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 Table of Contents  
Year : 2019  |  Volume : 33  |  Issue : 3  |  Page : 172-173

Narcotic prescription for terminally ill patient by proxy: Do we justify?

Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad, Telangana, India

Date of Web Publication5-Dec-2019

Correspondence Address:
Dr. Abhijit S Nair
Department of Anaesthesiology, Basavatarakam Indo-American Cancer Hospital and Research Institute, Hyderabad - 500 034, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijpn.ijpn_59_19

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How to cite this article:
Nair AS, Mantha SS, Kotthapalli KK, Rayani BK. Narcotic prescription for terminally ill patient by proxy: Do we justify?. Indian J Pain 2019;33:172-3

How to cite this URL:
Nair AS, Mantha SS, Kotthapalli KK, Rayani BK. Narcotic prescription for terminally ill patient by proxy: Do we justify?. Indian J Pain [serial online] 2019 [cited 2020 May 24];33:172-3. Available from: http://www.indianjpain.org/text.asp?2019/33/3/172/272384


Potent opioid medications are required to manage cancer pain in patients with advanced malignancy. Once disease becomes progressive and palliative care is planned for the patient, managing pain becomes difficult. In due course of time, patients are on potent opioids such as morphine tablets and fentanyl or buprenorphine transdermal patches.[1] As the disease progresses and the tolerance increases, the requirement of potent medications increases.[2] At this stage, the patient is either bedridden or due to debilitated state not able to visit the palliative care physician or the treating oncologist. It is the family members who attend the clinic as proxy for the patient and collect medications for pain relief and other supportive care medications.

Opioids are controlled substances which cannot be obtained over-the-counter. Hospitals stocking potent opioids such as morphine, fentanyl, and buprenorphine authorize physicians such as anesthesiologist, pain physician, and palliative care physician to prescribe such medications. These physicians are answerable to any life-threatening event or proven opioid abuse due to medications prescribed by them. With this background, the dilemma for the physician is whether to prescribe opioids to a terminally ill patient under his care with proxy, i.e., in patients' absence.

Denying medications is unethical, but prescribing without knowing the detailed clinical situation is also not right.[3] It has been shown in some studies that when opioid agonist therapy (OAT) is delivered using telemedicine, there are higher chances of uninterrupted treatment at 1 year than in-person OAT.[4],[5]

In our unit, we use two ways of ascertaining the patient's general condition: one is a direct approach and another is indirect approach. In direct approach, we make a video call using multimedia apps such as WhatsApp, Skype, or Google Duo.[6] We talk to the patient directly and take relevant history. We issue a prescription or make any dose adjustment of ongoing medications based on the clinical impression made over video call or information provided by the patient directly. In case the patient is very sick or drowsy, we talk to the family member around and enquire regarding medication frequency, dose, etc. If family is concerned and wants further medical attention, we instruct them to transport the patient to our hospital or to any nearby hospital.

Some patients and family members are not very well versed or technologically advanced to have a smartphone integrated with video call-compatible apps. To such a patient's family member, we request to get a certificate from a local practitioner practicing any specialty of medicine or alternative medicine. We give them a printed pro forma [Supplement 1] in which the relevant details about the general condition and gross systemic examination is entered by the attending physician. We also ask the practitioner to sign it and mention his or her contact details. In case there is no proper clarity with the details entered in the form, we call the practitioner and sought clarifications on unclear issues. In both direct and indirect approach, we document details in the patient's outpatient case record.[Additional file 1]

To conclude, terminally ill patients should not be denied opioid medications. However, the medications should be prescribed and issued after ascertaining patients present general condition either directly or indirectly as mentioned above. In either situation, details should be documented to avoid medicolegal hassles.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sim SW, Ho S, Kumar RK. Use of opioids and sedatives at end-of-life. Indian J Palliat Care 2014;20:160-5.  Back to cited text no. 1
[PUBMED]  [Full text]  
Swarm RA, Abernethy AP, Anghelescu DL, Benedetti C, Buga S, Cleeland C, et al. Adult cancer pain. J Natl Compr Canc Netw 2013;11:992-1022.  Back to cited text no. 2
Carvalho AS, Martins Pereira S, Jácomo A, Magalhães S, Araújo J, Hernández-Marrero P, et al. Ethical decision making in pain management: A conceptual framework. J Pain Res 2018;11:967-76.  Back to cited text no. 3
Eibl JK, Gauthier G, Pellegrini D, Daiter J, Varenbut M, Hogenbirk JC, et al. The effectiveness of telemedicine-delivered opioid agonist therapy in a supervised clinical setting. Drug Alcohol Depend 2017;176:133-8.  Back to cited text no. 4
Ho C, Argáez C. Telehealth-Delivered Opioid Agonist Therapy for the Treatment of Adults with Opioid Use Disorder: Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 05, October, 2018. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537877/. [Last accessed on 2019 Sep 06]  Back to cited text no. 5
Thurnheer SE, Gravestock I, Pichierri G, Steurer J, Burgstaller JM. Benefits of mobile apps in pain management: Systematic review. JMIR Mhealth Uhealth 2018;6:e11231.  Back to cited text no. 6


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