Title: “I was Dying and Now I’m Not!”: A Story of an Inappropriate Morphine Drip

Author(s): Zackery Zuga, MD; Anthony Cassachia, MD; Gina Matash, APRN-CNP

Email: ZWZuga@mercy.com

Introduction: Morphine drips are not without their place, however at times they may be ordered either inappropriately or more commonly at incorrect dosing intervals. Typically, in end of life care a morphine drip is ordered only in select situations when symptoms are persistent or progressive despite adequate scheduled pain medication¹. In the correct setting with proper titration and adjustment morphine drips are an acceptable choice in controlling symptoms. If titrated inappropriately, a patient may have poor symptom control with increased adverse effects including death.

Case Report(s): A 94 year old female presented to the emergency department for concerns of GI bleed. During the admission a CTA of the abdomen was obtained and showed concerns for bleeding at both the duodenum and rectum. Surgery was consulted for possible endoscopic intervention however family decided to transition the patient to comfort care with plans of proceeding with hospice. Patient was noted to be alert and oriented x4 during assessments leading up to this decision. Following transition to comfort care, the decision was made to place patient on a morphine drip prior to discharge from hospital as ordered by the ICU team. She was started on a morphine drip as per hospital comfort care order set. Of note, prior to starting morphine drip patient had received only 3 PRN boluses of morphine. She was started on a drip of 2 mg/hr and steadily was increased to 8 mg/hr over a 24 hour time frame. While on the morphine drip, she became increasingly more somnolent with decreased respiratory rate. The decision was made to transfer her to a hospice facility for further symptom management. On arrival at the hospice facility, the patient’s respirations were noted to be severely depressed, and she was also noted to have myoclonic jerks present. The morphine drip was stopped, and patient was transitioned to scheduled IV hydromorphone with PRN for breakthrough. Over the next several days, the patient slowly became more interactive and responsive, and she was also noted to have resolution of her jerks. Five days following admission to the hospice facility, the patient was discharged to an extended care facility. Shortly after discharge, the patient graduated from hospice services and went on to live another year before end of life.

Discussion: As outlined above, this case represents the common pitfalls and dangers of a morphine drip with improper titration in the absence of persistent or progressing clinical symptoms. Most commonly, morphine drips are reserved for only cases of intractable pain when proper scheduled medication is no longer adequate. As outlined in the above case, our patient was not properly trialed on scheduled or PRN medication and suffered an adverse medication event due to the inappropriate use and titration. More concerning, however, is that this occurred while following hospital protocol, which could have led to a false sense of security and inadequate oversight of the drip. As such, this case highlights the dangers of morphine drip and the need for proper implementation and order sets when ordering a morphine drip.