Hastening death due to administration of sedatives and opioids after withdrawal of life-sustaining measures: even in the absence of discomfort?

Abstract

In a previous issue of the Journal, the Belgian Society of Intensive care Medicine publishes a statement concerning “end-of-life” care in the intensive care [1]. They describe three principles. First, suffering should be avoided at all times. In addition they add an important statement to this first principle: A treatment considered to be without any meaningful perspective by the intensive care team will no longer bring benefit to the patient and might in addition even cause harm to the patient. Second, with the availability of modern organ support, most deaths in the intensive care unit (ICU) are preceded by a withhold/withdraw decision. And third, relatives should be informed of prognosis and end-of-life decisions at all times. We fully agree with these three generally well-accepted principles. Furthermore they propose 10 general complementary principles that they believe should be adopted. Notably, the authors see no clear ethical distinction between withholding/withdrawing supportive therapy of vital systems and increasing the dose of sedatives and/or opioids in patients in whom further treatment is no longer considered beneficial (complementary principle 2). They also state that “shortening of the dying process with use of medication, such as sedatives and opioids may sometimes be appropriate, even in the absence of discomfort” (complementary principle 6) arguing that actions like these can actually improve the quality of dying and also can help relatives accompany their dying relative through the dying process (complementary principle 6). These actions should be regarded as not intended to end the life of the patient, but as a humane act to support the patient at the end of his/her life (complementary principle 9). The proposed principles apply to pediatric and adult patients (complementary principle 10) (italics from us). Although the intention of these principles may be morally right— supporting dying patients and their loved ones and limiting and shortening suffering of a dying process, there is nevertheless a clear ethical dilemma in this. Is there a moral distinction between allowing a patient to die after withdrawal of life-sustaining measures and the deliberate termination of life? Is there a difference between allowing a patient to die following withdrawal of a life-support system on the one hand and shortening the dying process by increasing analogsedation in a comfortable dying patient on life-support on the other hand? Does it make a difference when the doctor does not have the intention to kill the patient in this process?