1. Janssen, Scott MA, MSW, LCSW


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Joan's breathing relaxes as the morphine starts working. Her son, Travis, on the other hand, is clearly upset as we sit at her bedside where she is dying. Despite his mother's intense respiratory distress before he gave her the morphine, he's convinced that he's just made a big mistake. "I'm sorry, Mama," he whispers.


He turns his head my way. "I wish you hospice folks had never brought that morphine out here," he says. "Now she's dead for sure and it's my fault."


For caregivers with this level of fear about morphine, it's a painful dilemma. If you don't use the best, sometimes the only, medication we have for getting acute respiratory distress in terminally ill patients under control, both patient and caregiver suffer. But if giving morphine is freighted, as it is for Travis, with a belief that it causes death and/or signifies giving up on, even betraying, a loved one, it can intensify a caregiver's distress.


The hospice nurse had already given the standard education, assuring Travis that in patients near the end of life morphine is safe and effective when used as prescribed. We had given him written information debunking some of the common myths about morphine-"it kills you"; "makes you crazy"; "it's addictive"-when used appropriately with hospice patients who have active symptoms. We had promised to start with a low dose and only go up in small increments as needed. It had done no good.


For Travis, his resistance was not entirely rooted in a lack of knowledge or an emotional charge. -Underlying his concerns was a strong sense of moral responsibility. He was his mother's protector. He was her voice. He had a duty to keep her safe and, as he saw it, morphine was a threat to her well-being. Not surprisingly, simply claiming our expertise as medical professionals, giving him education, and expecting compliance without addressing this deeper moral dimension had been insufficient.


There's just something about morphine that can raise anxiety in caregivers. Beyond its potential side effects and potency (especially when warnings about opioid medications seem to come daily), many associate its use in terminally ill patients with the last days of life. Though not necessarily true, it often is. This is because morphine is the perfect medication when a patient is near death and having respiratory distress and/or pain. It works quickly and effectively and can be easily administered to patients who cannot swallow.


But what people often see, or have heard, is that when morphine is given, patients die soon thereafter. This can create two potential barriers: a belief that morphine kills or a belief that if one agrees to it, she or he is giving up on a loved one, surrendering hope or even displaying insufficient faith in God's ability to heal.


Moreover, for caregivers who are not used to giving medication and who are providing care at home, simply giving morphine with a dropper can be frightening. What if I give the wrong dose? What if she has a bad reaction? What if she dies because of me? What if she goes to sleep and never wakes up again? What if this clouds her mind and I never get to talk with her again?


Such moral concerns can activate powerful ideas of loyalty, responsibility, and protectiveness that override education and reassurances from health care professionals. If we see resistance to morphine as rooted solely in knowledge deficits, emotions, or misconceptions, we may dismiss caregivers as oppositional or irrational. We may miss these deeper moral imperatives. Instead, it can be useful to recognize them when they arise, acknowledge them, and affirm the positive intentions at their core despite the ways such resistance may run counter to effective symptom management.


Usually, if we take time to ask, this moral dimension reveals itself. Travis's head is down. He's rubbing his temples. I mention that his mother looks comfortable and that the morphine seems to have worked. He doesn't respond.


"Travis," I say softly, "we've talked about morphine. Where's this pressure you're feeling about it really coming from?"


"I told her I'd take care of her," he whispers. "She took care of me. Now it's my turn. I made her a promise. I don't want to do the wrong thing."


There it was, the moral substrate: loyalty, duty, reciprocity, keeping a promise, a code of personal responsibility, and, of course, the love which these embody. Trying to respond to his objections without understanding the deeper ground from which they were arising had gone nowhere.


Making these values explicit and acknowledging them deepens our understanding and empathy. Once we do this, we may find ways to enlist these very values in making a case for essential medications-protectiveness and keeping a promise, for example, may change their meanings and expressions as circumstances change.