A.P. is a terminally ill 50-yr-old woman with metastatic breast cancer
who is hospitalized with severe bone pain. She moans at rest and
shows severe pain with any movement to reposition her. The present
dose of IV morphine is not controlling her pain. At the team
conference, the nurses discuss the need for more effective pain
control but are concerned that more pain medicine could hasten her
Ethical/Legal Points for Consideration
• Adequate pain relief is an important outcome for all patients,
especially patients who are terminally ill.
• The Code of Ethics for Nurses addresses the responsibility of the
nurse to relieve suffering and have conversations with patients
and families about pain and symptom management.
• The principle of beneficence means that we provide care to benefit
patients. The goal of adequate pain control in the terminally ill to
ease suffering is based on the principle of nonmaleficence
(preventing or reducing harm to the patient). The secondary
effect of hastening the patient’s death is ethically justified and
known as the double ef ect.
• Legally, the standard of care is used to define the nursing acts that
are required for safe and competent nursing practice. When the
actual nursing care falls below the standard of care, it is
considered negligent and unsafe, and the nurse is at risk for
being found incompetent.
• In a court of law, the standard of care in nursing is determined by
nursing experts and evidence-based practices. The increasing use
of technology to access the latest scientific findings is changing
the standard of nursing care to a national, if not global, standard
defined by research findings and nationally recognized expert
testimony. Standards for providing expert nursing care and
counseling at EOL are available.
• In A.P.’s situation the standard of care is that the patient will
have pain relief. Failure of the nurse to act assertively to achieve
pain relief for the patient and failure to effectively use resources
to obtain that pain relief will be considered below the standard of
care and unsafe and incompetent practice.
1. What types of discussions need to occur among the health care
team, patient, and family as the terminally ill patient
approaches this phase of care?
2. Distinguish between promotion of comfort and relief of pain in
dying patients and between assisted suicide and euthanasia.
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