase the patient's current dose of morphine is:
- Agitation, as it may be an indicator of uncontrolled pain or discomfort, which is a common reason for adjusting opioid doses in palliative care settings.
Other Considerations
Other factors, such as blood pressure, bowel sounds, brain metastasis, constipation, and pupillary size, are important to monitor but may not be directly relevant to the decision to increase the morphine dose. For example:
- Constipation is a common side effect of opioid use, but it may not be a direct indicator of the patient's pain level 5, 6.
- Brain metastasis may affect the patient's level of consciousness and ability to report pain, but it is not a direct factor in determining the morphine dose.
- Blood pressure, bowel sounds, and pupillary size are important vital signs to monitor, but they may not be directly related to the patient's pain level or the need for a morphine dose increase.