Duke Medical Ethics Journal

End-of-life care is becoming an aspect of healthcare that repeatedly appears in conversations of medical ethics. In such discussions, a plethora of questions commonly emerge. How do we navigate the delicate balance between a patient’s autonomy and right to make decisions about their care, as well as the obligations of healthcare providers? What role does palliative care play in end-of-life decision-making, and how can it be refined to ensure patient comfort and dignity? What are the ethical considerations surrounding pain management and the use of opioids in end-of-life care, particularly in light of potential risks and benefits? One of the key components of end-of-life care, and specifically what will be focused on in this article, is pain and symptom management, which involves addressing the physical, emotional, and spiritual distress experienced by terminally-ill patients. 

 

There exists a common understanding that relief of pain is a fundamental obligation of medicine, with a well-established foundation in medical ethics. The alleviation of pain requires the physician to act for the good of the patient and to prevent the infliction of harm. As stated by the National Institute of Health, “effective pain relief, especially at the end of life, is a primary ethical obligation based upon the principles of beneficence, nonmaleficence, patient autonomy, and particularly the concept of double effect” [2]. However, there often stands various barriers to effective pain management. Pain is, by nature, a subjective phenomenon, and “its treatment is neither an absolute science nor without risks” [5]. The barriers to effective pain management mainly exist on three levels: at the level of the institution and regulation, at the level of the provider, and at the level of the patient/family. 

 

Within the medical community, there are numerous misconceptions that commonly circulate surrounding the use of opioids to treat pain, such as the idea that “opioids are highly addictive, that dependence or tolerance are forms of addiction, that respiratory depression is common with opioids, that opioids have a narrow therapeutic range, and that opioids are ineffective by mouth and cause too much nausea” [2]. The use of opioids is a commonly debated decision amongst clinicians when it comes to pain and symptom management in end-of-life care. Opioids are known to have both desirable and undesirable effects – they provide analgesia, but, at increased doses, can cause sedation and respiratory depression. The risk of respiratory depression is of greatest concern in patients with comorbid cardiac, pulmonary, kidney, or hepatic dysfunction, along with those prescribed other central nervous system depressant medications. Although there are inherent risks, most studies have found no concrete link between opioid usage and mortality in seriously ill populations. With the continuous use of opioids, sedation and respiratory depression are effects to which patients tend to quickly develop tolerance [3]. 

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