The final dimension in whole person care is the spiritual. While this is important in caring for any patient who is seriously ill, it becomes imperative in dying patients. When facing death, patients often ruminate on guilt about how they have lived their lives. Others may develop uncertainty or doubts about even longstanding beliefs. They may have many questions about the meaning of life and the meaning of death.
It is rare indeed that one professional is able to address all of the physical, psychological, social, and spiritual needs of dying patients. It requires a multidisciplinary team including nurses, physicians, therapists, counselors, pastoral care workers, social workers, and lay volunteers. Such a team is usually best mobilized through a formal hospice or palliative care program, but may at times be coordinated through a primary care physician’s office or a community or church organization.
The Imperative for Good Pain Management
In spite of excellent resources too numerous to cite, and in spite of practice guidelines and quality improvement guidelines, pain management is often inadequate.13-15 JCAHO has issued pain management standards that affirm both the patient’s right to appropriate assessment and management of pain and the institution’s responsibilities.16
Perhaps the most commonly asked ethical question about pain management at the end of life is concern about the inadvertent—or even the intentional—suppression of respiration with the use of high doses of opioids that could lead to an earlier death. Experts in pain management maintain that this rarely—if ever—happens because pain is a good respiratory stimulant. Even with good empiric evidence that narcotic use does not hasten death, this myth continues to discourage many physicians from fulfilling their obligation to relieve suffering.17
But let us consider the worst-case scenario: What if a terminally ill patient with overwhelming pain requires rapidly increasing doses of narcotics and does actually suffers from respiratory depression. Is the physician morally obligated to use ventilatory support to overcome this side effect? Thomas Aquinas (1224-1274) answered this question with his “rule of double effect”: It is morally permissible to do an act that has both a good effect and a bad effect if all of the following conditions exist:
- The act must be inherently good, or at least morally neutral;
- The bad effect may be anticipated, but not intended;
- The good effect must not be achieved by means of the bad effect; and
- There must be a proportionately grave reason for allowing the bad effect.
Using high doses of narcotics to relieve pain fits these criteria.
Because of the continued legal and professional proscription against PAS/E, some have proposed the use of “terminal sedation”: the practice of giving sedation to a patient who is dying, expecting that he or she will die more quickly of dehydration. If the intention is clearly to hasten death, then this is euthanasia and, in my estimation, it is an immoral end-run around the current legal and professional prohibitions. If, however, maximal efforts have failed to adequately relieve the suffering of an imminently dying patient, it would be ethically permissible to render the patient unconscious in order to relieve pain, accepting the unintended side effect of an earlier death from dehydration. This too would be justifiable using the rule of double effect.
PSA/E have been outside the bounds of acceptable behavior for physicians for hundreds of years. The moral, legal, and professional acceptable alternative is excellent end-of-life care. TH
To cure, sometimes; to heal, often; to comfort, always.—15th century French proverb.