Nursing

The son is not alone in his resistance to the use of narcotic analgesics to manage terminal pain. Patients, family members, and even some health professionals continue to overestimate the harm of using narcotics to manage pain, and under-appreciate their benefits when used appropriately. Of course, it is possible to manage pain without narcotics, but if optimal pain management involves them, understanding the son's reasons for refusal becomes critical.

Engage the son in a respectful discussion about the meaning of pain, its management, and the goals of treatment. In a nonthreatening way, begin the conversation with an attempt at establishing common moral ground. For example, is effectively managing the patient's pain a shared goal? From a nursing perspective, managing pain is almost always a priority. In fact, if pain management must be sacrificed to deliver a specific treatment (e.g., dialysis), it's done reluctantly and with much justification. Other goals could take priority with the son. Religious or cultural beliefs could influence the way the son views pain, the use of medication—particularly narcotics—or all of the above.

Another reason behind the son's refusal might be fears about addiction or misconceptions about narcotics. There is no rational reason to be concerned about addiction in a dying patient. Many clinicians exaggerate the risk of addiction and needlessly deprive patients of narcotic analgesics because of confusion surrounding physical and psychological dependency. Physical dependency occurs after two or three weeks of therapy. Patients rarely become addicted to narcotics used for terminal pain. Those who are not terminal do develop physical dependency, but withdrawal can easily be managed by tapering the dose. Explaining the real risks of narcotics may help ease these concerns. Highlighting the benefits of narcotics for the patient, such as decreasing stress and helping the patient to rest and be able to focus on other things, may go a long way in getting the son to approve a plan to manage the mother's pain.

AMY HADDAD, RN, PhD, a member of the RN editorial board and a widely recognized ethicist, is a professor at the Center for Health Policy and Ethics at Creighton University in Omaha. She is the co-author of Ethical Dilemmas in Perioperative Nursing, Ethical and Legal Issues in Home Health Care, and The Arduous Touch: Voices of Women in Health Care.