Hot Topics: End of Life Care

Blog Posts (79)

May 20, 2016

BioethicsTV: Week of May 20 – Assisted suicide, public health crisis management, and making promises

Chicago Med
In its first season finale (episode 18), Dr. Downey arrives in the emergency department in distress—he is bleeding from his liver as a side effect from his cancer treatment.…

May 12, 2016

Euthanasia for Reasons of Mental Health

by Craig Klugman, Ph.D.

An article in the (UK) Daily Mail this week focused on a Dutch woman who chose euthanasia “after doctors decided her post-traumatic stress and other conditions were incurable.” Under Dutch euthanasia laws, a physician can end a patient’s life with a lethal injection for mental suffering.…

April 26, 2016

Legal history ignored by opponents of medically assisted death

by Stuart Chambers, Ph.D.

In a recent article in the National Review, author and lawyer Wesley Smith takes issue with what he describes as an unprincipled attack against Not Dead Yet (NDY), an American disability rights organization.…

April 14, 2016

Review Your Directives this National Healthcare Decisions Day

by Craig Klugman, Ph.D.

April 16 is National Healthcare Decisions Day (NHDD), a day dedicated to advance care planning—having conversations about end of life care and perhaps completing advance directives.…

April 6, 2016

BIOETHICSTV: Chicago Med-BIID, post mortem egg retrieval, scope of practice and forgiveness

by Craig Klugman, Ph.D.

This week on Chicago Med brought 3 new ethical issues as well as the unsatisfying resolution to a story arc.…

February 29, 2016

Unadorned: My Testament

by Steven Miles, MD

Many of you in the Bioethics community know me as a physician-ethicist. Early in my career, in the 1980s, I was prominent in the ethics and practice of end-of-life care.…

February 12, 2016

Pain Relief is an Ethical Issue

When patients lack capacity, physicians look to family and friends to step in and provide consent for treatment on behalf of the patient.  These surrogates, whether they were appointed by the patient as their health care agent or become health care surrogates by default under state law based on their relationship to the patient, have the right to receive information related to the care and treatment of the patient and have the corresponding responsibility to make health care decisions for the patient based on either the patient’s previously expressed wishes or her best interests.  What they don’t have, however, is the right to control and direct every minute aspect of the patient’s care in the hospital.  It would take several blog posts to discuss the conflicts that occur between surrogates and health care providers because of this (such as DNR orders, barriers to discharge, and demands for certain medications, to name a few), but perhaps the most concerning example of surrogate over-reach is the issue of inadequate pain management.

The use of pain medication can be difficult for both patients and providers, especially with the rate of opioid abuse in this country.  Patients and their families are often afraid of the possibility of addiction, while physicians are reticent to prescribe narcotics for fear of misuse.  Whether or not a patient is a “drug-seeker” is a common question that arises when physicians are deciding what to prescribe.  However, in the context of terminal illnesses – particularly at the very end of the illness – the shift in focus from curative to palliative care highlights the need for sufficient pain control in the face of nearly intractable pain.  It is in this context that denial of pain medication, or poor pain management, is most clearly an ethical issue.

I have often heard complaints from health care providers about how surrogates have refused to consent to pain medications, or insist that physicians give lower doses than medically appropriate.  When I ask how the provider responded to such requests, all too often the answer is, “I followed their direction.”  We are so used to turning to surrogates for consent for every treatment and procedure, but is it really within the surrogate’s authority to consent to or refuse pain medication?   Assuming there is no advance directive from the patient opposing adequate pain medication, do surrogates have the right to refuse it?  More importantly, is it ethical for physicians to withhold adequate pain medication at the direction of a surrogate despite obvious signs of pain in the patient?

While respect for autonomy is a bedrock principle in our society, and we would certainly honor the informed refusal of pain medication by a patient with capacity, this respect for autonomy does not mean we necessarily honor the directives of the patient’s surrogate to the same extent as we would the patient herself when it comes to pain control.  Without explicit direction from the patient, certain basic assumptions are made about what the patient would want: namely, relief of pain and suffering.  While questions of withdrawal of life-sustaining treatment or palliative surgery may properly be left to the surrogate, the provision of pain medication is assumed as part of basic care for the patient in accordance with the principle of nonmaleficence.  We have an obligation to do no harm to patients, and to the extent possible, to relieve suffering.  While the side effects of opioids should certainly be considered and discussed with the patient’s family, particularly as it may affect the patient’s awareness or respiration, if other palliative approaches are not sufficient to address the patient’s pain, these side effects should not preclude the use of pain medication.  Interventions aimed at pain relief should be given in the overall best interests of the patient, considering the risks and benefits.  Especially at the end of life, providing comfort to the patient should be of utmost importance, even if the surrogate objects.  When pain relief is an ethical issue, it is not an issue for the surrogate alone to decide.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.


February 10, 2016

Chicago Med Files DNR Under X-File

by Craig Klugman, Ph.D.

