My mum passed away three weeks ago and when I got over the shocked I started analyzing every moment before her death.
I have read a few posts about morphine and Ativan precipitating death in cancer patients and I started worrying and feeling guilty about not having given enough information about it.

My mum had colorectal cancer stage three. She had a PET scan in December and didn't have metastasis but the cancer was invasive.
They started her on radiotherapy sessions to minimize symptoms but after the 7th session she developed a back pain similar to lumbago. We thought it was an isolated thing but when we saw the oncologist he said the tumor was probably growing and pressing against her back. He didn't want to do anymore tests because his priority was to keep her pain free, he referred her to palliative care at home. He gave us a few clues that at 87 years old with heart and kidney problems things normally wouldn't progress for the better, but I still had hope that my mum eventually will improve she didn't have metastasis or at least that is what we thought.
The palliative care team started her on Palexia (tapentadol) two a day one in the morning and one in the evening. Withing a week she had her dose of Palexia increased to three in the morning and three in the evening, as well as a one corticosteroid, three metamizol (analgesic) three paracetamol 1 gr plus all her regular heart medication and diuretics. She was a little better but not a great deal we were positive that my mum would improve a little. At the end of the week she started having neck ache and was agitated again with pain. I waited a couple of days and called palliative care to come to the house (until then they were giving the prescriptions over the phone) to assess her pain I wasn't sure if my mum was just having zero pain tolerance or she was getting worse. I explained everything to them, he touched her back and she was screaming with pain but if she didn't move there was no much pain. The nurse then put a pump which the doctor said it was the same medication she was taking but in the pump so they can adjust what is the best dose for her and give it in tablet form. That first night that she had the pump she asked for a tablet in the middle of the night and we gave her what the doctor told us in case she had pain again. Next the nurse came back and put more medication and gave us an antiinflammatory just in case she needed pain relieved later on. That same day in the afternoon she seemed a bit confused and very sleepy which they put down to the medication, I though she was now resting because she had no pain after all she had a lots of sleepless nights and agitation her body and mind was exhausted. I decided to call palliative care and they told me to try and wake her up other wises she would not sleep at night but I couldn't, when I was calling her she was opening her eyes and closing them again, sometimes telling me off for trying to wake her up. She had a nutritional drink in the evening went to bed and after a three hours she woke up complaining of shortness of breath, emergency doctor was called. A couple of minutes after they arrived they were saying that these symptoms are normal because of the drugs, as they were saying that my mum drops her head and dies. They tried to reanimate her but couldn't and finally pronounced her dead, heart failure.

I was in real shock because I wasn't expecting her to die so suddenly she was eating and drinking the same day she didn't look terminal. Even her palliative doctor was shocked he didn't expect this to happen.

I started thinking that maybe the pump with the medication precipitated her death, I was trusting the doctors I should have never allowed them to put the pump. Is this a normal thing? The doctor never warned me about the risks of that happening! All he says is that the medication was a very low dose, that her heart was too weak that is why she died not the medication but I am very doubtful now. Could someone help me to understand?

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Sometime there are no good answers. It sounds as though her doctor weighed the pros and cons of the transfusion and decided that the possible side effects outweighed the hoped for benefits. Your dear mum may have rallied with the transfusion, but it would not have bought her month or years of quality life, more likely it would have been days or weeks filled with a different king of suffering. I highly recommend the book Being Mortal by Atul Gawande, perhaps it can help you understand the role of medical intervention and sort through the issues around quality vs quantity at end of life.
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Thank you for your answers, they have given me a lot of emotional support.
I was always very vigilant with my mum's symptoms and general well being. I will never now what caused her sudden death. When we saw the oncologist just over a week before she died he died the pain in her back was caused by the tumor growing. When I went to talk to him after my mum's death he told me a different history, that my mum's lower backache was caused by a nerve inflammation because of the shape of her spine, not the tumor, he said it was definitely her heart. Because of her anemia her heart had to pump harder and suffered more. He was the one as well that when I asked him for a blood transfusion when my mum's anemia was very bad, and he responded that it was a risk to do that because she could have heart failure while doing it, and because she was almost bed ridden she didn't need it, and now he tells me that. I did questioned him about why he didn't do the blood transfusion when I saw him last and he said because there were risks of her loosing the blood because of the hemorrhages and the extra fluid to the body which can cause heart failure. Why he didn't take the risk if my mum's was going downhill anyway. At least she would have got some of her strength back and could have coped with the pain better? I felt like crying when I left his office. I wished I taped the conversation when I saw him with my mum last. I think she should have been referred to the pain unit rather than palliative care and my mum should have given a blood transfusion. It is very complicated and I am aware that my mum's health was fragile. It's hard to came to terms with things but I am getting there.
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Star68, my mother (final stage dementia) started her last day normally i.e.: ate breakfast etc. in the early evening she went downhill. She was on hospice by the way. It wasn't until she began to get restless and complain of pain (she could barely speak so I don't know where her pain was) that is when we began to give her morphine to ease the pain. She finally fell asleep of which she never woke up, she slept all night and passed away early the next morning. I have no doubt that it was the morphine that made her pain free but it was the final stage of dementia that she died of; not the morphine. It was very sad to see her go but I'm thankful she went peacefully, pain free in her sleep.
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Star, anyone with all the health issues your Mom had could die at any moment. She most likely would have passed with or without the morphine pump. Try not to torture yourself with all the what if's and maybe's.
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I saw your post and wanted to share with you, if it helps,(hopefully) I had the same diagnosis 3 years ago but I was 59 not 87. It takes all the strength out of you to fight cancer. Also they were not sure if it had spread to the back and so today 3 year later although in remission have chronic back pain. I am taking care of my 89 year old mom and no way I could go though survive the treatment I had if I was your Moms age. I am really sorry for your loss and I know morphine would have been keeping me going and it should have helped her. Peace"
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I'm sorry about your mom star.

Hugs, Bella
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Thank you for your answer. Yes, indeed the shock still very raw and it's very hard to comprehend why it happened, my mum was eating and drinking the day she died, I just wondered weather the morphine pump could have triggered her death because she died a day and a half after that, even though it was a very low dose the equivalent of the medication she was already taking. If it would have happened two weeks after I wouldn't have suspected anything, but it was so sudden.
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Your mother died from cancer and a weak heart. No one, not even very experienced doctors, can accurately predict the moment of death.

It is normal that you wanted to reduce your mother's pain as much as possible. To not have done that, I think, would have been negligence.

It is normal to wish your mother hadn't died. Especially if you weren't expecting it, the "she shouldn't have died. We must have done something wrong" thoughts can be strong.

You mother died of cancer and a weak heart. Accept that. It is not helpful nor healthy to obsess over every dose, every action, every pain before her death. Maybe if things had been done differently she would have had more pain, or less pain, or greater or lesser lucidity. But she still would have died from the cancer and weak heart.

It's been three weeks. The shock is still very raw. I think you will feel better if you turn your attention to happy memories of your time with your mother.

My condolences.
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