Cases involving high-dose pain medicines can cause conflicts within the clinical team. Timothy E. Quill, MD, has been involved in many such cases.
Quill was the founding director of the University of Rochester Medical Center Palliative Care Program and a past president of the American Academy of Hospice and Palliative Medicine. Quill recently spoke with Medical Ethics Advisor (MEA) about ethical implications of high-dose pain medications.
(Editor’s Note: This transcript has been lightly edited for length and clarity.)
MEA: What are the considerations for the clinical team if high-dose painkillers are given to a patient?
Quill: There are some principles people should be aware of. If you follow those principles, your risks go way down. One is proportionality — to make sure that the suffering the person is experiencing warrants the dose of the medication that’s being used.
Generally, really high suffering might warrant higher doses than mild suffering. Also, when the suffering is clearly physical, it’s a little bit safer than if it’s primarily psychological.
If you are sedating somebody and giving them big doses purely for anxiety or for depression, there would be more risk. You might think about getting a second opinion from psychiatry, because the wish to die could be a symptom of those diseases. The more it’s purely physical and palpable to see, the safer the ground in giving higher doses.
The speed at which the dose is going up also is a piece of the puzzle. If you went from one to 10 in one step, it’s more risky than if you tried slower doses that weren’t working before going to higher doses. If suffering is very high, obviously, there’s more pressure to go to higher doses more quickly. Ethically, the worst thing to do is to say, “I won’t do it because I’m afraid of the risk.” Then, the patient ends up dying in tons of pain that could have been relieved. Everybody learns that it’s too scary and dangerous if you give high dosages, and that you have to do it in secret or not do it at all. That’s the wrong thing to learn, and other people will suffer because of that.
MEA: What can clinicians do to prepare for these cases?
Quill: Certainly, for people who work in this zone, you will run into things like this all the time. If you don’t see a lot of patients like this, it’s harder to grasp. For those cases where you find yourself going to very high doses, you want to, at a minimum, talk to someone experienced — and, preferably, get somebody to formally consult on the case.
It’s not simple terrain, either psychologically or medically. Your best protection is great documentation, all honest and true, and getting other people with experience involved and having them weigh in.
MEA: What should clinicians do if they are ethically concerned about administering high-dose pain medications?
Quill: Just sitting on it is not a good thing, because you don’t want to be complicit in something unethical. If they have a trusted colleague who is experienced in this zone, they could speak to that colleague confidentially. It might be somebody in palliative care, medical ethics, or pain management. The clinician can say, “This case is worrying me. Can you talk it through with me on a confidential basis?” You might find you are well within the boundaries of what’s accepted. But it’s really nice to have close friends or people you trust to talk through these difficult cases.
MEA: When do clinicians need ethical guidance?
Quill: If you’re the provider giving the orders, and you are getting uncomfortable with the doses or the process, then you might want to get an ethical or pain consult. Or, you might do both, depending on what resources you have at the place you work.
The pain people are very important; this is their thing. They know how to take the dosage up properly. If you are getting into high doses of one type of drug, possibly you can shift to a different type of drug to get the relief without using high dosages. The more you can get other people with experience to look at the case, the safer ground you are on.
If you feel the dose is out of proportion, and somebody else is the prescribing clinician, and you don’t feel comfortable talking to them directly, ethics is clearly one of the places one might go. That’s what ethics is for. Some ethics programs periodically do case-based in-services. When you get these cases, there are tremendous learning opportunities. If you haven’t managed patients with serious pain problems, particularly at the end of life, and haven’t had to give proportionately big doses of pain medication, then you will feel pretty uncomfortable giving those types of dosages.
If there is a case where that process was needed, it’s a great learning case. If it’s a really hot, sensitive case, though, going immediately to a public in-service might not be the best thing. You might want to first do a formal ethics consult and go through it.
But once you’ve worked through it, and you’re comfortable, then you might want to talk it over and say, “We were really struggling with this case, and maybe we could all learn from this.”
MEA: What are informed consent considerations with high-dosage pain medication?
Quill: If the patient has capacity, and there is risk because you are getting into dosages that may be more risky, you have to have a conversation. The patient should participate in the decision-making process on whether more relief is worth the risk of not being as responsive, or if they’d rather tolerate whatever the symptom is.
If the patient doesn’t have capacity, then you have to have a conversation with the surrogate decision-maker — and, ideally, with other treating clinicians — on how to think about this ethically.
MEA: What if there’s a conflict within the team about whether high-dose pain medications are ethically justified?
Quill: You’ve got to talk to the people who are in conflict — first, individually, probably. Then, you decide whether it’s worthwhile having those people in a meeting together. You have to have some individual conversation about how you are proposing moving forward. Are they OK stepping off the case? Or, is this an individual who just doesn’t feel comfortable because of a previous bad experience with pain medicine or sedation? You have to hear them out and give them the opportunity to disengage.
If they don’t want to be complicit in any way, you can help them find an out that they can live with, and the patient gets the care they need. You have to do what’s best for the patient. You can’t give poor treatment because someone on the team is not OK with it.
Cases involving high-dose pain medicines can cause conflicts within the clinical team. A palliative care expert explains the ethics of these situations and how to find resolutions.
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