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END OF LIFE QUESTIONS ON PALLATIVE CARE

INCLUDING MORPHINE:

Catholic Understanding and Teaching concerning Morphine Drip

Isn't a morphine drip just another way to hasten a terminal patient's death? What is the difference between that and assisted suicide?

A morphine (a strong opiate that offers the best, most common approach to severe pain relief) "drip" or continuous infusion (an efficient and convenient intravenous application) is often used when a terminally ill patient is experiencing progressive or intense pain. A morphine infusion (drip) is not prescribed to hasten a terminally ill patient's death, but to provide comfort to the patient. There is a method of gradually increasing strength of pain medicines as the pain changes with disease progression. Both the dosage and type of medicine can be changed to meet the individual's unique needs for relief and prevention of pain and discomfort. Beginning with mild, to moderate to strongest medications, the physician has options to maintain control over the person's pain over time.

There is a distinct difference between the action of prescribing pain medication for a terminally ill patient and prescribing a lethal drug for a terminally ill patient. In the first case, the intent of the prescriber is to relieve pain and the drug of choice would be an opiate such as morphine. In the second case the intent of the prescriber is to purposefully hasten death and the choice of drug would be a barbiturate. While it is true that the terminally ill patient's life may be somewhat shortened as a result of the ingestion of an opiate-that is not the intent of the prescriber. Catholic moral theology recognizes and accepts this situation-calling it the "rule of double effect. " (See discussion below.) Often the person who has struggled with pain for some time may be finally able to "let go" and die peacefully once they are no longer suffering. This can happen simultaneously but is rarely a direct result of the medication. The health care providers must assess and monitor and adjust the medication to achieve the proper dose and comfort balance.

"It is worth recalling here a statement of Pius XII that is still valid. A group of physicians had asked: 'Is the removal of pain and consciousness by means of narcotics... permitted by religion and morality to both doctor and patient even at the approach of death and if one foresees that the use of narcotics will shorten life?' The pope answered: 'Yes, provided that no other means exist and if, in the given circumstances, the action does not prevent the carrying out of other moral and religious duties... death is by no means intended or sought, although the risk of it is being incurred for a good reason; the only intention is to diminish pain effectively by use of the painkillers available to medical science.'"

What is the rule of "double effect"?

The rule of double effect, found in Catholic moral theology, has a long history of use by bioethicists and philosophers as a means to resolve a particular type of ethical conflict in clinical cases. Basically the rule comes into play when a proposed action (such as administering morphine to a terminally ill patient in pain) has two known outcomes. One outcome is intended and desired (relief of pain). The other outcome is neither desired nor intended (hastening death), although it may be foreseen.

Is it wrong to offer increasingly high doses of morphine to a terminally ill patient in severe pain? Won't the patient become addicted?

No, it is not wrong-even knowing that the medicine may actually, although not intentionally shorten the life of a terminally ill person (See discussion of "double effect.") A well informed physician is not worried about "addiction" but about providing adequate pain relief. Addiction is only a problem for those who are receiving curative care and who anticipate resuming ordinary life, or who have no underlying cause for pain and are taking strong pain medicine for the emotional high or escape from the euphoria. When a physical cause for pain exists it is utilized by the body and may need to be increased over time as the body adapts to it and changes occur in condition.

One of the primary purposes of medicine in caring for the dying is the relief of pain and the suffering caused by it. Effective management of pain in all its forms is critical in the appropriate care of the dying. Patients should be kept as free of pain as possible so that they may die comfortably and with dignity, and in the place where they wish to die. Since a person has the right to prepare for his or her death while fully conscious, he or she should not be deprived of consciousness without a compelling reason.

Medicines capable of alleviating or suppressing pain may be given to a dying person, even if this therapy may indirectly shorten the person's life so long as the intent is not to hasten death. Patients experiencing suffering that cannot be alleviated should be helped to appreciate the Christian understanding of redemptive suffering. When a person is more comfortable they have the energy and ability to focus on family, relationships, living as well as possible for whatever time they have. Relief of pain can improve the time and duration of life and provide a window of meaningful celebration of one's life. Family can then use the time to share stories, have gatherings, create lasting loving memories, using the time well with good pain relief. Family's benefit from pain relief just as patient does. When one suffers, the other does too.

A terminally ill patient (or those advocating for him or her) would be wise to seek out a physician who is well informed about pain management. One of the advantages of hospice care is that the medical personnel are well informed and well trained in the application of adequate and appropriate pain medication. Adequate pain relief is a right of every person and should be expected with good hospice or end of life care as well as during earlier treatment phase, as needed.