October 18, 2017

Pro-Tip for Your Next Shift: Doing No Harm: Opioids do not hasten death

In the ethics of medical treatments, the "Principle of Double Effect" permits some measure of harm in order to achieve an intended greater good. Many physicians believe that using opioids in comfort-care patients to reduce dyspnea is caveated by double effect, because of the theoretical possibility that it may depress respiratory drive and thus hasten death. There is now an abundance of research that dispels the notion of respiratory deleterious effects. Opioid use titrated to comfortable respiratory rates does not significantly alter PCO2, PO2, or overall survival, but does significantly increase comfort at the end-of-life. Furthermore, opioid-related toxicity first manifests as drowsiness, confusion, and loss of consciousness well before respiratory drive is significantly compromised.

One exception to note: For a patient with imminent airway loss, rapid and large boluses of opioids (and likely adjunct sedatives) are necessary to mitigate suffering. In this instance, the primary intent is to treat unusual and significant dyspnea, and an expected secondary effect from the medications would be loss of consciousness. Distinct from treating mild-moderate dyspnea for comfort, this is considered palliative sedation. These cases fall on the aggressive end of the spectrum of opioid use for comfort, and Double Effect dose operate here.


  • Clemens, K. E. and E. Klaschik (2007). "Symptomatic therapy of dyspnea with strong opioids and its effect on ventilation in palliative care patients." J Pain Symptom Manage 33(4): 473-481.
  • Sykes, N. and A. Thorns (2003). "The use of opioids and sedatives at the end of life." Lancet Oncol 4(5): 312-318.