Titration of narcotic meds now a preprinted order
Written policy allays fear of causing death
At Oregon Health Sciences University Medical Center in Portland, there is no longer any misunderstanding about whether a morphine drip may slowly cause a patient to die. Although it’s a fine line, physicians now understand the difference between active physician-assisted suicide and the appropriate relief of a terminally ill patient’s pain and suffering.
In its landmark decision earlier this year, the U.S. Supreme Court admitted this dilemma, stating, "The line between the two may not always be clear, but [determining whether medications hasten or cause death] certainly is not required, even were it possible." The court said that "letting a patient die" is legal.
The Oregon medical center would be the only facility in the state (as a state-operated facility) actually required to honor patient requests for physician-assisted suicide if Measure 16 is approved and upheld by the courts. Measure 16, the Oregon Death with Dignity Act allowing physician-assisted suicide, was passed by voters in November 1994. (For more on the U.S. Supreme Court decision and its implications for institutional policy and practice, see Medical Ethics Advisor, August 1997, pp. 85-88.)
The medical center uses a standard preprinted physician’s order for the "open titration of narcotics for the dying patient." (See preprinted order, inserted in this issue.)
"When a patient’s symptoms warrant the use of these medications, we can continue to manage pain, regulate vital signs, and titrate for control of the symptoms without the worry of causing death," says Paul Bascom, MD, medical director of the hospital’s comfort care team.
But despite the fact that the institution has sanctioned titration as an accepted medical practice for the comfort care of terminally ill patients, Bascom and others involved in this change in the culture of dying say the importance of ongoing education for health care professionals regarding pain management and other issues of palliative care should not be underestimated.
"A form cannot solve the crisis in terminal care," Bascom warns. "It is important because it gives physicians the permission to do what is best for the patient. But the use of this or any other form is not as critical as the basic ethical climate and principles you are trying to instill among health care team members." (See the medical center’s policy on open titration, p. 104.)
"So much more education needs to be done," says Lori Andreas, RN, MSN, a pain control specialist who serves as a critical nurse specialist on the Oregon medical center’s comfort care team and nurse manager on the oncology unit.
The pendulum is swinging in the direction of better care for the dying, Andreas says. "Our physicians have increased awareness about pain management, but we still need to increase their passion for alleviating pain and suffering."
As a member of the hospital’s practice council, one of the main stakeholders in any clinical policy change, Andreas nurtured the open titration policy through its original draft and through a one year review and approval process by several hospital committees.
A major lesson learned, she shares, is that you don’t need to get everyone’s opinion and approval. "Get a representative group to go through the initial review process," Andreas recommends.
Also, recognize that different groups of physicians will have differing viewpoints. "Surgeons think differently about this policy than oncologists," Andreas says. "They don’t necessarily oppose it, but their views are not the same because they see the treatment they have to offer as most important."
Working together
When the original draft of the open titration policy was circulated among administrative, nursing, and physician groups, Andreas and Bascom also included educational materials on the ethical theory of double effect as well as legal and medical facts about narcotic administration.
The titration order has no requirement of a maximum dosage, Andreas explains. The key factor in determining the appropriate amount of medication is working with the other members of the care team and the family to set goals of treatment and care, she says.
"When it is determined that the patient is indeed dying, it is important that everyone involved be working toward common goals," she says.
Sometimes, even with the new titration policy, nursing staff will feel pressured by family members to increase pain medications.
"One nurse recently came to our team and said the family wanted to up the mother’s pain medication because she was blinking her eyes. With a little education, the family learns that this action does not mean the patient is in pain. It is part of the dying process," says Andreas.
This is a simple but common example of what it means to help the family make end-of-life decisions, she reiterates.
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