Fast Fact and Concept #8: Morphine and Hastened Death

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Title: Fast Fact and Concept #8: Morphine and Hastened Death

Author(s): von Gunten, C.; Weissman, D.

This Fast Fact and Concept presents an overview of the ethical issues surrounding use of opioids at end-of-life. Suitable for ward rounds discussion or as a handout at a teaching conference.

Educational Objective(s):
Learn the importance of intent in understanding the ethical ramifications of using morphine at end-of-life. Understand the difference between assisted suicide and appropriate symptom control.
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 (e.g., relief of a symptom), knowing that there will certainly be an 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:
a. 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 considered ethical
b. If the intent is not desirable or will harm the patient and the potential outcome bad, the treatment is considered unethical
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:
a. the treatment is considered ethical
b. the risk of a potentially dangerous adverse secondary effects is minimal
c. 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 and Concepts are developed and distributed as part of the National Internal Medicine Residency End-of-Life Education project, funded by the Robert Wood Johnson Foundation.

Copyright Notice: Users are free to download and distribute Fast Facts for educational purposes only. Citation for referencing: Weissman, D. Fast Fact and Concepts #08: Morphine and Hastened Death. June, 2000. End-of-Life Physician 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 used.

Creation Date: 2/2000

Format: Handouts

Purpose: Self-Study Guide

Training: Fellows, 1st/2nd Year Medical Students, 3rd/4th Year Medical Students, PGY1 (Interns), PGY2-6, Physicians in Practice
Specialty: Anesthesiology, Emergency Medicine, Family Medicine, General Internal Medicine, Geriatrics, Hematology/Oncology, Neurology, OB/GYN, Ophthalmology, Pulmonary/Critical Care, Pediatrics, Psychiatry, Surgery
Non-Physician: Clergy/Chaplains, General Public, Graduate Students, Lawyers, Patients/Families, Nurses, Social Workers

ACGME Competencies: Medical Knowledge, Patient Care

Keyword(s): Assisted suicide/euthanasia, Cardio-pulminary, Pain treatment

The Fast Facts series is distributed for educational use only and does not constitute medical advice. For the most current version of Fast Facts visit the EPERC web site at www.eperc.mcw.edu. This mirror version is provided subject to copyright restrictions for educational use within the Inter-Instutional Collaborating Network on End-of-Life Care (IICN).