Patients and caregivers were interviewed on Day 1 and a full medical history was recorded. We reviewed the medical charts of all outpatients treated consecutively. Additionally, the patients are visited once a week or more, as dictated by their specific needs. Patients and team experts have daily telephone conversations. The team derives from a hospital-based inpatient hospice at a large tertiary hospital. The service was established in the early 1990s, and is comprised of a team of palliative medicine experts (i.e., a physician, a nurse, a social worker, and a psychologist). We performed a retrospective study of a consecutive population of 661 patients who were treated by a home-care hospice team during a 5-year period (1995–2000). The current study elucidates the characteristics of outpatients in a home-care hospice setting treated by different morphine doses, as well as the survival of these patients. One study concerning inpatient hospice care 8 that described the morphine dosage used for the terminally ill patients, demonstrated a high clinical safety profile, and concluded that morphine dosage did not affect the survival of the patients. Moreover, the estimation of survival time in these patients may provide useful information regarding hospice programs and funding eligibility, and overcome imprecision in the “expert” estimation of their life span. Survival data are important because many clinicians believe that high-dose morphine has inevitable severe side effects and may actively hasten the death of their patients. 6- 8 This may be one of the reasons why we did not find in the English literature any detailed study describing the extent or circumstances of high-dose morphine use in a classic outpatient hospice care, or the possible correlation between high-dose morphine and patient survival. To our knowledge, there are few data published to date regarding high-dose morphine use in patients with cancer. The high doses of morphine required to relieve patients' pain may result in “opiophobia” 4, 5 by physicians, patients, and caregivers.
This is especially true for the issue of pain control at home, which often remains problematic. 1- 3 Death at home is associated with greater satisfaction, yet the daily routine for a terminally ill patient may be exhausting for caregivers. Despite preferences to end life at home, hospitals remain a central place of death. Home-care service for patients with terminal cancer is a rapidly evolving field of palliative care. The use of high or very high-dose morphine should not be a barrier to providing palliative terminal care for home-care hospice patients. The use of high and very high morphine doses at home proved safe and did not appear to affect the patients' life expectancy adversely. Patients not treated with morphine survived for 22 days ( P = 0.001 by Mantel–Cox analysis P = 0.029 by Breslow analysis). Patients treated with low doses of morphine survived for 18 days. The median survival of patients treated with high doses of morphine was 27 days and was 37 days for those treated with very high doses. Adverse effects were similar in the groups receiving regular, high, and very high doses of morphine. Primary gastrointestinal ( P = 0.015) and lung ( P = 0.027) carcinomas, as well as metastatic bone disease ( P = 0.001), ovarian carcinoma ( P = 0.037), and brain tumors ( P = 0.0053) were associated with higher and very higher morphine dosages. Male patients required slightly higher dosages than female patients (62.5% of high-dose and 71% of very high-morphine groups, respectively). Morphine dosage was found to be inversely correlated (r) with age ( r = −0.254 P < 0.001). Overall, 39 patients (9%) received > 299 mg per day. Of these, 396 patients (91%) received a dose of 5–299 mg of morphine per day), 32 patients (7.4%) received 300–599 mg of morphine per day), and 7 patients (1.6%) received very high doses (≥ 600 mg of morphine per day). The authors identified 435 patients (65.8%) who received morphine for pain relief. The authors also compared the data of patients receiving high-dose morphine with those of a group of patients receiving regular doses. The authors collected data regarding demographic parameters, medical diagnosis, pain type, morphine dosage, use of rescue doses in addition to regular doses, use of coanalgesics and adjuvant treatments, and survival time as associated with morphine dosage. The authors retrospectively studied the medical charts of 661 outpatients, which were completed by a home-care hospice team. The goals of the current study were to assess the feasibility of high-dose morphine use at home, to characterize the patients, and to examine whether the use of high-dose morphine might affect their survival. High doses of morphine at home may be required to relieve patients' pain, and is therefore feared.
Management of cancer pain is one of the most important goals of palliative care.
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