Double Double Toil and Trouble

By Ellen T. Thatcher, GNP-C, CHPN

Ellen T. Thatcher, GNP-C, CHPN, is a certified geriatric, hospice, and palliative care nurse practitioner and community hospice care coordinator at the Bay Pines VA Healthcare System in Bay Pines, Florida.

The principle of double effect (PDE) has been around for centuries. It originated in Roman Catholic theology, as in aborting a fetus to save the mother’s life. PDE posits that, if the intention is not to do harm or kill, then it is morally ethical and allowable. This theory is now often used in hospice bioethics. As a novice, I used this principle often as a tool to explain that even though we know that narcotics and other pain medications may hasten death, the intention is to relieve pain and suffering. (See my article in the May 2012 issue: Try Abiding Instead of Hiding: An Approach to End-of-Life Care.) Thus, ethically PDE is the right thing to do.

Well, as I gained more hospice knowledge and experience, I realized that PDE caused problems and raised eyebrows. Research on the subject and breakout sessions in hospice conferences have enlightened me. First of all, studies support that narcotics do not hasten death. And once pain is relieved, the person has more power to “let go” and move on to the next realm, whatever that may be to them. Second, the theory of PDE can validate the fears and myths about narcotic pain management. Families and teams become leery and may withhold narcotics and medications for suffering, leaving symptoms poorly managed, and the dying may suffer unnecessarily, impeding their ability to “let go” and die in peace.  Please share your thoughts and feelings on this controversial topic.