Heart failure

Unfounded legal fears deter use of opioids in end of life care

Clinicians should not be deterred from prescribing opioids in end of life care due to misperceived fears of legal and professional sanctions, palliative care specialists say.

Writing in the MJA they note that warning letters have recently been sent out to the nation’s top 20% opioid prescribing doctors from the Department of Health, advising them that their clinical practice is being scrutinised.

Those letters, on top of “the current tension between standard end-of-life care and voluntary assisted suicide” and the high-profile public debate over opioid overuse had created a “perfect storm” that was deterring clinicians from prescribing opioids in appropriate amounts in palliative care, they wrote.

“An unintended but predictable consequence appears to have arisen: anecdotal reports of some practitioners choosing to abandon end-of- life care altogether rather than risk professional ruin should they persist in the use of any opioid therapy … The consequences for pain care could be serious,” they warned.

Doctors could be reassured, they said, that there had been only two legal cases with adverse findings against healthcare practitioners for opioid overuse hastening death and none of these led to criminal proceedings.

“This indicates that regulatory bodies are not seeking to blame practitioners when death occurs in the presence of opioid administration, and that the intention to alleviate suffering and adhere to good clinical practice is respected,” they wrote.

They therefore urged clinicians to continue to use opioids in doses that are
 clinically indicated to achieve pain relief or reduction of chronic breathlessness

“In some cases, the dose may appear very large, but as long as titration to that dose occurs steadily, the risk of adverse events such as respiratory depression being induced by the treatment is negligible. Clinical practice that seeks to alleviate suffering will be respected by the law and not punished,” they concluded.

Lead author Professor Geoff Mitchell, a palliative care specialist at the University of Queensland told the limbic that end-of-life care for some patients was already sub-optimal because doctors were wary of prescribing high dose opioids even when they were clinically warranted.

“Doctors are cautious people – sometimes too cautious,” he said.

While some clinicians may have a “bring it on” attitude to alleviating suffering with opioids, others were not as confident and would say “I don’t want to risk it”, he said.

Historically, the pendulum of medical opinion on opioids had swung from their use being initiated only in a pain clinic by a specialist, to the current situation where opioids can be provided regularly with a single review after 12 months. They were, he said, “a very powerful arsenal if you get it right”.

“But now we are now heading back the other way. There’s a small fringe who do the wrong thing and it gives everyone a bad name and gives the drugs a bad name,” said Professor Mitchell.

He dismissed the likelihood of criminal investigations as is happening in the UK in the Gosport Hospital case of Dr Jane Barton, a GP accused of hundreds of deaths of elderly patients as a result of opioid overprescribing. Professor Mitchell likened it to the risk taken when crossing the street of being hit by a bus. “Is it likely to happen? No”.

Similarly the public perception of an ‘opioid overuse crisis’ had to be seen in context of an ageing population.

“We’ve got more people living in Australia in more pain with more opioid use – is that an epidemic or is that demographics at work?” he asked.

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