“Thou shalt not die in pain”: Treatment decisions at the end of life

Professor in the Faculty of Medicine
Founding Director of the Faculty of Law's Centre for Medicine,
Ethics and Law at McGill University

A recent paper, Consensus Guidelines on Analgesia and Sedation in Dying Intensive Care Unit Patients (L.A Hawryluck, W.R.C. Harvey, L. Lemieux-Charles and P.A. Singer, University of Toronto, March 2002) attracted a great deal of media attention.  In the process, some confusion about the ethics and law of treating the pain and suffering of dying people, in particular, those in intensive care units, was revealed.  So, what are the current bottom-line ethical and legal rules?

Patient-centred decisionmaking…

First, decision making about treatment must be patient-centred — in the past, it was physician-centred.  Requiring the patient's — or the incompetent patient's representative's — informed consent to giving, withholding or withdrawing treatment, ensures patient-centredness. 

At a certain point, terminally ill patients — or their representatives — will decide not to continue treatment that has a goal of prolonging life, and to change to palliative treatment that has a primary goal of treating pain and suffering.  Note: this is a decision to change the nature of the treatment received and not a decision to cease treatment or an informed refusal of treatment.  In the past, it was not uncommon for physicians to say to dying patients, “There is nothing more we can do for you”. That statement would, now, encapsulate the antithesis of good, contemporary palliative medicine. 

“'Thou shalt not die in pain' Treatment decisions at the end of life”, Canadian Disability, Winter 2002, 9-11.