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 Table of Contents  
Year : 2019  |  Volume : 1  |  Issue : 2  |  Page : 45-47

Ethics and End-of-Life Care

Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands

Date of Submission12-Sep-2018
Date of Acceptance05-Jun-2019
Date of Web Publication27-Sep-2019

Correspondence Address:
Prof. Jozef Kesecioglu
Department of Intensive Care Medicine, University Medical Center Utrecht, F 06.149, PO Box 85500, 3508 GA, Utrecht
The Netherlands
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jtccm.jtccm_15_18

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How to cite this article:
Kesecioglu J. Ethics and End-of-Life Care. J Transl Crit Care Med 2019;1:45-7

How to cite this URL:
Kesecioglu J. Ethics and End-of-Life Care. J Transl Crit Care Med [serial online] 2019 [cited 2023 Mar 31];1:45-7. Available from: http://www.tccmjournal.com/text.asp?2019/1/2/45/268086

The concept of keeping critically ill patients together in one place was created in the forties and early fifties of the 20th century, due to several catastrophes such as the polio epidemic in Copenhagen in 1952.[1] This has eventually led to the installation of intensive care units (ICUs).[2],[3] During the early days of intensive care medicine, the main intention was to correct and normalize secondary pathophysiological complications resulting from the primary disease and facilitating management of the disease.

During the last half-century, intensive care medicine has gone through a huge evolution. Due to the scientific, organizational, and technological developments, the patients' survival and length of stay in the ICUs have significantly increased. This increase in length of stay has also contributed to a change in the pathophysiology of the sickness of the intensive care population. Respiratory care of the past has slowly developed into the care and treatment of the multiple organs that are critically ill. It is increasingly common to treat patients with situations that are no longer irreversible. On the other hand, modern technology enables the support or substitution of most of the nonfunctioning organs, thus keeping patients alive, sometimes without hope of a cure. While the patients died in the past, today we are often faced with the situation of letting them die.[4] End-of-life decisions have become a part of daily work of an intensivist. However, the existing terminology on the application of end-of-life care in the literature is complex and needs further attention.

  Definitions Top

A brief summary of the most common terms is summarized below:

  • Withholding of therapy: Refraining from starting life-support measures
  • Withdrawing of therapy: Stopping life-support measures
  • Palliative care: To ensure that the natural process of dying is as comfortable as possible, while treating unbearable pain, anxiety, and/or dyspnea
  • Euthanasia: To put an end to the life of a person in response to a patient request to die because of unbearable suffering
  • Physician-assisted suicide: To prescribe drugs in response to a patient request, with the explicit intention of allowing the person to put an end to his or her life. In this case, the physician has an active participation in advising, prescribing, or providing the means or information enabling a person to intentionally end his or her life by ingesting a lethal dose of medication. However, the physician does not directly administer the medication.

Additional terminology used in some medical literature may complicate the understanding of end-of-life decisions. They are misleading and not helpful. One example is the use of voluntary euthanasia which is defined above as euthanasia.

This is followed by nonvoluntary euthanasia which is performed when the consent of the patient is not available. This is mostly impossible in countries where euthanasia is legal because it only occurs with the request of the patient capable of giving consent. The users of this terminology refer to a special situation in children under age 1 which is illegal worldwide but decriminalized under certain specific circumstances in the Netherlands under the Groningen Protocol.[5] In this case, the final decision about active ending of life of the infants is not a decision of physicians. Only the parents may initiate the procedure, with physicians and social workers agreeing to it. Therefore, using another term as nonvoluntary euthanasia is not logical but confusing.

Involuntary euthanasia is done against the will of the patient and it is simply murder.

Other terms used are passive and active euthanasia. Passive euthanasia is similar to withdrawing or withholding the life-sustaining treatment. It is rather unspecific and does not give the differentiation as seen between withholding and withdrawing of life support. The same is true for active euthanasia. It is defined as using lethal substances, but it is not clear if the patient has given consent or not.

One last term mentioned often is animal euthanasia. This is most unlikely of all, since animals simply cannot give consent.

The excessive use of complex terms with complex definitions causes confusion. When there is confusion, there is no consensus. The best is to keep it simple and use the terms of withholding, withdrawing, euthanasia, and physician-assisted suicide as appropriate. Withholding and withdrawing life-support measures are commonly used procedures in ICUs of various countries. However, there is no indication for euthanasia in intensive care. In the Netherlands, no cases of euthanasia in patients admitted to intensive care have been published.[4],[6] Similarly, physician-assisted suicide is not used for intensive care patients.

  Palliative Care Top

Although palliative sedation and palliative administration of opioids are considered as normal care, the drugs and the doses used are subject for discussion.

In 2003, a Dutch physician was prosecuted for murder for administering 20 mg morphine and 5 mg midazolam intravenously, to a 77-year-old patient who was admitted with a severe stroke, in order to relieve severe dyspnea and terminal agitation.[6] The patient died soon afterward. The physician spent 9 days in custody.

During the court, expert evidence stated that administering morphine and midazolam in the dying phase is normal palliative care. The court acquitted the physician and rejected the prosecution's claim that the physician intended to accelerate the death of the patient. The public prosecutor appealed, but the appeal court dismissed the charges.

