PAIN MEDICINE USED IN COMFORT CARE MORALLY ACCEPTABLE UNDER CERTAIN GUIDELINES

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by Fr. Dennis Gonzales

 Many end-of-life issues involve the relief of pain and discomfort brought about by different illnesses.  We have been blessed that among the medical breakthroughs of our generation are treatments and interventions used to effectively relieve pain. Relief from pain helps a person go through the effects of illness in a dignified way.  The provision of comfort allows an individual to seek and pursue other important values at the end of life like prayer and spiritual preparation, reconciliation, and family unity.

Healthcare providers have the moral and legal responsibility to offer measures to alleviate the pain experienced by a patient. To say that everything has been exhausted to keep the patient from pain is not a valid excuse. Everything has not been exhausted if the patient continues to experience an unbearable pain.

Opioids like morphine sulfate are effective in treating severe pain

Some conditions require strong medications to manage or relieve pain. Opioids, like morphine sulfate, are effective in treating severe pain that is brought by terminal illnesses like cancer. [1] Dosages should be promptly and carefully titrated to achieve effective pain relief. It is very important that administration of certain doses is adjusted to a level sufficient and effective enough to relieve symptoms that can vary widely among patients.[2] Dosages of opioids can be increased until a satisfactory response is obtained.

However, there are doubts surrounding the use of opioids.  Family members raise moral questions of their use because of harmful side effects that include respiratory depression, which may hasten death.

 Administration of medications to relieve pain (opioids) is morally acceptable if the intention is not to end life

The Catholic Church teaches that the administration of medications to relieve pain is morally acceptable even if they have known undesired effects to shorten life. The Church’s principle of double effect is applied to situations in which one action is followed by two effects, one good (intended) and the other is evil (foreseen but not intended). The principle of double effect generally has to do with the intention and the nature of the action. Four conditions should be met to satisfy the requirements in the application of the principle of double effect. The administration of morphine to a patient who experiences an unbearable pain has met these conditions:

  1. The act must be good– The administration of medication is an act that is good;
  2. The intention must be good.  The good effect and not the bad effect is intended– The intention of giving the medication is to relieve pain;
  3. The act must first achieve the good. The good effect is not produced by bad effect— The relief of pain is achieved first. The evil, which is diminished consciousness follows;
  4. There is a grave reason for doing the action and for permitting the bad effect to happen–Medication is given to relieve an unbearable pain.

Since the only intention was to relieve the pain, and not to eliminate life to stop the pain, it is morally permissible to give pain relief and use sedative this way. Human and Christian prudence submits “for most sick people the use of medicines capable of alleviating or suppressing pain, even though these may cause as a secondary effect of semi-consciousness and reduced lucidity.”[3]

There is a stark difference between administering a medication to take away pain and administering medication to take away life.  The direct intention of giving pain medicine like opioid is not to end a person’s life but to relive his/her suffering.  Patients who are in tremendous pain can take the medication with a dosage properly adjusted by their physicians in response to the intensity of their pain.

Pope Pius XII made a passionate statement for the dying declared in the encyclical titled, Declaration of Euthanasia, that the suppression of pain and consciousness by the use of narcotics is permitted even at the approach of death and if one foresees that the use of narcotics will shorten life if there are no “other means exist, and if, in the given circumstances, this does not prevent the carrying out of other religious and moral duties.” [4]

In this case, death is in no way intended or sought, even if the risk of it is reasonably taken; the intention is simply to relieve pain effectively, using for this purpose painkillers available to medicine. However, painkillers that causes unconsciousness need special consideration. For a person not only has to be able to fulfill his or her moral duties and family obligations; he or she also must prepare himself or herself with full consciousness for meeting the Lord.[5] Thus, Pope Pius XII warns: “It is not right to deprive the dying person of consciousness without a serious reason.”[6]

However, even with careful dosage calculation and titration,  there are times that the amount of medication needed to alleviate pain renders the patient unconscious as he/she dies.[7]  This is indeed a case when a medication fails to eliminate pain while leaving the person conscious and is able to interact.  [8]  Since the intention, in this case, is not to kill the patient or to render him or her unconscious to numb pain sensation, but only to relieve pain, it is still morally permissible to use certain medications this way. This scenario is different from the so-called terminal sedation or palliative sedation. Terminal sedation may refer to the more controversial practice of intentionally giving of sedatives during a terminal illness to cause unconsciousness to relieve pain.[9]

 Each patient responds differently to pain

Patients respond differently to pain. If a patient decides that it is better to stop the pain and accept the side effects of pain medications, than to be in constant agony, that wish must be followed. If a patient wishes to endure the pain than lose the capacity to complete tasks, that wishes must be followed as well.[10]

Christians believe that suffering is a way of participation in Christ’s saving act. There are Christians who voluntarily accept the suffering brought about by an illness and associate them with the suffering of Christ. This particular belief leads some patients in the moderate use of painkillers. However, this should not be the norm for everybody.[11]

On the contrary, human, and Christian prudence suggest the use of medicines capable of alleviating or suppressing pain, even though they may have undesired effects of diminishing consciousness or reducing lucidity. As for those who are not in a conscious state to express themselves, one can reasonably presume that they wish to take these painkillers and have them administered according to the doctor’s professional judgment. It is morally acceptable to administer a well-titrated pain medication to relieve an extreme level of pain even though this results in unconsciousness or even if it may hasten death.[12]

Opioid medications should be properly titrated

In general, the administration of titrated and well-calculated medication dosages to relieve pain in dying patients, even when it causes undesired effects met the conditions of the principle of double effect. This is not considered euthanasia. It is important to stress this principle because it is always medically possible to relive pain. Moreover, it is also a moral and legal responsibility to administer medications to ease the physical pain in patients, unless they choose otherwise.

It is very important on the part of the medical staff to inform patients and family members of the possible unintended effects of unconsciousness when increasing the dosage of opioid. They may decide to hold on with the medication for a reasonable period of time in order to take care of some relational and spiritual concerns that require patient’s lucidity. This may include time to receive the Sacrament, to talk to a priest, chaplain or spiritual leader, to reconcile strained relationships or to wait for other family members to arrive.

__________________________________________________________________

 [1] Morita TTsunoda JInoue SChihara S.  Effects of High Dose Opioids and Sedatives on Survival in Terminally Ill Cancer Patients. Journal of Pain and Symptom Management. 2001 Apr;21(4):282-9. https://www.ncbi.nlm.nih.gov/pubmed/11312042

[3] Congregation of the Doctrine of Faith, Declaration of Euthanasia, Sec III: The Meaning of Sufferings for Christians and the Use of Painkillers. http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html, accessed on January 30, 2018

[4] Congregation of the Doctrine of Faith, Declaration of Euthanasia, Sec III: The Meaning of Sufferings for Christians and the Use of Painkillers. http://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19800505_euthanasia_en.html, accessed on January 30, 2018.

[5] Ibid.

[6] Ibid.

[7] David Kelly, Medical Care at the End of Life: A Catholic Perspective. Washington DC: Georgetown University Press, 2007, 19.

[8] David Kelly, Medical Care at the End of Life: A Catholic Perspective. Washington DC: Georgetown University Press, 2007, 19.

[9] McQueen Moira, Bioethics Mater, A Guide for Concerned Catholics, (London: Burns and Oates:2009), 84.

[10] David Kelly,  Medical Care at the End of Life: A Catholic Perspective. Washington DC: Georgetown University Press, 2007,19.

[11] Congregation of the Doctrine of Faith, Declaration of Euthanasia, Sec III.

[12] Ibid.

This resource is also used as a general reference on this topic:

Edward J. Furton and Rev Albert S. Moraczeski, OP, “Double Effect”, in Catholic Healthcare Ethics: A Manual for Practitioners (Philadelphia, PA: Natiional Catholic Bioethics Center), pp 23-29.

 

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