ETHICS FORUM

Case Outline A 75‐year‐old man has end‐stage prostate cancer with metastases to bone. He has received both external beam and parenteral isotope radiation therapy within the previous year. He now presents with increasing, severe pain, apparently in his spine and right hip, manifest by moaning, writhing, grimacing, and grunting. He is very restless and has very little capacity for verbal communication since suffering a hemispheric stroke within the last 6 months. His daughter has legal power of attorney for healthcare decisions, and he lives with her. The patient has been receiving hospice care at home for the last 3 weeks, and pain behaviors have been treated primarily with acetaminophen and naproxyn. He received an intravenous (IV) infusion of zolendronic acid (bisphosphonate) just prior to his admission to hospice. Oral intake is poor, and he has a diminished gag reflex. There is concern about absorption of oral analgesics and choking/gagging with pills and liquids, so parenteral morphine is recommended by the hospice team, and this is supported by his attending physician, a urological oncologist. The patient's daughter refuses subcutaneous (SQ) or IV morphine to be administered, stating, “Dad is going to be unconscious, may become addicted, may die from the drugs.” How shall the hospice team proceed?