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Blog articles are provided as informational purposes only and are not intended to constitute medical advice. Medication protocols are subject to patient’s medical provider’s authorization.



The patient was on a high dose morphine, patient-controlled analgesia (PCA) pump and had severe cancer pain. He reported to have "pain all over" even when not being touched. He developed a myoclonic twitch several days prior. He wanted to die early and was suicidal due to the pain and discomfort. Goals of care were to manage his pain with oral medications so he could be more mobile and spend time with family. But since his pain could not be controlled with IV morphine via PCA pump, the team was hesitant to remove or reduce the pump for fear of increasing his pain. They were stuck, and so was the patient.

As a result, ProCare PharmacyCare clinical pharmacy was consulted.


Pain is one of the most common symptoms we encounter as hospice clinicians, but it is also the most difficult to treat, particularly with opioid allergies, complex opioid conversions, and declining ability to swallow.

Opioid Allergies



Insomnia is defined as difficulty falling asleep, difficulty staying asleep, and/or having non-restorative sleep, and it is most often secondary to another cause or condition. Common causes of insomnia that can be especially common in the hospice population include the following: situational (e.g. interpersonal conflict/family dynamic issues); medical (e.g. cardiac, respiratory, pain, diabetes, GERD, epilepsy, Parkinson’s disease); psychiatric (e.g. depression, anxiety); and pharmacologic (e.g. beta-blockers, diuretics, steroids, SSRI antidepressants).  Whenever possible and as appropriate, it is recommended to treat and resolve the cause(s) of insomnia first, before adding a medication to treat the symptom of insomnia.


Hospice goals of care focus on optimizing comfort and quality of life, rather than treatment and prevention. Anticoagulation therapy and monitoring are not aligned with comfort and quality of life, and can cause harm from bleeding. Anticoagulation does not provide comfort or control symptoms. For these reasons, anticoagulation is frequently discontinued.


Ketamine shows promise as an effective option for hospice patients who have pain that does not fully respond to increasing doses of opioids. However, in all instances, this treatment option should be discussed and approved by the patient’s medical provider.  It may be especially useful for neuropathic pain that does not respond fully to usual pain regimens that may include, opioids, NSAIDS, certain antidepressants, anticonvulsants, and gabapentinoids.  Ketamine appears to be synergistic with opioids in patients who no longer have an analgesic response to high doses of opioids.   It is also reported to be opioid-sparing and appears to play a role in opioid potentiation.  Keep in mind the use of ketamine for pain is off-label and it can be very complex to dose, so coordination with the patient’s medical provide is critical.

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