I received the following comment on my Blog. "They are overmedicating Mom” (The family said of hospice professionals). “Following a brief rally, she slept most of the time and died within a week." Her sons concluded she was being overmedicated with pain medication; with less medication, she would wake up and be alert again. They wanted Mom back, understandably, but that was not to be and it was not because of the pain medication...she was dying.

You are correct in your assessment. Mom probably did not die because she was over medicated. The family concerns you mention are so often exactly what people believe, however. That if Mom just didn’t have the pain medicine she would talk with them, would be alert and may even not have died when she did.

What most people don’t know is that months before death from disease or old age the dying process begins. A person begins eating less and less, sleeping more and more and withdrawing inward, talking less and less.

In the weeks before death a person is asleep more than awake, eating almost nothing and generally does not initiate conversation. They will respond when spoken to although often are confused.

In the days to hours before death a person is generally non responsive, meaning they may be moving and talking but not making sense and not responding to the world around them. This is the normal progression of gradual dying from disease or old age.

How much medication a person has is not the issue here. This progression will occur with or without medication. Withholding the medication will not have the patient waking up and talking if indeed death is days to hours away. Withholding the medication will leave the patient less comfortable (if pain has been an issue in the disease process then maybe in severe pain), overly agitated, restless and possibly with aggravated air hunger (difficulty breathing).

The guideline to use for administering narcotics as death approaches is to look at the person’s disease history. If pain has been an issue through out the disease process then continue giving the narcotic’s prescribed dosage. (Over the course of time the dosage of pain medicines is often increased.)

If pain was not an issue during the disease process then just because a person is dying does not mean pain is present and that a narcotic is appropriate. For restlessness a mild tranquilizer is effective. For labored breathing a very small amount of Morphine can ease that discomfort.

Dying is not painful. Disease causes pain. Know that we the watchers generally have a more difficult time watching our loved one die than our loved one who is actually dying does. The person dying is so withdrawn and removed from their body in the days to hours before death from disease or old age they are not experiencing their body and its sensations in the same manner as a healthy person.

I made the new DVD, New Rules for End of Life Care, in part to address the misconceptions people generally have about the use of narcotics during end of life care including the separate issues of addiction and of dying. Educating families that caring for someone at the end of their life is very different from caring for someone who is going to get better is crucial during this challenging time.