"I don't want to be the one to give the last dose of morphine."
"What if the family thinks I killed her (the resident)?"
Have you overheard comments like these in your facility? Perhaps you've had similar thoughts. This month we will take a closer look at the concerns that surround administering opioids to a resident who is nearing death.
The primary concern about giving strong pain medicine at the very end of life is the fear of hastening a resident's death. This fear is based on the unfounded belief that administering opioids can depress respirations in dying patients. Confusion may arise as to what actions are considered symptom management and what actions might be seen as helping the patient to die or putting the patient to death. In other words, nurses and others might view their actions as assisted suicide or euthanasia rather than providing pain relief. The purpose of this Tip of the Month is to clarify these issues and assure nurses that administering opioids for pain relief is very different from assisting the patient to die.
First, let's consider whether or not opioids really do depress respirations and hasten death. There are many reasons for a resident's change in breathing at the end of life. Irregular respirations and Cheyne-Stokes breathing are common in the last days or hours of life. These changes may be caused by the underlying disease process, changes in metabolism, multi-system failure, and/or pneumonia.1, 2 Recent literature suggests there is little scientific evidence that death is hastened by administering opioids to imminently dying patients.2, 3 Susan Fohr, JD, MA, conducted an extensive literature search on this subject, and quotes numerous clinicians who conclude that respiratory depression is uncommon in terminally ill patients who have been on opioids. These clinicians suggest that pain is a powerful antagonist to respiratory depression so it's unlikely that opioids can severely slow breathing. In addition, many dying patients have been receiving opioids for prolonged periods. Since patients quickly become tolerant to the respiratory effects of opioids, it is unlikely that routine titration or administration of opioids will alone stop the patient's breathing.2
Even though there is insufficient evidence that giving morphine to patients in pain will cause their death, there is no absolute guarantee that the patient won't stop breathing shortly thereafter. However, even in this situation nurses are morally and legally justified in administering opioids. The "rule of double effect" (RDE) provides ethical support for actions that potentially have both good (in this case, pain relief) and bad (that is, hastening death) effects. Basically, the RDE provides four conditions that must be met when considering whether an act (in this example, giving morphine to a dying patient) is morally acceptable:
The intended act must be good, regardless of its potential consequences; for instance, giving medication with the desired goal of pain relief for a dying resident
Although the bad effect may be foreseen, it is not the intent of the act; for instance, death of the resident is not what the nurse intends
The bad effect must not be the means of bringing about the good effect; in other words, the patient doesn't have to die in order to achieve pain relief
The benefits of the good effect must outweigh the risks of the bad effect; for example, the benefit of providing the resident with pain relief outweighs the small risk of hastening their death4
Fear of blame and perceived risk of malpractice are other reasons that may hinder a physician's willingness to prescribe and a nurse's willingness to administer adequate doses of opioids at the end of life. These fears are likely unfounded. Melissa Buchan, MD, a scholar in the field of ethics and health care, reports that no physician in the US has ever been convicted of murder or assisted suicide for providing appropriate amounts of high-dose pain medication to a dying patient1. In fact, recent literature points out the risk of legal action for the undertreatment of pain.5, 6 Washington state legislature mandates "physicians and nurses should not withhold or unreasonably diminish pain medication for patients in a terminal condition where the primary intent of providing such medication is to alleviate pain and maintain or increase the patient's comfort.7" Professional organizations such as the American Nurses Association (ANA), the Hospice and Palliative Nurses Association, and the American Academy of Hospice and Palliative Medicine all have published statements supporting the use of opioids for symptom control, even at the very end of life.
Although ethical rules and the law support the administration of opioids to dying patients, some nurses have deeply held moral views that prevent them from doing so. This is acceptable if handled appropriately. The ANA Code of Ethics for Nurses allows for conscientious objection to an act that is personally morally objectionable, provided that there is adequate communication and time to make alternative arrangements for the patient's care. However, the nurse may not abandon the patient or in any way compromise their safety while awaiting the alternative plan.8
Assuring a resident's right to aggressive symptom management, including pain control, is a goal of end-of-life care. Now is the time to think through any concerns you may have about opioid administration to the actively dying resident. Talk about it with your colleagues or discuss it with your Director of Nursing Services and Medical Director. Another approach is to ask that your facility formulate a policy addressing this issue. All of these steps will ensure that your resident's comfort is upheld when you are faced with this potentially uncomfortable situation.
Assisted suicide: making a means of suicide (e.g., providing pills or a weapon) available to a patient with knowledge of the patient's intention. In assisted suicide, someone makes the means of death available, but does not act as the direct agent of death.9
Conscientious objection: a principle that allows a nurse to refuse to participate in an activity or treatment they find morally objectionable.8
Euthanasia: someone other than the patient commits an action with the intent to end the patient's life, for example injecting a patient with a lethal dose of medication. Also referred to as "mercy killing." In euthanasia someone not only makes the means of death available, but serves as the direct agent of death.10
Rule of double effect: an ethical principle that provides moral justification for an action aimed at benefiting a patient that may also result in shortening the patient's life.11
References
Buchan ML, Tolle SW. Pain relief for dying persons: dealing with physicians' fears and concerns. Journal of Clinical Ethics. 1995;6(1):53-61.
Fohr S. The double effect of pain medication: Separating myth from reality. Journal of Palliative Medicine. 1998;1:315-328.
Sykes N, Thorns A. The use of opioids and sedatives at the end of life. Lancet Oncology. 2003;4(5):312-318.
Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th ed. ed. New York: Oxford University Press; 2001.
Herrick T. Pain management - A chronic problem for clinicians: what's being done to improve this standard of care? Medscape. Available at: http://www.medscape.com/viewarticle/438809_print. Accessed 11-14, 2003.
Furrow BR. Pain management and provider liability: no more excuses. Journal of Law, Medicine & Ethics. 2001;29(1):28-51.
Natural Death Act. Revised Code of Washington. Vol RCW 70.122.010; 1992.
American Nurses Association. Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Association; 2001.
American Nurses A. Position Statement: Assisted Suicide. American Nurses Association, Task Force on the Nurse's Role in End-of-Life Decisions, Center for Ethics and Human Rights [Website]. December 8, 1994. Available at: http://www.ana.org/readroom/position/ethics/etsuic.htm. Accessed 05-04, 2000.
American Nurses A. Position Statement: Active Euthanasia. American Nurses Association, Task Force on theNurses' Role in End-of-Life Decisions, Center for Ethics and Human Rights [Website]. December 8, 1994. Available at: http://www.ana.org/readroom/position/ethics/eteuth.htm. Accessed 05-04, 2000.
Thorns A. Sedation, the doctrine of double effect and the end of life. International Journal of Palliative Nursing. 2002;8(7):341-343.