TERMINAL ANALGESIA AND SEDATION

    All of the above general principles of pain management apply to patients at end-of-life except that issues of dependence and tolerance have little or no relevance. However, a common occurrence during the last days, hours or minutes of a patient’s life is significant, even extreme emotional and physical discomfort. Although such discomfort is treatable and even preventable, such comfort is frequently not provided. Healthcare workers often fear giving adequate analgesia and sedation due to lack of knowledge of the larger doses of medications that may be required, inappropriate concerns that the patient may become tolerant or “addicted,” and confusion between relief of terminal suffering and euthanasia. Physicians should be aware of the large doses of opiates, or even occasional unconscious sedation, that may be required to provide a comfortable death and of the fact that dying patients never “get addicted.” Discontinuation of mechanical ventilation in a patient who cannot be weaned due to an irreversible condition and does not wish to remain on a ventilator is ethical and appropriate. Such individuals may, however, suffer severe dyspnea prior to death and should be heavily sedated if conscious or if family members are present who may suffer emotional distress from witnessing physical signs of dyspnea.

    The American Medical Association recommends that every practicing physician use large enough doses of analgesics and sedatives to alleviate the suffering of their dying patient, even if that hastens the moment of death. If physicians are inexperienced or uncertain about sedation of the dying, appropriate consultation should be sought. Physicians and nurses frequently experience and express anxiety about the ethics of providing such treatment, typically because of confusion of appropriate relief of symptoms in dying patients with euthanasia.

    A clear distinction between terminal, palliative care and euthanasia is made by applying “the rule of double effect.” The rule of double effect differentiates between the intent and foreseeable result of an action.(1) Allowing nature to take its course is simply not interfering in nature’s will to end life, according to the patient’s values. In other words, it is ethically, morally and legally right to “let die,” but not to “make die”. Although the result is the same in both instances, the intent is totally different, thus, the ‘rule of double effect.(2) To subject a dying person to needless and punishing suffering is contrary to the core values of medicine.  An injection of potassium chloride to end a life, on the other hand, is illegal and immoral, however noble the intentions may be. (3)(4)

^[1] Quill TE, Dresser R, Brock DW. The Rule of Double Effect – A Critique of Its Role in End-of-Life Decision Making. N Engl J Med 1997 337(24):1768-1771.

^[2] Council on Ethical & Judicial Affairs, American Medical Association. Decisions near the end of life. JAMA 1992;276:2229-33.

^[3] Dyer C. Rheumatologist Convicted of Attempted Murder. Br Med J 1992;325:731.

^[4] Basta LL, Doty WD, & Geldart MDD. Medical Treatment of the Cardiac Patient Approaching the End-of-Life. In: Gerstenblith, Gary, Ed. Contemporary Cardiology: Cardiovascular Disease in the Elderly. Humana Press Inc., Totowa, NJ 2005:393.

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