HEC Forum

, Volume 28, Issue 2, pp 95–101 | Cite as

Ethical Tensions in the Pain Management of an End-Stage Cancer Patient with Evidence of Opioid Medication Diversion

  • Arvind Venkat
  • David Kim


At the end of life, pain management is commonly a fundamental part of the treatment plan for patients where curative measures are no longer possible. However, the increased recognition of opioid diversion for secondary gain coupled with efforts to treat patients in the home environment towards the end of life creates the potential for ethical dilemmas in the palliative care management of terminal patients in need of continuous pain management. We present the case of an end-stage patient with rectal cancer who required a continuous residential narcotic infusion of fentanyl for pain control due to metastatic disease. His functional status was such that he had poor oral intake and ability to perform other activities of daily living, but was able to live at home with health agency nursing care. The patient presented to this institution with a highly suspect history of having lost his fentanyl infusion in a residential accident and asking for a refill to continue home therapy. The treating physicians had concerns of diversion of the infusion medication by caregivers and were reluctant to continue the therapeutic relationship with the patient. This case exemplifies the tension that can exist between wanting to continue with palliative care management of an end-stage patient and the fear of providers when confronted by evidence of potential diversion of opioid analgesic medications. We elucidate how an ethical framework based on a combination of virtue and narrative/relationship theories with reference to proportionality can guide physicians to a pragmatic resolution of these difficult situations.


End-of-life care Opioid diversion Clinical ethics Virtue theory Narrative/relationship theories Proportionality 


  1. Daut, R. L., & Cleeland, C. S. (1982). The prevalence and severity of pain in cancer. Cancer, 50(9), 1913–1918.CrossRefGoogle Scholar
  2. Ferrell, B. (2005). Ethical perspectives on pain and suffering. Pain Management Nursing, 6(3), 83–90.CrossRefGoogle Scholar
  3. Giordano, J. (2006). Moral agency in pain medicine: Philosophy, practice and virtue. Pain Physician, 9(1), 41–46.Google Scholar
  4. Hermerén, G. (2012). The principle of proportionality: Interpretations and applications. Medicine Health Care and Philosophy, 15(4), 373–382.CrossRefGoogle Scholar
  5. Parala-Metz, A., & Davis, M. (2014). Cancer pain. Center for Continuing Education. Cleveland Clinic Foundation. Retrieved July 29, 2014, from
  6. Silver, J.D., Fuoco, M.A., & Navratil, L. (2014). Local death toll from powerful heroin hits 22. Pittsburgh Post-Gazette. January 28, 2014. Retrieved July 29, 2014 from
  7. van den Beuken-van Everdingen, M. H., de Rijke, J. M., Kessels, A. G., Schouten, H. C., van Kleef, M., & Patijn, J. (2007). Prevalence of pain in patients with cancer: A systematic review of the past 40 years. Annals of Oncology, 18(9), 1437–1449.Google Scholar
  8. Venkat, A., Fromm, C., Isaacs, E., & Ibarra, J. (2013). An ethical framework for the management of pain in the emergency department. Academic Emergency Medicine, 20(7), 716–723.CrossRefGoogle Scholar
  9. Walsh, D. (2000). Pharmacological management of cancer pain. Seminars in Oncology, 27(1), 45–63.Google Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  1. 1.Department of MedicineAllegheny Health NetworkPittsburghUSA
  2. 2.Department of Emergency MedicineAllegheny General HospitalPittsburghUSA

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