Question:  What is the distinction between the use of morphine and other opioids at the end of life to control symptoms and euthanasia/assisted suicide? 

Case Scenario:  An 83-year-old former industrial worker has been hospitalized because of severe abdominal pain due to metastatic pancreatic cancer with tumor involvement in the liver and lung. Opioid therapy with morphine is recommended for pain relief. 

Main Teaching Points 

1. Several studies have indicated that morphine and other opioids can be safely used in patients with serious illness at the end of life without hastening a dying process.  
2. Many clinicians inaccurately believe that opioids have an unusually or unacceptably high risk of an adverse event that may cause death, particularly when the patient is frail or close to the end of his or her life. In fact, large studies of opioid use at the end of life found no difference in survival with absolute opioid dose or change in opioid dose.   
3. Caution should be used with those who have end-stage pulmonary or cardiac disease or when co-prescribing opioids with benzodiazepines. 
4. In those unusual instances where use of morphine or other opioids risks hastening a dying process, “the principle of double effect” (PDE) could apply and provide ethical justification for its use, especially if the patient was anticipated to have a short prognosis anyway.  “The principle of double effect” is commonly understood as follows: 
   
   a. The action itself is good or at least indifferent (e.g., provide analgesia or dyspnea relief a the end of life). 
   b. The good effect (e.g., pain relief) is intended while the bad effect (hastened death) is not.
   c. The bad effect is not a means of obtaining the bad effect.  In other words, the therapy is not prescribed to mercifully kill the patient, so they are spared future pain.
   d. The good effect outweighs the bad effect in proportionality.  In other words, the value of providing pain or dyspnea relief at the end of life is outweighed by hastening a dying process especially if prognosis is anticipated to be very short regardless (e.g., hours to days).   

• All medical treatments have both intended effects and the risk of unintended, potentially adverse, secondary consequences, including death. Some examples are total parenteral nutrition, chemotherapy, surgery, amiodarone, etc. 

• Assisted suicide and euthanasia are not examples of “double effect.” The intention in offering the treatment in assisted suicide and euthanasia is to end the life of terminally ill person who is suffering. Some ethicists have raised concerns about the proportionality of assisted suicide and euthanasia to relieve suffering.    
• If the intent for using morphine or other opioids in the scenario above is to relieve pain or dyspnea and not to cause death, and accepted dosing guidelines are followed: 
  a. The treatment is considered ethical.
  b. Efforts should be made to mitigate any risk of adverse effect.  For example, the clinician should start at a low dose of a shorter acting opioid and titrate to effectiveness.
  c. The risk of a potentially dangerous adverse secondary effects particularly hastening death appears to be small. 

References 

1. Morita T, et al.  Effects of high dose opioids and sedatives on survival in terminally ill cancer patients.  J Pain Sympt Manage. 2001; 21:282-9.
2. Pawasauskas J, Stevens B, Youssef R, Kelley M. Predictors of naloxone use for respiratory depression and oversedation in hospitalized adults. Am J Health Syst Pharm. 2014 May 1;71(9):746-50.  
3. Wholihan, Dorothy DNP, AGPCNP-BC, ACHPN, FHPN; Olson, Ellen MD. The Doctrine of Double Effect: A Review for the Bedside Nurse Providing End-of-Life Care. Journal of Hospice & Palliative Nursing 2017 19(3):p 205-211.

Conflicts of Interest: None to report.
Version History:  This Fast Fact was originally edited by David E Weissman MD.  2nd Edition published July 2005; 3rd Edition May 2015; 4th edition February 2024 after being revised by Adam Marks MD, MPH.