What is the recommended starting dose of morphine (opioid analgesic) for hospice patients requiring comfort medications?

Recommended Starting Dose of Morphine for Hospice Patients

For opioid-naïve hospice patients requiring comfort medications, the recommended starting dose is 2 mg of intravenous morphine or 5-10 mg of oral morphine every 4 hours, titrated to effect. 1

Initial Dosing Algorithm

For Opioid-Naïve Patients:

• Oral route (preferred if patient can swallow):

  • Start with 5-10 mg PO every 4 hours 1
  • Lower end of range (5 mg) for elderly, frail, or patients with renal/hepatic impairment
  • Higher end of range (10 mg) for younger patients with severe symptoms

• Intravenous route (if oral route not possible):

  • Start with 2 mg IV, titrated to effect 1
  • Can be repeated every 15 minutes as needed for breakthrough symptoms

For Patients Already on Opioids:

• Continue current opioid at stable dose if patient is comfortable 1
• If converting from "weak" opioids (e.g., codeine), start at 10 mg oral morphine every 4 hours 2
• If converting from other strong opioids, calculate equianalgesic dose and adjust as needed

Titration Guidelines

• No specified dose limit - morphine should be titrated to symptom control 1
• If patient receives 2 bolus doses in an hour, consider doubling the infusion rate 1
• For continuous symptoms, follow bolus dose with continuous infusion 1
• For breakthrough pain:
  • If on continuous morphine infusion, use bolus dose equal to 2× the hourly infusion rate 1
  • Can be given every 15 minutes as needed for IV morphine 1

Route of Administration Considerations

• Oral route is preferred when possible (convenience and cost) 1

• Parenteral route (IV/SC) indicated when:

  • Patient cannot swallow
  • Patient has excessive nausea/vomiting
  • Poor peripheral circulation
  • Last few hours of life 3

• Bioavailability conversion:

  • Oral to parenteral ratio is approximately 3:1 3
  • When converting from oral to parenteral, divide oral dose by 3 4

Important Clinical Pearls

• Document rationale for giving any dose of comfort medication during withdrawal 1
• Always prescribe antiemetics PRN with opioids to prevent nausea 1
• Always prescribe laxatives concurrently to prevent constipation 3
• Morphine is the opioid of choice for opioid-naïve patients with pain or dyspnea 1
• In significant renal impairment (GFR <30 mL/min), morphine should be used with caution or switched to another opioid without active renal metabolites 1
• Sedatives should only be used after pain and dyspnea are effectively treated with opioids 1

Common Pitfalls to Avoid

1. Underdosing due to fear of respiratory depression - remember that in hospice care, symptom control takes priority and there is no dose ceiling for morphine when titrated appropriately 1

2. Failing to provide breakthrough medication - ensure PRN doses are available between scheduled doses

3. Not adjusting for renal/hepatic impairment - common in terminal patients and affects morphine metabolism 5

4. Overly complex or flexible regimens - research shows that caregivers administer less morphine with flexible prescriptions (21.84%) compared to structured regimens (39.52%) 6

5. Not anticipating side effects - always prescribe preventive medications for common side effects like nausea and constipation

Remember that morphine dosing in hospice is guided by symptom control rather than prognosis, and there should be no hesitation to increase doses as needed to ensure patient comfort at the end of life.