Ethical thoughts on persistent signs of agony at the end of life in the intensive care unit

Abstract

The death of a loved person is often viewed as a hardship and a tragedy by those who witness it, as death is not merely the end of a life, but also the end of an existence, the loss of a unique individual who is special and irreplaceable. In some situations, signs of agony that accompany death, such as agonic gasps, can be an almost unbearable “spectacle” because of the physical manifestations, which are difficult to watch and that can lead to subjective interpretation and irrational fears. Ethical discomfort arises as the dying patient falls prey to both death throes and the expression of remaining life and the physician can only stand by and watch. Physicians can put an end to agony by administering a neuromuscular blocking agent; however, thereby, life will cease at the same time. It is difficult not to respond to sufferings of loved ones and care givers. The ethical problem then becomes the transfer from the original ethical concern, i.e. the dying patient, to the patient’s loved ones. Is such a rupture due to a difference in nature or a difference in degree, given that the dying patient remains a person and not a thing, as long as the body continues to lead its own life, as expressed by movement and sounds? Because there cannot be any simple and unequivocal answers to this question, the ethics committee of the French society of intensive care medicine (CE-SRLF) is offering ethical thoughts on persistent signs of agony and the use of neuromuscular blockade at the end of life in the intensive care unit, with lectures done by two philosophers and members of the CE-SRLF, Ms Lise Haddad and Pr Dominique Folscheid. The CE-SRLF hopes to help each reader to further contribute to this question, aiming not at providing ready-made solutions or policy but rather at allowing conscious thoughts.