Palliative Care and Euthanasia

talaxandra · Apr 23, 2005

Intent is at the heart of the Doctrine of Double Effect, a Jesuitical concept which allows Catholic carers to administer pain relief even where death is a known potential result, provided the administrators' intent was to relieve pain.

The alternative would be (as Mother Theresa practiced) withholding pain relief from the dying. (Her rationale was allegedly that pain and suffering are good for the soul).

As Gwenith pointed out, before asking whether euthanasia plays (or ought to play) a role in palliative care, you will need to define what you mean by 'euthanasia'. If you mean 'a good death' then that's what lies at the heart of palliative care theory. If you mean 'deliberately bringing about an earlier death at patient request' that's a meatier question, and if you mean something like 'ending a patient's suffering without invitation' or 'ending the life of one who's life is not worth living' then you're in very murky water indeed.

Good luck - it's a really interesting area to research, write about and work in :)

Katillac, RN · May 7, 2005

It's interesting, isn't it? If a person is struggling at the end and a loved one comes and gives them comfort and ease and they are able to relax and slip away, we never point to the visit as the thing that killed the patient. We recognize that the visit may have allowed them to slip away sooner than if they had been fighting against discomfort, yet this does not disturb us. But if a medication is given that has the same effect, the medication and the giver are suspect.

As to respiratory depression from narcotics, the lazy, slow and sedated breathing of someone who has too much narcotics on board is very different from what you see when you go from someone who is terribly dyspneic and then relaxes into a slower and more comfortable pattern, or someone who has been in pain and then relaxes into sleep once relieved of it. Of course it's possible to overshoot the mark. Of course it's possible to kill someone with an OD of narcotics. But good nursing judgement and practice prevents this.

leslie :-D · May 7, 2005

Of course it's possible to overshoot the mark. Of course it's possible to kill someone with an OD of narcotics. But good nursing judgement and practice prevents this.

but then again, that too is a balancing act.

if you give the prototype mso4 q4h prn, we all know as nurses that we're supposed to stay ahead of the pain therefore many give the mso4 even when they're not distressed. and often times, it does indeed hasten the pt's death.

i never, ever wait until the pt is starting to experience pain but rather keep them in a pain-free state. yet my nsg judgement and philosophy is to keep that pt comfortable, even if it does hasten death.

leslie

Katillac, RN · May 7, 2005

but then again, that too is a balancing act.
if you give the prototype mso4 q4h prn, we all know as nurses that we're supposed to stay ahead of the pain therefore many give the mso4 even when they're not distressed. and often times, it does indeed hasten the pt's death.
i never, ever wait until the pt is starting to experience pain but rather keep them in a pain-free state. yet my nsg judgement and philosophy is to keep that pt comfortable, even if it does hasten death.
leslie

Well, I see it differently, and so, I hasten to reassure readers out there, do most hospice nurses.

I don't give PRN meds routinely, especially narcotics, or because I think that the patient may need them in the future. To me, PRN means just that.

I don't "know that I'm supposed to stay ahead of pain". I do know that it's hard to chase and catch pain, but sublingual MSO4 starts to act in 20 minutes, sometimes less. If I assess carefully and routinely, I can catch pain when it first breaks through and get it under control using the perameters provided by the MD. If I can't, I call and get the order changed. And if I'm giving a lot of breakthrough doses, I get an order for a long acting.

But I would agree with you that giving morphine to patients who are not distressed and not showing signs of experiencing pain may in fact hasten their death. That's why it's my practice to not do it; there is no ethical justification for it.

sbic56, BSN, RN · May 8, 2005

Well, I see it differently, and so, I hasten to reassure readers out there, do most hospice nurses.
I don't give PRN meds routinely, especially narcotics, or because I think that the patient may need them in the future. To me, PRN means just that.
I don't "know that I'm supposed to stay ahead of pain". I do know that it's hard to chase and catch pain, but sublingual MSO4 starts to act in 20 minutes, sometimes less. If I assess carefully and routinely, I can catch pain when it first breaks through and get it under control using the perameters provided by the MD. If I can't, I call and get the order changed. And if I'm giving a lot of breakthrough doses, I get an order for a long acting.
But I would agree with you that giving morphine to patients who are not distressed and not showing signs of experiencing pain may in fact hasten their death. That's why it's my practice to not do it; there is no ethical justification for it.

