Keeping the terminal patient comfortable is the purpose of comfort care

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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  • Nepenthe

    In my experience, it is the opposite. I’ve worked steadily as an RN in a number of Major Medical Centers, and some small hospitals, as well as a few hospices. I’ve never seen a patient who is “care for comfort” given too little pain med. Often, they are dying anyway because the vasopressors ( medicine to keep the blood pressure up) have been discontinued,as has dialysis and possibly the ventilator.
    I have seen many attempts at euthanasia, though. Not by
    the doctors but by the nurse influenced by the family. The family gets tired of waiting. This is contrary to the doctors’ orders. The reason I know, is at shift change, I would inherit a patient that was actively being euthanized, ( completely comatose with no response and no other sign of pain, like HR) and quickly dial down the morphine drip. The patient should be allowed to die in their own time, pain free, but not hastened.

    • http://www.aneurysmsupport.com/ Mike

      I agree Nepenthe, they should be allowed to pass in their own time. It is rather disturbing, though not really surprising, to me that there are nurses, and probably doctors as well, who would do something like this, even at the behest of family. Who are they to assume such a responsibility. Though I am certain there are many who would argue with me and claim that it is a humanitarian act of mercy, I see it as little better than murder.

  • http://minochahealth.typepad.com doc

    I agree with comments above. I do however believe that this is not the norm and that only a small fraction of health providers tend to “exepedite” the process at the wishes/wink from the family.

  • mic

    i agree with mike. there is a fine line here….and its been crossed too many times.

  • http://medicalmysteries.wordpress.com May

    This is a very interesting post. I’m not a doctor or a medical student yet, but I couldn’t help wondering about the same thing. What will I do one day when I am faced with this type of situation? Nice post!

  • ninguem

    Has anybody read this book:

    http://www.amazon.com/No-Good-Deed-Medicine-Accusations/dp/006172176X/

    Go to Amazon and look at just a sampling of the stories.

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