This week appears to be advance directive week on television. First, on the rebooted X-Files, Dana Scully finds her mother’s advance directive.…

January 13, 2016

Professional Judgment and Justice: Equal Respect for the Professional Judgment of Critical-Care Physicians

by David Magnus, PhD and Norm Rizk, MD

This issue’s target article by Kirby (2016) raises an incredibly important and challenging set of issues: Whether, when, and how should limits be placed on patient access to intensive medical care?…

December 4, 2015

The Bell Tolls for Death by Neurologic Criteria: Aden Hailu

by Craig Klugman, Ph.D.

A judge in Reno, Nevada this week denied a request by St. Mary’s Regional Hospital to conduct an evidentiary hearing to determine that a patient is dead.…

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Published Articles (8)

AJOB Neuroscience: Volume 7 Issue 1 - Apr 2016

A Closer Look at Health Care Providers' Moral Distress Regarding the Withdrawal of Artificial Nutrition and Hydration Kari Esbensen

American Journal of Bioethics: Volume 15 Issue 8 - Aug 2015

Persistent Problems in Death and Dying David Magnus

American Journal of Bioethics: Volume 15 Issue 8 - Aug 2015

The Texas Advanced Directive Law: Unfinished Business Michael Kapottos & Stuart Youngner

American Journal of Bioethics: Volume 15 Issue 1 - Jan 2015

Ethical Obligations and Clinical Goals in End-of-Life Care: Deriving a Quality-of-Life Construct Based on the Islamic Concept of Accountability Before God (Taklīf) Aasim Padela & Afshan Mohiuddin

American Journal of Bioethics: Volume 14 Issue 8 - Aug 2014

Brain-Dead and Pregnant in Texas Thomas Wm. Mayo

American Journal of Bioethics: Volume 13 Issue 3 - Mar 2013

Withdrawal of Nonfutile Life Support After Attempted Suicide Samuel M. Brown, C. Gregory Elliott & Robert Paine

American Journal of Bioethics: Volume 13 Issue 3 - Mar 2013

Suicide and the Sufficiency of Surrogate Decision Makers Hywote Taye & David Magnus

AJOB Neuroscience: Volume 4 Issue 1 - Feb 2013

Communicating with the Minimally Conscious: Ethical Implications in End-of-Life Care Kathrine Bendtsen

News (382)

May 18, 2016 8:04 am

How Much Time Is Left? Doctors, Loved Ones Often Disagree (US News)

Loved ones acting on behalf of critically ill patients are often more optimistic about outcomes than physicians. But not necessarily because they don’t grasp the gravity of the case, new research suggests.

May 13, 2016 8:41 am


Andrew Levy’s parents knew that the rare and deadly cancer in his blood could not be
beaten, so they began to prepare for the worst. Then something mysterious happened.

April 28, 2016 9:53 am

Taking Sperm From the Dead (The Atlantic)

Post-mortem sperm extraction gives widows the chance to have children with the recently departed.

April 18, 2016 9:47 am

Doctors Unsure About How To Talk With Patients About End-Of-Life Care

Doctors know it’s important to talk with their patients about end-of-life care. But they’re finding it tough to start those conversations. When they do, they’re not sure what to say, according to a national poll released Thursday.

April 15, 2016 9:58 am

Justin Trudeau Seeks to Legalize Assisted Suicide in Canada

The government of Prime Minister Justin Trudeau introduced legislation on Thursday to legalize physician-assisted suicide for Canadians with a “serious and incurable illness,” which has brought them “enduring physical or psychological suffering.”

March 28, 2016 11:46 am

Choosing to die at home does not hasten death for patients with terminal cancer

A large study from Japan found that cancer patients who died at home tended to live longer than those who died in hospitals. Published early online in CANCER, a peer-reviewed journal of the American Cancer Society, the findings suggest that oncologists should not hesitate to refer patients for home-based palliative care simply because less medical treatment may be provided.

February 10, 2016 5:57 pm

Assisted Suicide Study Questions Its Use for Mentally Ill

A new study of doctor-assisted death for people with mental disorders raises questions about the practice, finding that in more than half of approved cases people declined treatment that could have helped, and that many cited loneliness as an important reason for wanting to die.

October 6, 2015 2:14 pm

Physician-Assisted Suicide to Become Legal in California

Governor Jerry Brown signed the “End of Life Option Act” on Monday, granting terminally ill patients in California the right to end their lives with the help of a physician.

October 5, 2015 7:14 pm

California Governor Signs Assisted Suicide Bill Into Law

California on Monday joined the short list of states allowing doctors to prescribe drugs for terminally ill patients to end their lives as Gov. Jerry Brown signed the measure into law, ending months of silence on one of the most emotional issues for the state this year.

September 28, 2015 4:38 pm

U.S. 'right to try' laws may not help dying get unapproved drugs

So-called “right to try” laws, intended to expand dying patients’ access to experimental treatments, may not work as expected – and might strip patients of federal safety protections, some experts say.

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