A final service
BMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7474.1079 (Published 04 November 2004) Cite this as: BMJ 2004;329:1079All rapid responses
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'During September Freud's condition worsened progressively. Putrid
secondary infections ate a hole through his cheek - the smell drove away
his beloved chow, Lun. Even though exhausted, Freud refused sedation
until the last few days. On september 21 he reminded Schur of their pact,
saying "Now it's nothing but torture and makes no sense any more." At
Freud's request Schur discussed the tacit decision with Anna. She
eventually agreed with Schur, that there was no point in prolonging dying.
Schur gave Freud a morphine injection, twice repeatedly the following day.
At 3 a.m. on September 23 Freud died in a coma.'
The Diary of Sigmund Freud 1929 - 1939 Hogarth Press, London 1992
Competing interests:
None declared
Competing interests: No competing interests
I have read the article " A final service" in the BMJ of 6th
November. Dr. Naomi Bronzite describes the "terminal sedation" of a
patient dying of a brain tumour.
When my husband died of a brain tumour in St. John's Hospice four
years ago, peacefully and with dignity, I and his family knew that his
doctor was not trying to kill him. If we had not been able to know that,
our lives would have been a nightmare.
Competing interests:
Honorary Secretary ALERT
Competing interests: No competing interests
I can appreciate Dr Bronzite’s humane concern about her terminally
ill patient. However I am unsure as to the need for terminal sedation in
somebody who is already comatose—unless something is missing from the case
description. Given this man’s rapid decline it is unlikely that he would
survive more than 48 hours anyway, and he would not suffer unduly. Why
medicalize his death? I suspect that sedation only helped ease the
family’s (and the doctor’s?) anxiety, without offering an additional
service, at least to this particular patient.
Competing interests:
I specialize in lung cancer and have an interest in palliative care.
Competing interests: No competing interests
a memorable patient?!
Working in an oncology clinic in the Netherlands, we are concerned
that the report ´a final service´ from a memorable patient by Naomi
Bronzite (BMJ, 2004;329:1079) gives the readers a wrong impression on the
position of terminal sedation and euthanasia in the Netherlands. As there
is ongoing debate on the proposition to regulate terminal sedation like
euthanasia, this report might confuse the discussion.
Our main concern on this report is, that terminal sedation was performed
in an elderly man suffering from a glioblastoma, who was already comatose.
Terminal sedation is restricted to dying patients to end intractable
suffering refractory to other interventions. Examples are intractable
pain refractory to state of the art pain management or intractable
delirium refractory to antipsychotics, for patients in the last days of
their life. The main difference with euthanasia is that euthanasia can be
done solely upon the specific and consistent request of a competent
patient. Both euthanasia and terminal sedation can only be performed in
patients whose suffering cannot be relieved otherwise. Demands made by
relatives, however pressing and perhaps understandable, are irrelevant.
As this patient is described as having slipped into a coma we cannot
understand or appreciate the nature of his suffering. The description of
the role of the terminal care nurse blurs the situation even further as
she seems to have run the show. The phrase on the saying goodbye before
the pump was attached, is equally confusing. Perhaps the patient was not
that comatose? What then was his suffering? What therapies were tried?
In our experience, in comatose patients with a terminal illness nature
will take its natural course within days; no medical interventions are in
place or needed for.
The Dutch law on euthanasia is often regarded as difficult and prone to
misinterpretations; terminal sedation can be equally hazardous. Despite
the comfort of the relatives, the patient and last but not least the
doctor herself, this report does not clarify the place of terminal
sedation in the relief of intractable suffering.
M.Bannink, psychiatrist
A.R.Van Gool, psychiatrist
L. van Zuylen, medical oncologist
Erasmus MC-Daniel den Hoed Oncology Centre, Rotterdam, the Netherlands
reactions to: m.bannink@erasmusmc.nl
Competing interests:
None declared
Competing interests: No competing interests