Ethical considerations in effective pain management at the end of life
- Vicki Jackson, MD, MPH
Vicki Jackson, MD, MPH
- Associate Professor of Medicine
- Harvard Medical School
- Lida Nabati, MD
Lida Nabati, MD
- Instructor of Medicine
- Harvard Medical School
- Section Editors
- Janet Abrahm, MD
Janet Abrahm, MD
- Section Editor — Pain: Assessment and Management
- Professor of Medicine
- Harvard Medical School
- Kenneth E Schmader, MD
Kenneth E Schmader, MD
- Editor in Chief — Geriatric Medicine
- Section Editor — Geriatrics
- Chief, Division of Geriatrics
- Duke University
- Director, Geriatric Research Education and Clinical Center
- Durham VA Medical Centers
Many patients and families suffer from untreated pain at the end of life. Failure to treat pain effectively can result both from a lack of clinician training in palliative care and also from the fear of violating ethical, moral, and legal tenets in the administration of pain medication to the dying patient. Clinicians often have an exaggerated perception of the risk of hastening death by treating pain with opioids. Furthermore, they are frequently unclear about the distinctions between pain management, sedation for intractable symptoms, physician-assisted dying, and euthanasia. Physicians are faced with balancing these concerns with their legal duty and moral obligation to treat pain in the suffering patient. (See "Palliative sedation" and "Euthanasia and physician-assisted death".)
Studies of patients in their last week of life reveal that up to 35 percent describe pain as severe or intolerable . Quill and Brody define the escalation of pain that is uncontrolled at the end of life as a "medical emergency" . Untreated pain can be devastating to the patient and family not only because of the suffering it produces, but also because it interferes with the ability to complete many important tasks at the end of life. These tasks include, for example, getting legal affairs in order, grieving the loss of his/her life, making amends in strained relationships, and saying goodbye to loved ones.
Pain management at the end of life is the right of the patient and the duty of the clinician. The World Health Organization states that patients have a right to have their pain treated . This is supported by the Supreme Court ruling in Vacco versus Quill, which addressed the use of aggressive palliative care in the last days of life. Justice O'Connor stated in her concurring opinion that "…suffering patients have a constitutionally cognizable interest in obtaining relief from the suffering that they may experience in the last days of their lives" . (See "Legal aspects in palliative and end of life care".)
This topic review will focus on the ethical issues surrounding pain management in patients receiving end of life care. Other ethical issues that arise in patients receiving palliative care (eg, advance care planning, withholding and withdrawing care, physician assisted suicide, and euthanasia), principles of pain management, and palliative sedation for control of refractory symptoms at the end of life are discussed elsewhere. (See "Advance care planning and advance directives" and "Ethical issues in palliative care" and "Withdrawal from and withholding of dialysis" and "Euthanasia and physician-assisted death" and "Pain assessment and management in the last weeks of life" and "Palliative care: End-stage renal disease", section on 'Pain' and "Palliative sedation" and "Palliative care for patients with advanced heart failure", section on 'Pain'.)
Many clinicians are unclear about how aggressive symptom management in palliative care differs from physician assisted dying and euthanasia. Palliative care is a comprehensive approach to treating physical, spiritual, and psychological suffering in a patient at any stage of a serious illness, including at the end of life. While this may include prescribing pain medication that carries with it a very small risk of hastening death, any hastening of death is not the intention of the treating clinician. The use of medication intended to treat pain or relieve discomfort is legal in all states.
- Ventafridda V, Ripamonti C, De Conno F, et al. Symptom prevalence and control during cancer patients' last days of life. J Palliat Care 1990; 6:7.
- Quill TE, Brody RV. 'You promised me I wouldn't die like this!' A bad death as a medical emergency. Arch Intern Med 1995; 155:1250.
- World Health Organization, Cancer Pain Relief and Palliative Care. Geneva. World Health Organization, 1990.
- Vacco v. Quill, 117 S.Ct. 2293 (1997).
- Tucker KL. Aid in Dying: An End of Life-Option Governed by Best Practices. J Health Biomed Law 2012; 324:691. Available at http://www.suffolk.edu/documents/Law%20Journal%20of%20H%20and%20B/Tucker-2-19.pdf (Accessed on July 13, 2015).
- Quill TE, Lee BC, Nunn S. Palliative treatments of last resort: choosing the least harmful alternative. University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel. Ann Intern Med 2000; 132:488.
- Catechism of the Catholic Church. 1994. Part Three, Life in Christ, Section 2, Chapter 2, Article 5. Pauline, St. Paul Books and Media.
- Fohr SA. The double effect of pain medication: separating myth from reality. J Palliat Med 1998; 1:315.
- Quill TE. Principle of double effect and end-of-life pain management: additional myths and a limited role. J Palliat Med 1998; 1:333.
- Zedler B, Xie L, Wang L, et al. Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients. Pain Med 2014; 15:1911.
- Pawasauskas J, Stevens B, Youssef R, Kelley M. Predictors of naloxone use for respiratory depression and oversedation in hospitalized adults. Am J Health Syst Pharm 2014; 71:746.
- Clemens KE, Quednau I, Klaschik E. Is there a higher risk of respiratory depression in opioid-naïve palliative care patients during symptomatic therapy of dyspnea with strong opioids? J Palliat Med 2008; 11:204.
- Twycross RG. Ethical and clinical aspects of pain treatment in cancer patients. Acta Anaesthesiol Scand Suppl 1982; 74:83.