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Relieving suffering or intentionally hastening death: Where do you draw the line?*

Sprung, Charles L. MD; Ledoux, Didier MD; Bulow, Hans-Henrik MD; Lippert, Anne MD; Wennberg, Elisabet MD, PhD; Baras, Mario PhD; Ricou, Bara MD; Sjokvist, Peter MD; Wallis, Charles MD; Maia, Paulo MD; Thijs, Lambertius G. MD; Duran, Jose Solsona MD the ETHICUS Study Group

doi: 10.1097/01.CCM.0000295304.99946.58
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Objective: End-of-life practices vary worldwide. The objective was to demonstrate that there is no clear-cut distinction between treatments administered to relieve pain and suffering and those intended to shorten the dying process.

Design: Secondary analysis of a prospective, observational study.

Setting: Thirty-seven intensive care units in 17 European countries.

Patients: Consecutive patients dying or with any limitation of therapy.

Interventions: Evaluation of the type of end-of-life category; dates and times of intensive care unit admission, death, or discharge; and decisions to limit therapy, medication, and doses used for active shortening of the dying process and the intent of the doctors prescribing the medication.

Measurements and Main Results: Limitation of life-sustaining therapy occurred in 3,086 (72.6%) of 4,248 patients, and 94 (2.2%) underwent active shortening of the dying process. Medication for active shortening of the dying process included administration of opiates (morphine to 71 patients) or benzodiazepines (diazepam to 54 patients) alone or in combination. The median dosage for morphine was 25.0 mg/hr and for diazepam 20.8 mg/hr. Doses of opiates and benzodiazepines were no higher than mean doses used with withdrawal in previous studies in 20 of 66 patients and were within the ranges of doses used in all but one patient. Doctors considered that medications for active shortening of the dying process definitely led to the patient's death in 72 patients (77%), probably led to the patient's death in 11 (12%), and were unlikely to have led to death in 11 (12%) patients.

Conclusions: There is a gray area in end-of-life care between treatments administered to relieve pain and suffering and those intended to shorten the dying process.

From the Department of Anesthesiology and Critical Care Medicine (CLS), Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Anesthesiology and Intensive Care Medicine (DL), University of Liege, Liege, Belgium; Department of Anesthesiology (HHB), University Hospital of Glostrup, Glostrup, Denmark; Department of Anesthesiology (AL), Herlev University Hospital, Herlev, Denmark; Department of Anesthesia and Intensive Care (EW), Sahlgrenska University Hospital, Gothenburg, Sweden; The Hebrew University–Hadassah School of Public Health (MB), Hadassah Hebrew University Medical Center, Jerusalem; Department of Anesthesiology, Pharmacology and Intensive Care (BR), Geneva University Hospital, Geneva, Switzerland; Department of Anesthesiology (PS), Orebro University Hospital, Orebro and Huddinge University Hospital, Stockholm, Sweden; Department of Anesthesiology (CW), Western General Hospital, Edinburgh, United Kingdom; Department of Intensive Care (PM), Hospital Geral Santo Antonio, Porto, Portugal; Department of Medicine (LGT), VU Hospital, Amsterdam, The Netherlands; and Department of Anesthesiology (JSD), Hospital del Mar, Barcelona, Spain.

†Deceased.

Funded as part of the European Concerted Action project ETHICUS—“End of Life Decision Making and Life Ending Procedures in European Intensive Care Units” funded by the European Commission (contract PL 963733); in part by grant 4226 from the Chief Scientist's Office of the Ministry of Health, Israel; in part by OFES Switzerland (Biomed) 980271; in part by the European Society of Intensive Care Medicine; and in part by the Walter F. and Alice Gorham Foundation. The authors are solely responsible for the publication; it does not represent the opinion of the European Commission, and the commission is not responsible for any use of the published data.

The authors have not disclosed any potential conflicts of interest.

Address requests for reprints to: Charles L. Sprung, MD, General Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, P.O. Box 12000, Jerusalem, Israel 91120. E-mail: sprung@cc.huji.ac.il

© 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins