By Erwin J. D. Kompanje –
Translated from Dutch into English from the NNVE newsletter ‘RELEVANT’. (Vol.30. Number 1.2004):-
It is often suggested that terminal patients die sooner after having received a higher dose of morphine or terminal sedation. Some people even consider terminal sedation a form of euthanasia. During a symposium in October 2003 [Dutch] nursing staff confessed to being afraid to apply morphine plasters as they supposed they could be fatal. What is true and what is untrue? It is high time for some transparency on the subject.
The dying phase of life is understood to be the period that death is near and no more curative treatment is given. This phase can last from some hours to days on end, and mostly affects patients with chronic diseases or old age. The patient, the family and nursing staff can do nothing but wait for the end. During the final phase, physical processes tend to change: breathing falters, blood pressure drops, the patients eats nor drinks, consciousness is irregular. Pain, tightness of the chest and anxiety may increase. The latter factors may make the doctor decide to administer terminal sedation or terminal opiates. There is quite a difference between the two, as explained below.
This treatment is meant to tranquillize the patient who at times can be extremely restless and panicky. In most cases midazolam (Dormicum) is given, often used also as an anaesthetic before an operation. It makes the patient sleepy, he is unaware of the circumstances. Terminal sedation is a standard procedure of palliative care for terminal patients. A recent report on a German nursing home found that 190/o of 548 patients received terminal sedation; in 670/c of these cases the reason for giving the sedation was to generate peace of mind.
The administering of opiates has an altogether different indication. The purpose is to relieve (often unbearable) pain or severe breathing problems. Morphine is a strong painkiller and lessens tightness of the chest. The patient may become somewhat sleepy but it is by no means terminal sedation. Opiates are mostly used for cancer and aids patients. They often get opiates for a longer period.
In the last phase, the dosage may be increased. Both terminal sedation and terminal opiates are exclusively given to patients in their very last phase of life. That is why the term ‘terminal’ is added. In all cases death is near. The possibility of an earlier death because of sedation is nil, provided it is used properly (so no extreme overdose). The sole intention is to ease the pain and agony: in most cases a normal dose is sufficient. The patient dies of an incurable illness or of old age. It is a natural death, legally and ethically a normal medical procedure. Terminal sedation should never be compared to euthanasia, which is solely performed to end life and is irreversible, whereas with sedation a patient can be woken up and made to sleep again.
Erwin J.O. Kompanje is a nurse specializing in Intensive Care. He studied Philosophy at Erasmus University Rotterdam (EUR), where he got his PhD on “Giving and taking. Critical observations on the practice of postmortal organ donation”. He is staff member and researcher at the EUR department of neurosurgery, specializing in ethical issues.