Care for the Patient and Carer

Ms. Smith, a terminally ill patient with metastatic lung cancer, is admitted in-patient for palliative care due to severe pain. Health care providers grapple with an ethical dilemma: how to balance aggressive pain management with the potential to hasten death through a continuous IV morphine infusion, titrated to Ms. Smith’s pain level. Medical interventions may unintentionally hasten death, such as increasing pain medication to alleviate suffering, but our intention is to provide the patient with comfort, not to expedite their death. 

The nurse suggests increasing the morphine dose hourly for “a comfortable death,” questioning the need for continuous titration. In such a case, one ought to share with the nurse that by continuous infusion and titration of morphine, therefore following a more consistent approach to pain management. The titrated dosage is based on Ms. Smith's specific needs, therefore we can minimize the risk of over-sedation or under-sedation. This approach helps to maintain a balance between pain relief and other important factors, such as respiratory function and overall comfort. Knowing that Ms. Smith’s pain is being managed in a controlled and systematic manner offers a layer of reassurance and peace of mind — not only for the patient and their family, but for the care staff as well.

Next, the doctor voices their concern about the ethics of increasing the morphine dose, worried that it might unintentionally hasten the patient's death. The Doctrine of Double Effect can shed light on this tricky situation — it can help them understand that while the goal ought to be easing pain, there might be unintended consequences. In this case, the intended good of administering morphine is to alleviate the patient's pain, knowing that this could also hasten death. Here, the intention is pain relief, which is a “good effect,” not the “bad effect” of hastening death (Quill, Lo, & Brock, 2101). Therefore, death is seen as a foreseen but unintended consequence — as Ms. Smith’s doctor, it’s important to understand that alleviating pain is a means to an end. 

However, the Doctrine of Double Effect becomes more complex when it’s applied to palliative sedation, where a patient is sedated to unconsciousness and life-sustaining interventions are withheld. While proponents of palliative sedation argue that the intention is to relieve suffering, the sources point out that the additional step of withholding fluids and nutrition directly leads to death (Quill, Lo, & Brock, 2102). This blurs the line between a foreseeable consequence and an intended outcome, and it's something that should be discussed openly with the patient, their family, and the health care team.

This case highlights the complexities surrounding end-of-life care, particularly when balancing comfort and potential life-limiting interventions. Ms. Smith deserves comfort, which involves consistent pain management, even if it might unintentionally hasten her death. In tandem, the care team ought to know that providing this care is a compassionate act of beneficence, despite feelings of causing harm.

References

Quill, T. E., Lo, B., & Brock, D. W. (1997). Palliative Options of Last Resort: A Comparison of Voluntarily Stopping Eating and Drinking, Terminal Sedation, Physician-Assisted Suicide, and Voluntary Active Euthanasia. JAMA, 278(23), 2099-2104. https://doi.org/10.1001/jama.1997