The Rule of Double Effect and Its Role in Facilitating Good End-of-Life Palliative Care

Judith Kennedy Schwarz PhD, RN


Journal of Hospice and Palliative Nursing. 2004;6(2) 

In This Article

Palliative Care Clinicians: Questions About the Need for Double Effect

Unlike commentators who are philosophers, clinical experts in pain management and palliative care maintain that providing effective symptom management to dying patients is a recognized professional imperative that needs no further justification. Many of these clinicians also challenge the presumed connection between appropriate use of opiate analgesia and a resulting hastened death.

Susan Fohr[9] conducted an extensive search of medical literature looking for clinical support for the frequently referred-to risk of opiate-related hastening or causing death in the management of EOL pain and suffering. She was unable to locate data supporting the presumption that "appropriate use of opioids hastens death in patients dying from cancer and other chronic diseases."[9(p318)]

There is no debate among clinical specialists in pain management and palliative care that, when used appropriately, clinically significant respiratory depression from opioid use is a rarely occurring side effect. The reasons for this are clear: patients in pain respond differently to opioids than do persons without pain and pain is a powerful antagonist to the respiratory depressant effect of opioids, and as pain increases and the level of opioid necessary for pain relief goes up, so does the tolerance to the respiratory side effects.[10] Palliative care experts also agree that tolerance to the sedating and respiratory depressant effects of opioid use develops relatively quickly when compared with its analgesic effect.[7,22] Timothy Quill[23] is an experienced palliative care physician who notes that the risk of encountering clinically significant respiratory depression is greatest when opioids are first begun; he adds that this "infrequently occurring side effect" can be easily managed with dose adjustment or low doses of an opiate antagonist.[23(p333)] Other palliative care physicians describe

...the myth that opioids, when used for the treatment of pain, are associated with a substantial risk of respiratory depression and death...the clinical impression of those treating pain in the terminally ill with opioids is that the patient's death is related to the progression of the disease, not to the use of opioids. [8(p139)]

Several small studies provide empirical support for the assumption that opioid use in dying patients does not increase the likelihood of a hastened death, and under some circumstances, appropriate opioid use may prolong the life of dying patients.[24,25] These findings lend support for the conclusion by Fohr[9] and others who maintain that proper use of opioid analgesia for end-of-life pain management renders the RDE largely irrelevant to the majority of pain management cases because the actual risk of causing death is remote and clearly unintentional were it to occur as a side effect.[22,23]

Little is currently known about how nurses understand and apply the principle of double effect to their clinical decisions about EOL care. What is known is derived from recently completed descriptive studies in which nurses were interviewed or wrote comments about their EOL practices that included implicit and explicit use of the RDE to facilitate care of dying patients.


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