A 93-year-old woman was transferred to the palliative care unit after a subacute, non-malignant, right-sided cardioembolic incomplete middle cerebral artery (MCA) infarction. On arrival in the palliative care unit, the patient was comatose. She received morphine delivered subcutaneously at a dose of 48 mg/24 h (equivalent to 2 mg/h) by an infusion pump. Since no distressing symptoms were observed by staff, we reduced the infusion rate of the morphine infusion pump over the next 24 hours and eventually discontinued the treatment. The patient woke up and started to eat and drink again (Figure). She agreed to be transferred to a geriatric department to undergo early rehabilitation for left-sided hemiparesis (MMT 3/5) and mild dysarthria. In very old patients, treatment with a morphine infusion pump for pain or dyspnea should initially be started with a maximum dose of 5–10 mg/24 h (approx. 0.2–0.4 mg/h) subcutaneously or intravenously and then be carefully titrated and adapted in order to avoid unnecessary or unsafe sedation. A suspected end-of-life situation as such is not an indication for treatment with a morphine infusion pump.
Figure:
Initially comatose patient with incomplete middle cerebral artery infarction shown after reduction and discontinuation of continuous subcutaneous morphine administration. An already scabbed wound from the MCA infarction-related fall is noted as well as a partial hemiparesis of the left extremity.
Photo: Schulte
Acknowledgments
Translated from the original German by Ralf Thoene, MD.
Footnotes
Conflict of interest statement: The authors declare no conflict of interest.