Following this event, the Dutch Medical Association laid down guidelines on the use of sedation in dying patients. Today, in the Netherlands, palliative sedation and palliative administration of opioids are considered as normal care for treating pain, dyspnea, terminal tachypnea, terminal agitation, anxiety, and restlessness. Moreover, it is an ethical obligation to relieve patients and their relatives in the dying phase of the patient.

The guidelines also make clear that the patients die due to the underlying terminal organ failure and not due to the sedatives and opiates. This brings us to the doctrine of double effect (DDE).[7]

The DDE implies that when a morally legitimate and good act such as preventing pain or anxiety results in unintentional and bad side effects, it is acceptable because the good outcome outweighs the bad effect. The bad effect is not intended, even though it could have been foreseen that it could happen. The act is considered to be justifiable because the intent of the action is to prevent suffering and not to shorten life. In other words, discontinuation of a treatment or giving morphinomimetic agents and anxiolytics can shorten the life of the patient. However, the intention of the treatment is not to shorten life but to ensure that the natural process of dying is as comfortable as possible, while also treating unbearable pain, anxiety, and dyspnea.

Nevertheless, the situation is potentially complex as shown in a study performed by Sprung et al.[8] The purpose of the article was to make the argument and show evidence that there is no clear-cut distinction between treatments administered to relieve pain and suffering when withdrawing life-sustaining treatment, and those intended to shorten the dying process. The results of the study showed that, in some cases, physicians could have been hastening the patient's death by providing what is classified as relief measures. In other patients, physicians supposedly intending shortening the dying process could have been providing drugs that are only capable of relieving pain and suffering. They concluded that the distinction between therapies intended to relieve pain and suffering and those intended to cause death may not be as clear as previously thought.

Hawryluck et al. developed consensus guidelines to guide the administration of analgesics and sedatives to dying ICU patients and to help distinguish palliative care from euthanasia.[9] They stated that the intention of the intensivist administering narcotics/sedatives to palliate dying patients should be assessed by careful documentation in the chart of the patient. The documentation should consist of the patient's medical condition and reasons leading to the initiation of palliative care, the aim being to relieve pain and suffering, and the way in which drugs will be increased and why. According to these guidelines, palliative care should be individualized. The initial dose of narcotics and sedatives in palliation should be determined according to the patient's previous narcotic exposure age, previous alcohol or drug use, and the underlying illness. There should not be a maximum dose for narcotics or sedatives because the goal of palliative care is to provide relief of pain and suffering. The dose of drugs that reach this goal may be different for each patient. Declaring a maximal dose would result in pain and suffering at the end of life in some patients.

This type of clear guidelines is important and needs to be developed according to the needs and laws of different cultures and countries. They will help to develop a standard of care and thereby improve the quality of end-of-life care in the ICU.

  Conclusion Top

The use of confusing terms such as “euthanasia” should be avoided in ICUs. Withdrawing or withholding disproportional life support and palliative care in intensive care patients not competent to give consent has no relation to euthanasia which is in response to a patient request to die.

Palliative sedation and palliative administration of opioids after withdrawal of treatment are common practice, normal care, and an ethical requirement. The intent of the physician and not the dose of the medicine used is the determinant factor.

The terminology we use may be confusing in end-of-life care. Even the most common terms such as “do not resuscitate,” “withholding,” or “withdrawing” treatment may give an impression as if the patient would be abandoned. In fact, what we do is, discontinuing disproportional life-sustaining treatments due to the incurable nature of the disease or when the maximum quality of life to be achieved is poorer than the minimum acceptable quality of life for the patient. Yet, we continue the treatments to provide comfort and treat pain, anxiety, and dyspnea until the patient dies.

  References Top

Wackers GL. Modern anaesthesiological principles for bulbar polio: Manual IPPR in the 1952 polio-epidemic in Copenhagen. Acta Anaesthesiol Scand 1994;38:420-31.  Back to cited text no. 1
Calvin JE, Habet K, Parrillo JE. Critical care in the United States. Who are we and how did we get here? Crit Care Clin 1997;13:363-76.  Back to cited text no. 2
Vincent JL, Thijs L, Cerny V. Critical care in Europe. Crit Care Clin 1997;13:245-54.  Back to cited text no. 3
Belloc Rocasalbas M, Girbes AR. End of life decisions, the Dutch form through Spanish eyes. Med Intensiva 2011;35:102-6.  Back to cited text no. 4
Verhagen AA, Sol JJ, Brouwer OF, Sauer PJ. Deliberate termination of life in newborns in the Netherlands; review of all 22 reported cases between 1997 and 2004. Ned Tijdschr Geneeskd 2005;149:183-8.  Back to cited text no. 5
Kompanje EJ. Care for the dying in intensive care in the Netherlands. Intensive Care Med 2006;32:2067-9.  Back to cited text no. 6
Hahn MP. Review of palliative sedation and its distinction from euthanasia and lethal injection. J Pain Palliat Care Pharmacother 2012;26:30-9.  Back to cited text no. 7
Sprung CL, Ledoux D, Bulow HH, Lippert A, Wennberg E, Baras M, et al. Relieving suffering or intentionally hastening death: Where do you draw the line? Crit Care Med 2008;36:8-13.  Back to cited text no. 8
Hawryluck LA, Harvey WR, Lemieux-Charles L, Singer PA. Consensus guidelines on analgesia and sedation in dying intensive care unit patients. BMC Med Ethics 2002;3:E3.  Back to cited text no. 9


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