Cultures

Swelling reflects the burden of illness on a person’s body. As the illness progresses, the burden increases further, and swelling may increase as well. If the swelling is the result of fluid collecting in the abdomen, it likely can be drained by paracentesis. As the rate of accumulation increases, paracentesis may be more frequent. At late stages of the illness, paracentesis may no longer be a benefit. Like many treatments, paracentesis may present its own burden on the body.

While swelling can reflect an increasing burden of illness, the following are signs that more reliably indicate that the end of life is approaching:

• decline in energy and range of activity, from regular movement to being bedridden;
• loss of appetite and thirst and a resulting loss in weight;
• breathing becoming more irregular, and very close to death sometimes noisier;
• changes in mental state, including confusion, restlessness, withdrawal or unconsciousness.

Many people worry about the use of morphine in palliative care. Morphine and other medications in the morphine family, such as hydromorphone, codeine and fentanyl, are called opioids. These medications may be used to control pain or shortness of breath throughout an illness or at the end of life.  Patients and families sometimes worry that opioids will speed up the dying process.

Morphine is sometimes used when a person is in the advanced stages of illness, and his or her overall condition is declining. If the person is experiencing moderate to severe pain or shortness of breath, his or her doctor will often prescribe morphine. This opioid helps maintain the person’s comfort throughout the illness and up to the time of death. The person declines because of the illness with or without the morphine.

When a patient is receiving regular pain medication such as morphine in the final hours or days of life, there is always a “last dose”.  To family at the bedside, it may seem like the drug caused or contributed to the death, especially if death occurs within a few minutes.  However, this dose does not actually cause the person’s dying.  It is simply the last medication given in the minutes or hours before the death naturally occurs.

We know that morphine and other opioids are not a factor in the death of a person with advanced illness. The following information explains why:

• There is no evidence that opioids such as morphine hasten the dying process when a person receives the right dose to control the symptoms he or she is experiencing. In fact, research suggests that using opioids to treat pain or shortness of breath near the end of life may help a person live a bit longer. Pain and shortness of breath are exhausting, and people nearing the end of life have limited strength and energy. So, it makes sense that treating these symptoms might slow down the rate of decline, if only for a few hours.
   
• If a person has never received morphine, the initial doses given are low. They are gradually increased to relieve the person’s level of pain or shortness of breath. After a few days of regular doses, the body adjusts to the morphine. The patient becomes less likely to be affected by morphine’s most serious side effect—the slowing of breathing. It would take a large dose increase over a short time to harm someone. Morphine doses are increased gradually and only as needed to maintain comfort.
   
• The last dose is the same as the doses the patient has previously received and tolerated. The way the medication is given might change when someone can't swallow any longer. If the medication needs to be given by a different route, the dose is calculated to equal  the amount  previously given by mouth.
   
• There’s a difference between natural dying and dying from too much morphine. When someone has received too much morphine, he or she usually can’t be woken up. The person’s breathing becomes very slow and regular. Sometimes only one or two breaths are taken in a minute. The person also appears calm and comfortable.

In the last few hours of the natural dying process, a person’s breathing becomes shallower and faster than normal.  The breathing muscles become weak like all the other body muscles.  When the breathing muscles are weak, extra muscles help out. It may look like the person is working hard to breathe, but does not always mean that they feel short of breath. The person’s breathing pattern often becomes irregular with pauses. These pauses are often followed by a few fast and deep breaths. The person dies when he or she does not draw a breath again after a pause.

These changes in breathing are a sign that the control centre for breathing is failing. The person may seem to be working hard to breathe, but this is a natural and normal response.

If there are concerns about increased rate and work of breathing, gasping for air, and that the person is distressed, we know that morphine is not a factor in the dying process. Instead, this suggests an ongoing need for giving the person additional regular doses of morphine to relieve distress.

Morphine and other medications in the morphine family, often play an important role in maintaining the person’s comfort throughout an illness and the dying process.

See also:
Pain
Assessing comfort at end of life (1 min 51 second video)
Tips for Talking with Someone Who is Dying
When Death is Near

A need for laxatives doesn’t mean there’s a bowel obstruction. People who are seriously ill often have trouble with bowel function. Laxatives are used to treat this before it has a chance to create a bowel obstruction.

Two main reasons why a person who’s ill may need a laxative are:

• Some cancers affect how the bowel works. Any tumor located near the bowel may press on it and make it difficult for the bowel to work properly. For example, ovarian cancer may do this because the ovaries are located near the bowel.
• Many medications affect how the bowel works. For example, opioid medications, such as morphine or Dilaudid, cause the bowel to slow down and not work well. Someone taking such medications needs to take a laxative also, in order to promote bowel movement.

As long as someone is passing regularly formed stools (stool consistency unchanged), and reasonably frequently (at least every three days), then it’s unlikely that person has a blocked bowel. A bowel obstruction produces abdominal pain that’s different from pain related to the underlying illness. It also produces nausea. The person is unlikely to pass any stool at all. At times there may be diarrhea or loose stool, as this can pass around a blockage. X-rays are often used to determine if someone has a bowel obstruction.

It’s important to contact a health care provider immediately if any of these symptoms appear:

• no bowel movement within three days;
• unusually high number of stools per day;
• blood in the urine, stool or anal area;
• no bowel movement within one day of taking a laxative;
• persistent cramps and vomiting.