Dealing with an incurable illness or terminal condition is an inevitable reality of the practice of medicine. Not uncommonly, especially in the intensive care unit, we care for the patient with no chance for recovery and survival. Keeping that patient comfortable and allowing him or her to die with dignity becomes the priority of care.
Occasionally, I hear requests from the family members of the dying patient – “Can you give her a little something to … you know … make her comfortable and let her pass away quickly?”
Keeping the terminal patient comfortable is the purpose of comfort care. Facilitating or hastening death is considered unethical or even illegal. Physician assisted suicide or euthanasia is illegal in most states.
In theory, comfort care is quite different from euthanasia. Keeping the patient comfortable and letting the nature take its course is at the core of palliative care approach. Yet, the line between keeping comfortable and facilitating death is often blurry.
The same medications used to control pain and discomfort, primarily opioid analgesics and sedatives, could be used to “help” the patient to stop breathing. The concept of terminal sedation assumes death as an outcome of the intervention.
There are no standards regarding the amounts of medication that could be given for the purpose of comfort before it could be considered a “lethal dose”. Patients on chronic opioids, like many cancer patients, may develop tolerance to the medication and require very significant doses just to control the pain. In contrast, it might not require a lot to stop the breathing of an 89 year old with bad kidneys.
As one transplant surgeon in California found out, it is possible to get in trouble for trying to keep the patient comfortable before death.
Dr. Hootan Roozrokh was accused of hastening the patient’s death by administering large amounts of Morphine and Ativan. The incident took place in November of 2006. The prosecutors alleged that Dr. Roozrokh was hastening the patient’s death to harvest his organs for donation. Subsequently the doctor was acquitted of all charges. His defense was able to prove to the jury that the medications were administered to keep the patient comfortable.
The patient in the above incident had been on opioid analgesics and likely was tolerant to the effects of those drugs. It was very reasonable to assume that he required seemingly exuberant doses of Morphine just to control his pain and discomfort.
This case indicates that there could be a very thin line between what we consider terminal sedation and euthanasia. The purpose is clearly different – keeping comfortable vs. hastening death. Yet, in clinical practice, it is more of a continuum or spectrum of actions and outcomes. Often, it’s not all that difficult to cross that line.
Ralph Gordon is a critical care physician who blogs at realICU.
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