Expert: Ronald Levy, M.D. - 8/14/2009

Question
Dr. Levy,
       I would like to ask a question. There are a lot of details that you may need to know before answering but i will attempt to be brief anyway.
My father died of Lung cancer in Dec. 08 he was diagnosed in Sept. 08. He knew there was a tumor 5CM in the upper right lobe for a year prior. he was avoiding the diagnosis and was treating holistically. The day before my father died he was placed on a morphine pump for breathing problems ( he wasn't requesting much for pain) He was used to using Vicodine at about every 6 hours for the previous few weeks. He was not coherent enough to push a button for pain. I was told by the nursing staff to push it for him, I was assured that i could not overdose him that i could give him a dose every 12 min if needed. It was a pump of a beginning dose and 1 mg.dose with a 12 min. lockout. That day he only received 2 doses the initial dose from the nurse and one about 6 hours later. During that night my father struggled to breathe was extremely restless. The nurse told me i was not helping my father unless I pushed the button to relieve his pain.
I could only bring myself to push it about once per hour for a total of 7 doses of 1 mg each through out the night. He died the next morning. My question is did I give him too much morphine or too little? I am tortured by the thought of overdosing him or letting him struggle unnecessarily. he was 71 years old and weighed about 150 lbs by that time. Thank you, I look forward to your response.

Answer
You didn't give him either too much or too little. The problem is that a PCA pump really needs to be operated by the person in pain. Pain is a very subjective entity and no one else can know how much pain you are feeling. 7 mg of Morphine for a person with severe pain is not much so you certainly didn't overdose him. He should have been put on a continuous background dose and only given boluses for breakthrough pain. The PCA pumps are set up so that, no matter how many times you push the button, you can only get so much medicine per hour. That dose is usually well within the non-toxic range. The other reason that we want the patient to push their own button is because, if they HAVE gotten too much, they will be too sleepy to push the button again to give themselves an overdose. Your father died from his lung cancer, not from the Morphine. Ass to whether you gave too little, the liklihood, again, is probably no. If you did, he would have given some indication of being in pain (fast heart rate, rapid breathing, grimacing, etc). I am sure you did the right thing and you need not torture yourself any more.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston