Palliative Care and the End of Life

The termpalliative care was coined by Canadian urological surgeon Balfour Mount in 1974. Mount visited St. Christopher's Hospice in England before opening one of the first hospice programs in Canada, and he found the wordhospice to be objectionable to some Canadians. To members of the French Canadian culture, the word implies a place of last resort for the poor and other disenfranchised members of society rather than a place that provides care and comfort for dying patients and their families. Mount came up withpalliative care, a term considered as acceptable to both English-speaking and French-speaking Canadians.

The World Health Organization defines palliative care as improving the quality of life of patients with life-threatening illnesses and their families. Pain has been a major contributor to the low quality of life for some patients facing imminent death, and proponents of the palliative care approach developed expertise over the years in how to manage pain.

Managing pain at the end of life can include administering traditional analgesics such as aspirin, ibuprofen, codeine, and morphine. In addition, counseling, psychological and spiritual support, relaxation techniques, music, and imagery all are components of palliative care.

The experience of pain is subjective and to some degree defies description. Using pain assessment tools, especially with children and nonverbal adults, has been helpful in quantifying individuals' pain and, in turn, in finding more optimal pain management. Such tools include the Abbey Pain Scale and the Face, Legs, Activity, Cry, Consolability pain assessment tool.

Pain might not be treated effectively because physicians do not prescribe adequate doses of opioids and nurses do not give patients all of the doses that physicians prescribe. Physician and nurse reluctance to prescribe and give sufficient opioids to relieve patients' pain is attributed to their fear of contributing to patients' physical and psychological dependence, increased physical tolerance, and ultimate addiction to the prescribed analgesic medications. Their reluctance also stems from knowledge of the side effects that some medications can cause, including the unintended hastening of the patient's death—the most dreaded fear of physicians and nurses. However, controlling pain, in spite of the serious side effects, is ethically justified through the “rule of double effect.”

The rule of double effect distinguishes between intended effects and expected effects. This important distinction allows practitioners to prescribe needed palliative care medications to alleviate pain and suffering without carrying the moral burden of having caused the death of the patient. The key question in such a situation is as follows: What is theintent of prescribing the dose of medicine that may prove fatal to the patient? If the intent is to kill the patient, thereby alleviating the pain, then prescribing the medication cannot be ethically justifiable. However, if the intent is to relieve the patient's pain and suffering, and death is hastened as a result of administering the medication, then the action is justifiable. Although death may be expected, it is not intended. Some physicians who oppose euthanasia and physician-assisted suicide (PAS) may hesitate to use an opioid analgesic such as morphine to control the pain and suffering of dying patients because of its potential to hasten death. Double effect is an important and effective tool to justify its use in the care of dying patients.

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