Correspondence
Barbiturates in the Care of the Terminally Ill
N Engl J Med 1993; 328:1350-1351May 6, 1993
- Article
To the Editor:
Truog et al. (Dec. 3 issue)1 think that physicians should be willing to accept the risk of using barbiturate-induced general anesthesia to relieve suffering in certain terminally ill patients. This and similar well-meaning recommendations2,3 could be misconstrued by the public as representing a change in the medical profession's traditional commitment to life. That would be unfortunate. Evidence of erosion in the value society places on human life is ubiquitous, and our profession should be speaking out more loudly about that erosion rather than appearing to add to it.
In terminal but conscious states there is no medical symptom or sign known to me that indicates the exact moment at which one's own life or that of another ceases to have meaning. Deathwatches are usually grim, but periods of verbal and nonverbal communication during them can be extraordinarily meaningful.
I come down on the side of those who hold that life with dignity at any stage is better than death with dignity and that caretakers, particularly physicians, should relieve suffering in other ways than by expeditiously dispatching the sufferer4.
4 ReferencesJohn G. Sholl, M.D.
4 Landing Way, Biddeford, ME 040051
Truog RD ,Berde CB ,Mitchell C ,Grier HE . Barbiturates in the care of the terminally ill. N Engl J Med 1992;327:1678-1682
Full Text | Web of Science | Medline2
Quill TE ,Cassel CK ,Meier DE . Care of the hopelessly ill -- proposed clinical criteria for physician-assisted suicide. N Engl J Med 1992;327:1380-1384
Full Text | Web of Science | Medline3
Brody H . Assisted death -- a compassionate response to a medical failure. N Engl J Med 1992;327:1384-1388
Full Text | Web of Science | Medline4
Richman J . Sanctioned assisting suicide: impact on family relations. Issues Law Med 1987;3:53-63
Medline
To the Editor:
Truog et al. openly acknowledge instances in which severe pain and other types of suffering occurred despite unrestrained efforts by experts in pain relief. In such circumstances, the possibility of using infusions of barbiturates to sedate such patients, even to the point of unconsciousness, is presented.
The authors suggest that in such cases death is “unintended although foreseen,” and they rightly emphasize their primary motivation to relieve intolerable suffering when other measures have failed. Although such hazy ethical distinctions may allow us to maintain the illusion that we are not intending or assisting death, we must be certain that the methods derived from these principles ultimately serve the best interests of our patients, not simply the self-interest of our profession.
In this case, the option of sedation with barbiturates allows a potential escape for some patients who do not find adequate relief with current palliative methods, while maintaining the veneer of a prohibition against directly assisting death. As our profession and society try to work through the thorny issues of physician-assisted suicide and voluntary euthanasia,1 our dying patients need all such options we can provide.
1 ReferencesTimothy E. Quill, M.D.
University of Rochester School of Medicine, Rochester, NY 146071
Quill TE ,Cassel CK ,Meier DE . Care of the hopelessly ill -- proposed clinical criteria for physician-assisted suicide. N Engl J Med 1992;327:1380-1384
Full Text | Web of Science | Medline
To the Editor:
We disagree with the approaches proposed by Truog et al. and suggest that different management is possible. . . . The physician's role is not to assist suicide. Our primary goal is to relieve suffering. Practices and policy must be consistent with that goal. The identification of criteria for the use of barbiturates that respect the prohibition against killing is not analogous to the situation with opioids. Opioids have a proved record1 as safe and effective analgesics. They should not be used to sedate the minority of terminally ill patients in whom sedation is indicated. Chlorpromazine2 and midazolam3 are effective sedatives in this setting. Sedating terminally ill patients to relieve distress is appropriate, but sedating them because they are becoming an inconvenience through the inappropriate use of medical technology is not. With appropriate decision making and the provision of services throughout the illness by a skilled palliative care team,4 this problem can be avoided.
4 ReferencesSinead Donnelly, M.D.
Kristine Nelson, M.D.
T. Declan Walsh, M.Sc.
Cleveland Clinic Foundation, Cleveland, OH 441951
Walsh TD . Opiates and respiratory function in advanced cancer. Recent Results Cancer Res 1984;89:115-117
Medline2
Walsh TD ,West TS . Controlling symptoms in advanced cancer. BMJ 1988;296:477-481
CrossRef | Web of Science | Medline3
McNamara P ,Minton M ,Twycross RG . Use of midazolam in palliative care. Palliat Med 1991;5:244-249
CrossRef4
Walsh TD . Continuing care in a medical center: the Cleveland Clinic Foundation Palliative Care Service. J Pain Symptom Manage 1990;5:273-278
CrossRef | Medline
Author/Editor Response
The authors reply:
To the Editor: In our article we attempted to distinguish between the use of barbiturates for the relief of suffering and their use to cause death directly. The respondents all fail to acknowledge the relevance of this distinction. Although we appreciate Quill's endorsement of our approach, we disagree that we are merely “maintaining the veneer of a prohibition against directly assisting death.” We acknowledge that those who support euthanasia and physician-assisted suicide will not see the relevance of the distinctions we draw. In the morally pluralistic environment of a hospital ward or intensive care unit, however, only approaches that can be justified across a wide spectrum of ethical views are acceptable, and we argue that the administration of barbiturates can be justified accordingly under some circumstances.
Sholl also conflates our views with the views of those who advocate euthanasia and assisted suicide. In addition, he gives credence to the fear of many patients that physicians value the preservation of human life more than they value relief from suffering or respect for the patient's wishes.
We agree with Donnelly and colleagues that “our primary goal is to relieve suffering” and that chlorpromazine, midazolam, and other agents may be used effectively as sedatives to achieve this goal. The ethical issues raised by the use of these sedatives are identical to those involved in the administration of barbiturates; indeed, our paper could just as well have been titled “Sedatives in the Care of the Terminally Ill.” We chose to focus on barbiturates because they are frequently associated with active killing, and we wanted to highlight the contrast between their use as sedatives for the relief of suffering and their use as lethal agents for the purpose of killing. Nevertheless, physicians who use any sedative to treat the terminally ill must struggle with the questions we raise.
Robert D. Truog, M.D.
Charles B. Berde, M.D., Ph.D.
Holcombe E. Grier, M.D.
Children's Hospital, Boston, MA 02115- Citing Articles (1)
Citing Articles
1
L.Caroline Stirling, Anna Kurowska, Adrian Tookman. (1999) The Use of Phenobarbitone in the Management of Agitation and Seizures at the End of Life. Journal of Pain and Symptom Management 17:5, 363-368
CrossRef
