Fast Fact and Concept #008; Morphine and Hastened Death

2nd Edition

Author(s): Charles F. von Gunten, MD

Question : What is the distinction between the use of morphine at the end of life to control symptoms and euthanasia/assisted suicide?

Case Scenario: An 83 year old former industrial worker has been hospitalized because of severe pain. He has pancreatic cancer with metastases to liver and lung. He has severe abdominal pain.

Main Teaching Points :

1. Many physicians inaccurately believe that morphine has an unusually or unacceptably high risk of an adverse event that may cause death, particularly when the patient is frail or close to the end of his or her life. In fact, morphine-related toxicity will be evident in sequential development of drowsiness, confusion and loss of consciousness before his respiratory drive is significantly compromised.
2. Many physicians inappropriately call this risk of a potentially adverse event, a double effect, when it is in fact a secondary, unintended consequence. The principle of double effect refers to the ethical construct where a physician uses a treatment, or gives medication, for an ethical intended effect where the potential outcome is good (eg, relief of a symptom), knowing that there will certainly bean undesired secondary effect (such as death). An example might be the separation of Siamese twins knowing that one twin will die so that the other will live. Although this principle of “double effect” is commonly cited with morphine, in fact, it does not apply, as the secondary adverse consequences are unlikely.
3. When offering a therapy, it is the intent in offering a treatment that dictates whether it is ethical medical practice:
   • if the intent in offering a treatment is desirable or helpful to the patient and the potential outcome good (such as relief of pain), but a potentially adverse secondary effect is undesired and the potential outcome bad (such as death), then the treatment is consideredethical
   • If the intent is not desirable or will harm the patient and the potential outcome bad, the treatment is consideredunethical
4. All medical treatments have both intended effects and the risk of unintended, potentially adverse, secondary consequences, including death. Some examples are TPN, chemotherapy, surgery, amiodarone, etc.
5. Assisted suicide and Euthanasia are not examples of “double effect.” The intent in offering the treatment is to end the patient’s life.
6. If the intent in morphine in the scenario is to relieve pain and not to cause death, and accepted dosing guidelines are followed:
   • the treatment is considered ethical
   • the risk of a potentially dangerous adverse secondary effects is minimal
   • the risk of respiratory depression is vastly over-estimated.

Reference: Emanuel LL, von Gunten CF, Ferris FD. (1999) The Education for Physicians on End-of-Life Care (EPEC) curriculum. American Medical Association, Chicago.

Fast Facts were edited by David Weissman MD, Palliative Care Center, Medical College of Wisconsin until January 2007.  For comments/questions write to the current editor, Drew Rosielle MD: drosiell@mcw.edu. The complete set of Fast Facts is available at EPERC: www.eperc.mcw.edu

Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: von Gunten CF. Morphine and Hastened Death . Fast Fact and Concept #8; 2nd Edition, August 2005. End-of-Life / Palliative Education Resource Center www.eperc.mcw.edu.

Disclaimer: Fast Facts provide educational information, this information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Fact information cites the use of a product in dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is use

Creation Date: 2/2000; 2nd Edition, August 2005.

Purpose: Self-Study Guide

Audience(s)

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Pain>opioids, Ethics, law, policy, health systems