The ethical justification is that you would be providing the best possible care by assuring constant pain relief for the patient. There is no reason why a dying patient should feel any unnecessary pain. The narcotic may be written PRN, but it is nearly a given with diseases such as terminal CA that it will be needed regularly, so the nurse needs to anticipate that likelihood. Even the best, most attentive nurse may not be able to stay on top of when the patient is feeling pain. Always better to err on the side of possibly giving the narcotic before it is needed than waiting until pain has arrived.

leslie :-D · May 8, 2005

I don't "know that I'm supposed to stay ahead of pain". I do know that it's hard to chase and catch pain, but sublingual MSO4 starts to act in 20 minutes, sometimes less. If I assess carefully and routinely, I can catch pain when it first breaks through and get it under control using the perameters provided by the MD. If I can't, I call and get the order changed. And if I'm giving a lot of breakthrough doses, I get an order for a long acting.
But I would agree with you that giving morphine to patients who are not distressed and not showing signs of experiencing pain may in fact hasten their death. That's why it's my practice to not do it; there is no ethical justification for it.

katillac,

i need to let you know that i find your philosophy extremely distressing.

why should you have to chase pain if you can prevent it all together?

i am strictly talking about those pts who are in much pain.

but why would any hospice nurse allow their pt to suffer for 1/2 hr, nevermind the anxieties and fears invoked by the pts.because of the anticipated pain once the mso4 starts wearing off.

and the "ethical justification" would be to stay ahead of the pain...to prevent suffering. :madface:

i've taken the liberty of providing you w/some insight re: staying ahead of pain.

http://www.juneauempire.com/stories/051000/com_hospice.html

http://www.capitalhospice.org/patients/caregiver/managing.asp#h4

http://www.silencetovoice.com/narratives.html

http://www.pathology2.jhu.edu/ovca/hospitalexperience.cfm

http://www.americanradioworks.publicradio.org/features/hospice/a3.html

do you work in hospice?

leslie

soapynurse@adel · May 8, 2005

I absolutely believe it is better to stay ahead of the pain than letting it rear it's ugly head. And it can happen so quickly. I tried very hard to keep my patients comfortable for them and for their families. I often encouraged the family to stay with the patient, crawl in bed with them to comfort them, whatever it takes.

I had a gentleman pass away one day with his family, two cats and a dog at his side. Can't get much more peaceful than that and yes, he was comfortable.

Happy Nurse's Week everyone.

Alice

Katillac, RN · May 8, 2005

katillac,
i need to let you know that i find your philosophy extremely distressing.
why should you have to chase pain if you can prevent it all together?
i am strictly talking about those pts who are in much pain.
but why would any hospice nurse allow their pt to suffer for 1/2 hr, nevermind the anxieties and fears invoked by the pts.because of the anticipated pain once the mso4 starts wearing off.
and the "ethical justification" would be to stay ahead of the pain...to prevent suffering.
i've taken the liberty of providing you w/some insight re: staying ahead of pain.
www.juneauempire.com/stories/051000/com_hospice.html
www.capitalhospice.org/patients/caregiver/managing.asp#h4
www.silencetovoice.com/narratives.html
www.pathology2.jhu.edu/ovca/hospitalexperience.cfm
www.americanradioworks.publicradio.org/features/hospice/a3.html
do you work in hospice?
leslie

I'll pass on the references, thanks, and stick to credible professional and academic stuff and the recommendations of the WHO and the HPNA (who gave me the CHPN after my name). I'll also stick with a practice and resulting documentation that passed close scrutiny by the state when we were last surveyed.

And I'll try to answer your questions, but I think we just disagree on this one.

Your question of why a hospice nurse would allow a patient to suffer is inflammatory. I don't allow patients to suffer, I respond to suffering with appropriate interventions, including giving medications AS ORDERED. That means not presuming to know for sure how much pain my patients will have and when, but rather giving PRN medications as soon as I see evidence of pain. If my patients need frequent dosing (> 4 per day) I seek to establish or, if already in place, to increase their long acting medication. If that isn't appropriate, I may seek to have the PRN made routine.

As far as fear and anxiety over pain medication wearing off, if I saw either I would intervene, either with an anxiolytic or by a call to the MD after a discussion with the patient. I would ask if he or she was willing to to sacrifice a little alertness to be more sure that he or she would not feel pain or fear. Many are not willing, and in such cases I would work on making sure I assess very frequently and build the patient's trust in me that I will be there at the first sign of discomfort, as identified by me or the patient. If desired by the patient, I would explore the idea of palliative sedation with my IDT. But I would NOT risk my license and the standing of my agency by giving medications in a manner that went against the orders we had been given.

Our state regulations and best practice standards mandate that we document, among other things, the objective and subjective data that led us to give each PRN. That means, "Call light on, pt states she woke up in pain @ 2/10 in L flank," or, "Pt unresponsive and lying quietly until 0900 @ which time he was observed to have a slightly furrowed brow. Respirations noted to have increased to 20 per minute, HR increased to 96 from baseline of 80. Foley patent and draining, bowel status WNL for pt." The old standby of "given to promote comfort" is not acceptable.

