Situation

A.P. is a terminally ill 50-yr-old woman with metastatic breast cancer

who is hospitalized with severe bone pain. She moans at rest and

shows severe pain with any movement to reposition her. The present

dose of IV morphine is not controlling her pain. At the team

conference, the nurses discuss the need for more effective pain

control but are concerned that more pain medicine could hasten her

death.

Ethical/Legal Points for Consideration

• Adequate pain relief is an important outcome for all patients,

especially patients who are terminally ill.

• The Code of Ethics for Nurses addresses the responsibility of the

nurse to relieve suffering and have conversations with patients

and families about pain and symptom management.

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• The principle of beneficence means that we provide care to benefit

patients. The goal of adequate pain control in the terminally ill to

ease suffering is based on the principle of nonmaleficence

(preventing or reducing harm to the patient). The secondary

effect of hastening the patient’s death is ethically justified and

known as the double ef ect.

• Legally, the standard of care is used to define the nursing acts that

are required for safe and competent nursing practice. When the

actual nursing care falls below the standard of care, it is

considered negligent and unsafe, and the nurse is at risk for

being found incompetent.

• In a court of law, the standard of care in nursing is determined by

nursing experts and evidence-based practices. The increasing use

of technology to access the latest scientific findings is changing

the standard of nursing care to a national, if not global, standard

defined by research findings and nationally recognized expert

testimony. Standards for providing expert nursing care and

counseling at EOL are available.

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• In A.P.’s situation the standard of care is that the patient will

have pain relief. Failure of the nurse to act assertively to achieve

pain relief for the patient and failure to effectively use resources

to obtain that pain relief will be considered below the standard of

care and unsafe and incompetent practice.

Discussion Questions

1. What types of discussions need to occur among the health care

team, patient, and family as the terminally ill patient

approaches this phase of care?

2. Distinguish between promotion of comfort and relief of pain in

dying patients and between assisted suicide and euthanasia.