SYMBOLOne of my patients, who has terminal cancer, has been prescribed high doses of intravenous morphine sulfate to control pain and promote comfort as needed. These doses have the potential to decrease respiration enough to hasten death. As an RN, what guidelines can I follow in deciding whether to medicate this patient?
A nurse's role with regard to a terminally ill patient encompasses promotion of comfort and an optimal dying experience and extends through the continuum of life through death. Careful assessment and management of pain should be the principal goal of a palliative care plan. The ANA position statement, Promotion of Comfort and Relief of Pain in Dying Patients, explores the issue of pain control in the terminally ill. The statement makes two important points:
* Pain relief and promotion of comfort as primary acts are hallmarks of professional nursing practice.
* The possibility of hastening death through the acts of promoting comfort and alleviating pain is a possible consequence of the primary act and is therefore ethically justified.
Many factors in a patient's personal profile should be considered when administering potentially lethal doses of medication. These include the existence of a living will, cultural background, family influences, and the patient's desires. The appropriate consideration of these factors necessitates reciprocal relationships among physician, nurse, patient (if able), and family, in which there is open discussion of all parties' concerns and needs.
Pain relief, facilitation of comfort, and an optimal dying experience must be differentiated from two unethical means of ending life, active euthanasia and assisted suicide. These acts stand in conflict with the ANA's Code for Nurses with Interpretive Statements, 1985, which serves as the main ethical resource for the guidance of nursing actions.
Active euthanasia is "the act of putting to death someone suffering from a painful and prolonged illness or injury." Active euthanasia can be voluntary (the patient consents), involuntary (the patient refuses), or nonvoluntary (patient is unable either to consent or refuse). The code opposes all forms of active euthanasia, stating that the nurse is not to act deliberately to terminate the life of any patient.
Assisted suicide is the act of making available at the patient's request the means of ending his or her own life. When a patient suffers and decides that he does not desire to go on living, he and his family may request that the nurse provide the means of ending his life. But according to the code, the nurse's professional obligations are to "promote and restore health, prevent illness, alleviate suffering, and care for the dying." Again, the code states clearly that the nurse is not to act deliberately to terminate the life of any patient. While assisted suicide and active euthanasia differ, the ANA considers both acts ethically unacceptable and antithetical to the mission of the nursing profession.
However, these actions should never be confused with ethically justified end-of-life decisions and actions taken to control pain and promote the comfort of a dying patient. The high doses of morphine ordered by the physician are a legitimate part of end-of-life treatment and administering them is within the scope of proper nursing practice.
The Pain Relief Promotion Act (H.R. 2260), introduced in Congress in 1999, includes a troubling proviston allowing the Drug Enforcement Agency to investigate the intentions of health care professionals who prescribe medication. The ANA opposes this legislation, believing it would create a barrier to effective palliative care and prevent patients from receiving end-of-life treatment. The ANA has urged Congress to vote against the proposed legislation and to focus more attention on federal support for pain management and palliative care.
RESOURCES
Promotion of Comfort and Relief of Pain in Dying Patients. Go to http://www.nursingworld.org/readroom/position/ethics/etpain.htm or call (800) 274-4ANA.
Code for Nurses with Interpretive Statements, 1985.
Go to http://www.nursesbooks.org or call (800) 637-0323 to order. The cost is $9.95 ($7.95 for members of state nurses' associations).