Intermittent subcutaneous infusion of opioids in hospice home care: An effective, economical, manageable option

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Abstract
Administration of oral opioids is not always possible for terminally-ill patients. Obstruction, emesis, or inability to swallow frequently force us to seek alternative routes of administration. When the rectal route is contraindicated, impractical, or otherwise rejected by the patient or caregivers, we must resort to the parenteral route. The purpose of this study has been to validate the effectiveness, manageability, and side effects of bolus infusions of opioids utilizing an indwelling subcutaneous butterfly needle. The retrospective chart review included a convenience sample of 50 patients enrolled in our home-based hospice program who required subcutaneous infusion of opioids at some point during their enrollment. The total number of patients served during this time was 112. In the majority of cases (88 percent), the indication was inability to swallow or difficulty swallowing, which was related to impending death. Morphine sulfate was the opiate used in 955 of the cases reviewed. The mean four-hourly dose was 14.3 mg, with a range of 5 to 60 mg. Pain ratings were recorded using a 0 - 10 scale, both prior to initiation of and during the use of subcutaneous injections. Of the 42 percent of patients able to indicate a pain rating (0 - 10 scale) all rated their pain at 2 or below while using the subcutaneous route. No objective signs of pain were noted by caregivers or hospice nurses in the 58 percent of patients who were unable to rate their pain. The mean duration of time the needle remained in place was 4.62 days, with a range of 1-26 days. It should be noted that only one patient experienced erythema at the site which necessitated an early site change; the other patients were unable to swallow because of impending death, which occurred within a few days (thus, the short duration of placement). None of the patients required hospitalization to control their pain. The opiate was administered by lay-persons in all cases.

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