Ethical dilemmas in pain management for terminal cancer patients

Ethics

As a new graduate of six months working night shift on a small cancer unit, I am faced with a dilemma. Mr. V has been in and out of the unit several times over the last few months. He has liver cancer and has gone through several episodes of chemotherapy. His wife has been staying with him since his admission. There are two RN's on this unit.

Mr.V recently joined the hospice program. His current admission is for pain control with orders to start a morphine drip to be regulated for pain control.

The only set parameters indicated by hospital policy are to decrease the drip when respirations are less than twelve breaths per minute. Mr. V has requested that the drip be increased several times during my shift. Even though he does not appear to be in any discomfort, I increase the drip. On my final round of the shift, Mr. V requests that the drip be increased again, stating that the pain is increasing. I note that his respirations remain stable at 12 breaths per minute.

An Ethical Question

This man is dying of liver cancer. For a while, morphine will control his severe pain. However, it may further reduce respiration. As a medical professional, I feel responsible to give this patient enough morphine to ease his suffering without causing him harm. However, I must consider the legal and ethical issues at hand.

On one hand, if I continue to increase his pain medication, I may be accused of overprescribing narcotics or hastening death. On the other hand, my patient has a right to proper pain management. For most terminally ill patients, pain can be controlled and, as a hospice worker, I am responsible to provide pain control.

In the past, many nurses did not fully understand pain control. As a result, many terminally ill patients were denied enough medication to relieve their pain because nurses were afraid of addicting patients or of killing them.

The medical industry and the public believed many untrue statements about the use of strong narcotic drugs, such as morphine. People were afraid that morphine would lead to problems with drug addiction and that drugs would lose their effectiveness after a long period of time.

Today, however, medical professionals know a lot more about pain control. The American Nurses Association's (ANA) Position Statement on Promotion of Comfort and Relief of Pain in Dying Patients completely supports the use of full and effective doses of pain medication for dying patients.

We now know that the pain control process involves using a "baby steps" approach. This approach uses small doses of analgesics, such as aspirin, then using stronger drugs, such as morphine, to maintain pain control. Medical standards dictate that pain medications should be given at regular intervals and in large enough doses to maintain a patient's comfort level and pain control.

Hospices and oncology services report that respiratory depression is uncommon in patients who are receiving opioids for the control of pain. Pain is itself a respiratory stimulant, and the opioid effect on the respiratory center diminishes rapidly with chronic use. If the patient is terminally ill and the dose of opioid required to produce comfort does happen to depress respiration, it is still reasonable to allow the undesired effect (respiratory depression) in order to achieve the desired effect"

In addition, according to the ANA, increasing a dying patient's dose of medication to achieve adequate symptom control is ethical, even if it causes the person to die sooner.

Conclusion

Medical professionals have an ethical, moral, and legal obligation to manage pain, especially when the patient is dying. The American Medical Association's (AMA) Ethical Standard E-2.20 states that "[p]hysicians have an obligation to relieve pain and suffering and to promote the dignity and autonomy of dying patients in their care."

As a nurse, I would not hesitate to use more pain medication to manage Mr. V's pain. His respiration is under control and I feel that increasing his morphine dose to achieve adequate pain control, even at the expense of life is ethically justified.

It is also legally justified, according to ANA and Registered Nurse Association (RNA) guidelines, which state that when cure or prolongation of life in terminally ill patients is no longer possible, the focus of nursing is on the individual's response to dying. Mr. V is requesting relief and I feel compelled to provide it for him.

As a registered nurse, I assume responsibility and accountability for all nursing judgments and actions made during my shift. I would not hesitate to use full and effective doses of pain medication for the proper management of pain in the dying patient. I would hope that, as a result of my decision, Mr. V is able to get through another day with little or no pain.