Letters to the Editor

Pain Management Is Part of Advance Directives Discussion


Am Fam Physician. 2006 Apr 15;73(8):1331-1332.

to the editor: The authors of “Respecting End-of-Life Treatment Preferences”1 in American Family Physician provide a good synopsis of how family physicians can assist patients in developing their care plans before a terminal illness is diagnosed; however, a discussion of pain management should be included when deciding on advance directives. Patients generally understand the concept of withholding or withdrawing treatment when it is futile, but physicians and patients may not think to include pain relief options when discussing an advance directive because these documents traditionally address removal of treatment, not active treatment.

Palliative sedation, an aggressive intervention that may hasten death, evokes ethical dilemmas that will be difficult to sort through once the patient is suffering intractable pain despite other interventions.2 Educating patients about choices for treatment of pain should be done early, and these should be added to an advanced directive to aid in avoiding confusion about the patient’s wishes once the disease has progressed. Also, providing information early will allow patients to discuss their desires with family members. Treatment of pain may lead to a prolonged unconscious state or may even result in death, and patients have the right to have these possibilities presented to them before they develop pain.

The intent of palliative sedation is to relieve suffering, not to hasten death, and thereby differs from euthanasia and physician-assisted suicide. This is the doctrine of “double effect.”2,3 The U.S. Supreme Court has agreed with this opinion.4 Exploration of the ethics of palliative sedation is beyond the scope of this letter, but the topic provides an example of the difficulties that arise with pain management decisions at the end of life. Admittedly, written documents may sometimes fail, and although specific interventions may not need to be included, an advance directive should provide an expression of the patient’s general preferences.5 Perhaps, if nothing else, the scenario of palliative sedation should lead to a discussion during the preparation of their advance directives of the patient’s desires for pain management.

Family physicians are well suited for addressing the spectrum of issues surrounding end-of-life care and pain because of their unique relationship with entire families. This relationship can enhance communication, which is essential during end-of-life care.5

Pain is not an inevitable experience. Courts in the United States have not overlooked the treatment of pain in dying individuals. In two cases, Estate of Henry James v. Hillhaven Corp., 89 CVS and Bergman v. Wing Chin, M.D. and Eden Medical Center,6 the courts have awarded the plaintiffs large sums because of neglect to relieve suffering and pain at the time of death.4 Physicians should neither neglect treatment of pain nor neglect to discuss pain management options while helping patients prepare an advance directive.


show all references

1. Crane MK, Wittink M, Doukas DJ. Respecting end-of-life treatment preferences. Am Fam Physician. 2005;72:1263–8....

2. Lo B, Rubenfeld G. Palliative sedation in dying patients: we turn to it when everything else hasn’t worked. JAMA. 2005;294:1810–6.

3. Snyder L, Leffler C. Ethics and Human Rights Committee, American College of Physicians Ethics manual: fifth edition. Ann Intern Med. 2005;142:560–82.

4. Rich BA. The process of dying. In: Sanbar SS. Legal medicine. 6th ed. Philadelphia, Pa.: Mosby, 2004:308–14.

5. Tulsky JA. Beyond advance directives: importance of communication skills at the end of life. JAMA. 2005;294:359–65.

6. Estate of Henry James v. Hillhaven Corp, 89 CVS 64 (NC Super Ct 1991); and Bergman v. Wing Chin, MD and Eden Medical Center, No. H205732–1 (Cal App Dept Super Ct 1999).

Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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