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

How Nurses Apply the RDE to End-of-Life Decision Making

When experienced hospice or palliative care nurses speak about titrating morphine to manage dying patients' symptoms of pain or suffering, most readily acknowledge the possibility of secondarily hastening death. Several oncology nurses wrote about instances of opiate-related hastened death on questionnaires they completed about their EOL nursing practices. "I do not know of any nursing colleagues who have not increased a morphine drip to increase comfort, and most likely hastened death."[27(p69)] In another study, a nurse wrote, "Although I have never intentionally given a lethal injection, on numerous occasions the appropriate dose given was enough to hasten the patient's death."[28(p453)] Yet clinicians not trained in palliative care have well-documented fears about causing opiate-related instances of hastening, and these fears are thought to be a significant factor in the widespread undertreatment of dying patients' pain. Solomon and colleagues[14] reported that as many as one-third of surveyed medical and surgical residents agreed with 44% of 759 institutionally based nurses that fear of hastening death was the reason clinicians gave inadequate amounts of pain medication.

Nurses who are both knowledgeable and experienced in providing care for dying patients report feeling no moral conflictions about the possibility of secondarily hastening death when administering opiates. An experienced critical care nurse in a study by Schwarz[13] implicitly applied the RDE to the clinical use of opiates in the following description:

It's a wonderful drug for relieving pain, relaxing people, and helping with pulmonary edema...if a hastened death occurs secondarily as a result of giving opiates for pain—that's no problem. Pain should not be an issue—it should be managed regardless of the secondary effects. (p136)

However, another experienced nurse participant in that same study illustrated several of the difficulties that can occur when nurses attempt to use the RDE as a guide to EOL care decisions. She offered the following description as an example of how she understands and actually applies the RDE in her practice.

If I give this person 20 mg of morphine so that they're basically not experiencing the pain—without the 20 mg of morphine they may last 5 hours, and with the 20 mg of morphine they may last 2 hours. So it [the morphine] may indeed hasten the [dying] effect, but the idea is—Do you want 5 hours of suffering, or do you want 2 hours of relative comfort? [13(p142)]

It would be difficult to identify this nurse's intent in the description she provides. As previously indicated, in order to appropriately appeal to the principle of double effect, the agent must intend only the good and not the bad effect, and the bad effect—which in this case seems to be a hastened death—must not be the means used to bring about the good effect. The above description illustrates how easily the line that is supposed to distinguish foreseen but unintended effects from those that are intended may be crossed.

In another study, an oncology nurse wrote that although she would not intentionally give a lethal drug (eg, KCl) to a patient, she acknowledged her difficulty drawing a line that separated comfort care and effective pain management that might hasten dying from intentionally causing death. She wrote, "There is a very fine line between [providing] comfort in the patient's last days and actually giving drugs that will absolutely cause death."[27(p69)] In a study by Volker,[15] an experienced oncology nurse described feelings of uncertainty when a patient died immediately after she administered a bolus dose of morphine:

I felt guilty. The question was, of course, did that dose of morphine cause further respiratory compromise and hasten her death? Intellectually I knew better—that it [her death] would probably have happened anyway that day. I kept trying to reassure myself that I was an experienced professional with expertise in caring for patients in pain...surely this had happened to every physician and nurse at least once. Maybe I had overstepped my bounds? Maybe I was treating the family member (and myself?) instead of the patient? [15(p45)]

As a dying patient's death becomes increasingly imminent, even experienced palliative care nurses may find it difficult to know whether their palliative interventions are aimed exclusively at relief of suffering or whether a hastened death is also an "acceptable" outcome. In a study by Tarzian,[29] a home hospice nurse observed that:

As you get close to death, if you're going to die of respiratory arrest, is it the respiratory arrest because your lungs finally gave out or is it the respiratory arrest because you had a little too much morphine? You know, it almost doesn't matter at that point. [29(p141)]

One last description of how some hospice and palliative care nurses use the RDE further illustrates the clinical complexity of appealing to this rule as a guide to practice. In Schwarz's[13] study of the experience of nurses who were asked by patients for help in dying, one participant described how several of her hospice nurse colleagues avoided the work of moral reflection that was required to justifiably apply the RDE to EOL decision making. She said that they resisted exploring their own intentions and were reluctant to examine what they truly wanted to achieve by their EOL interventions. Rather than examining whether their intent was to end pain and suffering or end the patient's life, some nurses short-circuited the process of moral reflection and hid behind the principle of double effect. "We're afraid to say that we facilitate death, but we do. We hide behind the principle of double effect. We say we're medicating for symptoms, but in our hearts we know."[13(p245)] This hospice nurse was particularly candid in describing occasions when she had personally "manipulated double effect a little."

When I'm medicating someone, if they're truly at the end of life and they just want it over...I have found myself saying, 'Oh yes, I'm increasing that dose because of respiratory distress' or 'because of the pain.' But truly, in my heart I know, I really want that suffering over for that patient, because I think that their journey has been long and hard, and enough is enough. [13(p144)]

When she discussed these experiences with her hospice nurse colleagues she described those occasions when she believed she might have hastened the dying process as "a form of euthanasia." Her colleagues strongly disagreed with her assessment, saying, "Oh no! That's the principle of double effect, and your intent was to manage that symptom, not end that patient's life." She responded, "You know, I think we say that to make ourselves feel it's okay."[13(p144)]

How should we understand these statements about the clinical application of the RDE? Was this nurse's description of her experience of hiding behind double effect and occasionally intending to hasten death unique within the culture of hospice and palliative care nursing? Or was the unique factor her candid acknowledgement of occasionally intending to hasten death while hiding behind the RDE? To effectively answer that question will require further research that focuses on nurses' experiences of EOL decision making.


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