Palliative morphine use in patients aged 90 years or older with advanced heart failure receiving best supportive care

Morphine may be used for refractory dyspnea or distress in advanced heart failure near the end of life, but evidence in patients aged ≥90 years is limited and concerns remain regarding sedation and respiratory depression. We compared early symptom response and observed safety events after low-dose morphine initiation according to age.

We retrospectively studied 173 consecutive patients with advanced heart failure receiving best supportive care at morphine initiation, categorized as <90 years (n = 110) or ≥ 90 years (n = 63). The primary outcomes were a ≥ 1-point improvement in the Facial Pain Scale (FPS) at 48 h and a sedation/respiratory event, defined as Richmond Agitation-Sedation Scale (RASS) ≤ -3 or an apnea-like event, within 48 h. An apnea-like event was defined as documented apnea or an apparent cessation of breathing in the medical record.

Baseline FPS was 3 (Heidenreich et al., 2022; McDonagh et al., 2021 [3,4]) in patients aged <90 years and 3 (Kitai et al., 2025; McDonagh et al., 2021 [2,4]) in those aged ≥90 years. The initial morphine dose was 5 [2.5, 5] mg/day in both groups. At 48 h, FPS was 1 [0,1] in each group. A ≥ 1-point improvement occurred in 72/80 evaluable patients (90.0%) aged <90 years and 41/44 (93.2%) aged ≥90 years (odds ratio 1.51, 95% confidence interval 0.34-9.34; p = 0.745). Sedation/respiratory events occurred in 35/98 (35.7%) and 20/59 (33.9%) patients, respectively (odds ratio 0.92, 95% confidence interval 0.44-1.91; p = 0.864). Sensitivity and adjusted analyses were generally consistent, although ≥2-point FPS improvement was less frequent among patients aged ≥90 years in the analysis restricted to in-hospital deaths.

We found no clear evidence that age ≥ 90 years was associated with a lower early response rate or a higher frequency of observed sedation/respiratory events after low-dose morphine initiation. However, the limited sample size does not allow equivalence between the age groups to be established.