The murky world of morphine and palliative care

Sometimes, my colleagues report cases in which palliative or comfort care crosses the line into euthanasia.

Palliative care is intended not to treat illness or prolong life but to keep someone with a terminal or debilitating condition “comfortable.” An example: the use of morphine to lessen the pain and ease the death of a person with incurable cancer.

When deaths of people receiving morphine for palliative care are reported to the medical examiner for some reason – because they sustained an injury or a family member “suspects something” – findings must be carefully interpreted.

The measured level of morphine in the deceased’s body may be very high. People who take this drug chronically – recreationally or as prescribed – become tolerant. They require more and more for adequate relief and may achieve drug levels well into the reported lethal range without obvious ill effect.

Medical examiners must interpret drug levels in context. You can’t just look up a number in a book to see whether a given level caused death. It’s important for medical examiners to consider whether the prescribed dosage and frequency meet the standard of care and whether the level measured is consistent with the amount prescribed.

Sometimes, dosage standards are exceeded, usually because that’s what it takes to manage agonizing pain. Years ago, doctors held back, fearing their patients might become addicted. That’s no longer the case. So what if somebody about to die becomes addicted?

But many of my colleagues have investigated cases where the pain didn’t seem so great or the deceased’s condition so hopeless as to warrant a dose that greatly exceeded standards of care and obviously caused or at least hastened death.

In such a case, medical examiners must consider whether the person intentionally was euthanized – “put to sleep” – and decide whether to certify the death a homicide by drug overdose. Such cases are discussed by forensic pathologists with surprising frequency, and the discussions are always contentious.

If it’s clear that the deceased was a competent person – even one whose condition was neither terminal nor untreatable – and clear that the deceased chose palliative care because his disease was burdensome and his quality of life poor, most of my colleagues are inclined to withhold judgment.

But what if the deceased was unconscious or demented or mentally retarded, and the decision to give large or even lethal doses of medicine was made by doctors or family members – perhaps for their comfort?

While some cases are so egregious that most medical examiners would certify them as homicide by drug overdose, many others are less clear. One colleague, who says he’s certified homicide by drug overdose several times, says families generally “don’t seem to care.” To his knowledge, none took legal action.

In the experience of another colleague, “district attorneys consider such deaths a problem for the medical licensing board.” Licensing boards “take (these) cases under consideration and do nothing.”

Medical examiners are supposed to defend the public interest, but in such deaths, the public interest can be hard to discern. Dr. Carol J. Huser, a forensic pathologist, served as La Plata County coroner from 2003-12. She now lives in Florida and Maryland.

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