Pain Management for the Elderly and Terminally Ill

Abstract & Commentary

Source: Carver AC, et al. End-of-life care: A survey of US neurologists’ attitudes, behavior, and knowledge. Neurology 1999;53:284-293.

Medical science and care since the end of World War II has brought out an astounding number of medications, specific disease therapies, and novel surgical procedures. The work of Carver and colleagues has resulted in extending the mature and, especially elderly, lives of a large percentage of the U.S. population. Antihypertensives, cardiac surgery, anticancer therapy, renal transplants, and novel pharmacologic drugs have all contributed to the success. On the down- side, however, one finds a substantial increase in the incidence of irreversibly demented patients in nursing homes, patients suffering excruciating pain as they encounter the painful dwindling benefits of chemotherapy, and the terror that affects persons with late amyotrophic lateral sclerosis (ALS) as the disease deprives them of their ability to breathe, speak, or even gesture.

Against this background, the American Academy of Neurology surveyed the opinions of 600 randomly chosen neurologists, 250 neuro-oncologists, and 149 ALS specialists, not all neurologists. Two specific questions were addressed: 1) Would you participate in doctor-assisted suicide (e.g., to give a fatal dose of morphine)?; or 2) Would you assist in voluntary euthanasia (e.g., by intentionally giving the patient a fatal dose of drugs both of which would be at the patients’ request)? Although 95% of the respondents reported that advanced directives would ease the decision process of withdrawing life-sustaining treatment when needed, only about 30% of their patients had provided advanced directives. Most important was that only 18% of doctors endorsed providing advanced medication sufficient to produce suicide at a subsequent date. Ninety-four percent of the respondents indicated that they would provide palliative care with morphine, but only 21-25% with consent would give a morphine dose large enough to kill even the most agonized patient. However, if physician-assisted suicide with firm constraints became legal, 70-75% of reporters indicated that chronic, severe, intolerable pain would be an appropriate reason for responding to pleas for physician-assisted suicide. Under present laws, about 13% of neurologists would participate in physician-assisted suicide and only 4% would prescribe in advance sufficient drugs for the patient to commit suicide. What is really troublesome, however, is that less than 50% of respondents indicate that even when legally protected they would not participate in either physician-assisted suicide or the patients’ voluntary euthanasia. (See Brief Alert, "Pain: Mechanisms and Treatment," p. 7.)

Commentary

Figures similar to the above are expressed by many other groups of doctors in this country, irrespective of their disciplines. Nevertheless, distinguished physicians and surgeons in the past have quietly recognized that patients suffering non-remediable, agonizing, protracted and incurable pain must be relieved even if fatal doses of analgesics were the only solution. It is true that recent Supreme Court decisions have an ambiguity that merely indicates that assisted suicide is not an individual’s constitutional right (Burt RA. N Engl J Med 1997;337:1234-1239). Nevertheless, in a subtle but unquestionable way, the court accepts terminal patient-demanded euthanasia delivered by lethal levels of sedation. This obviously opens a wide door of potential activity in which palliative management no longer relieves the patient’s suffering.

The puzzle is that in many other medical disciplines, less than 50% of the members would provide euthanasia even if the law directly supported the act. The reaction must be more than just doubt that the patient might recover. Why have more than 50% of doctors resisted the ultimate treatment for irreversible, increasing, prostrating pain? Is it a religious principle? If so, that conflicts with the patient’s constitutional rights. Is it because they fear prosecution for the action? Ethical committees can help to solve this quandary. I strongly favor palliative treatments for pain that can restore a patient’s well-being for as long as possible. But when palliation is totally against the wall of improving, how will this 50% serve their patients? —fp