Obviously there are times when we learn the right on the dot of three hours after her last medication Mrs. Smith is uncomfortable. In such cases, why put the patient through eight doses of medication a day? Why not get a long acting analgesic with an appropriate breakthrough?

I don't imagine that you give people medications that aren't ordered, or at least for your patients' sake, your sake and your hospice I hope you don't. You call and get an order. And you keep trying until you get the order, I would imagine. So why would you give a PRN med routinely? That is as poor a practice as giving more than is ordered or giving a med that is not ordered. And yes, I know all about "wiggle room" and I use it. And of course families may choose to give meds in a manner differently than they are instructed, but I'm a licensed professional and I need to give medications as ordered.

I cringe at the thought of nurses doling out PRN narcotic analgesics because they "want to eliminate any possibility of suffering". It cheats the patient out of the possibility of needing less medication and therefore not suffering the side effects of the meds. It's not OK to assume that because I had 40mg of Roxanol every two hours last night I need the same amount today. It's not OK because of the side effects, and it's not OK because it's poor practice.

But again, the bottom line may be that we disagree.

Liddle Noodnik · May 8, 2005

I absolutely believe it is better to stay ahead of the pain than letting it rear it's ugly head. And it can happen so quickly. I tried very hard to keep my patients comfortable for them and for their families. I often encouraged the family to stay with the patient, crawl in bed with them to comfort them, whatever it takes.
I had a gentleman pass away one day with his family, two cats and a dog at his side. Can't get much more peaceful than that and yes, he was comfortable.
Happy Nurse's Week everyone.
Alice

Hi Alice, enjoyed this post and the previous - gee, can you still volunteer on some level? You sound so sad to be leaving this.

I have always loved taking care of the dying and their families. It is such an important time. So few nurses even look them all in the eye, the patient and family - they are scared, sad, sometimes mad, sometimes just hoping for the end. Just an acknowledgement to family members that their presence is essential makes them more comfortable.

leslie :-D · May 8, 2005

Your question of why a hospice nurse would allow a patient to suffer is inflammatory.

no, it is not inflammatory.

waiting til a pt. exhibits their first sign of pain is allowing them to needlessly suffer until their mso4 is absorbed.

i have already emailed the hpna but will provide you with a blurb from them:

"Although there is agreement that the goals of palliative care must focus on the PREVENTION (emphasis mine) and relief of pain and suffering...."

http://www.hpna.org/pdf/Providing_Opioid_at_the_End_of_Life_Position_Statement_PDF.pdf

i also am not professing that all eol pts need prns on a scheduled basis.

but for those who have intractable pain and are already on a long-acting narcotic, then yes, i will give the prn a/o and on a scheduled basis until i can reach the primary and tell him/her that this pt necessitates the prns ongoing. but NEVER would i wait until i see the 1st sign of pain. why should any patient have to suffer 1 minute never mind 1/2 hr before the prn takes its' effect?

i would love for you to provide me with references where it states that you wait until the pt exhibits their first sign of pain before administering.

it's tragic enough that these pts are dying; they needn't have to fear being in pain, thus escalating their anxieties. no reason for it.

even if their pain is well managed, many of them still require an anxiolytic unrelated to pain. i watch, observe and assess my patients very closely. i get to know them; i develop therapeutic relationships with them. they feel safe w/me.

and it makes me cringe that any nurse would let someone be in pain, however brief.

leslie

Katillac, RN · May 8, 2005

I believe that it's appropriate to give PRN pain meds for pain. You believe, apparently, that it's appropriate to give PRNs to prevent pain from ever occurring. We differ in our definition of what PRN means. I'm comfortable with my practice and my definition. I think your definition prompts you to practice outside your scope. We differ. More posts won't help that. I'm done.

leslie :-D · May 8, 2005

I believe that it's appropriate to give PRN pain meds for pain. You believe, apparently, that it's appropriate to give PRNs to prevent pain from ever occurring. We differ in our definition of what PRN means. I'm comfortable with my practice and my definition. I think your definition prompts you to practice outside your scope. We differ. More posts won't help that. I'm done.

one of the reasons i responded is because you cited hpna as one of your resources- i provided you w/a quote from the hpna which clearly contradicts what you've stated.

i also requested hard data regarding your allegations; you choose to deny my request. that in itself speaks volumes.

you ignoring the links i've provided tells me you are not receptive to seeing a different perspective- or more accurately, the consistency of those links that all state that pain should be prevented and to stay ahead of it.

it's regrettable you are so unreceptive to learning.

again, i would love to read anything that vindicates your beliefs.

but since you choose not to do that, there is nothing more to discuss, except that as professional nurses, all of us should be receptive to learning in order to serve our patients more therapeutically.

leslie