A 72-year-old man comes to see you because of severe pain from metastatic prostate cancer to the bones

A 72-year-old man comes 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 radiation, flutamide, or goserilin. In addition, numerous pain medications have failed to achieve an acceptable level of analgesia. He needs more intense pain management with subcutaneous or intravenous opiates. He also has severe CO.PD and there has been concern about the effect of the opiate medications I 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, inadvertently, j because of respiratory depression. The patient is fully alert and has the capacity to understand 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. L
d. Intubate the patient then give the pain medications.
e. Leave him in pain as long as the respiratory drive is not impaired.
f. Offer to end his life with pain medications.

Explanation

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. It is unacceptable and unethical to leave him to suffer. As long as he understands that the pain medications may have the “double-effect” of both relieving his pain and possible shortening his life and he agrees then it is acceptable. It is the same as performing a
risky 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 transplantation in 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 avoiding risk. Physician-assisted suicide is illegal in virtually all jurisdictions. You cannot purposely end the patient’s life. The primary issue is the intent of the physician in giving the pain medications. If the primary 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 life with the medications then it is unacceptable. The direct statement of the U.S. Supreme Court is “the state permits physicians to administer medication to patients in terminal conditions where the primary intent is to relieve pain, even when the medication is so powerful as to hasten death and the patient chooses to receive it with that understanding.”