A 72-year-old man cones to see you because of severe pain from metastatic prostate
cancer to the bones. His pain has become progressively more severe and has not
responded to localized raeliation, flutanritie, or goscrilin. ln addition, numerous pain
medications have failed to achicve an acceptable level of analgesia. He needs more
intense pain malta€iement with subcutaneous or intravenous opiates. He also has
severe COPI) and there has been concern about the effect of the opiate medications
on the patient’s respiratory drive. In other words, the only way to achieve a sufficient
amount of pain relief is to use medications that may shorten his life, inadvertentlri
because of respiratory depression. The patient is fully alert and has the capacity to
understandl the problem.
Which of the following is the most ethical way to approach his pain management?
a, It is all right as long as he is DNR.
b. It is acceptable as long as the patient understands the risks.
c. It is unacceptable to shorten life.with physician administered medications.
d. Intubatc the paticnt then give the pain medications.
e. Leave him in pain as long as the respiratory drive is not impaired.
f. Offer to cnd his life with pain medications.
(b) It is acceptable as long as the patient understands the risks.
Your primary duty to a patient with a terminal condition and intractable pain is
to relieve suffering. lt is unacceptable and unethicar to leave him to suffer. As rons
as he understands that the pain medications may have the ,double_eftect… of both
relieving his pain and possible shortening his life and he agrees then it is acceptable.
It is the same as performing a riskT surgical procedure in which the patient consents
to a lifesaving surgery knowing there is a risk of possible death. This is the same as
cardiac bypass grafting in which the surgery will prolong life if successful, but has
a risk of death from the procedure. This is the same as a bone marrow transplanta_
tion ir.r which the patient has a very significant risk of death, but must do it in order
to prevent death from leukemia. A DNR order alone is not a way of avoicling risk.
Physician-assisted suicide is illegal in virtualy all jurisdictions. you cannot purposely
end the patient slife.
The primary issue is the intent of the physician in givilrg the pain nedications. If the
prirnary aim is to relieve suffering and there is an inadvertent shortening of life as
an adverse effect, then it is acceptable. If the primary intent is to end his Iife with the
medications then it is unacceptable.
The direct statement of the rJ-S. supreme court is "the state permits physicians to
administer medication to patients in terminal conditions where the primary intent
is to relicve pain, e’en when the medication is so powerful as to hasten death and the
patient chooses to receive it with that understandins.’,