The use of drugs that hasten a patient’s death by down-regulating their respiration is euthanasia and is ethically unacceptable, according to a U of T doctor in a recent letter to the Journal of Medical Ethics.

When patients suffering from terminal illness approach death, they often begin to gasp. Gasping is the last respiratory pattern prior to terminal apnea, or cessation of breathing. Neuromuscular blocker drugs are often used in anesthetized patients to provide muscular paralysis, and prevent gasping. But because no patient has survived the gasping phase to explain what it feels like, doctors can never be sure whether they suffer from pain. High doses of painkillers and sedatives do not prevent this pre-terminal gasping.

In the June issue of the Journal of Medical Ethics, two doctors proposed that in rare circumstances, there is an ethical basis in using neuromuscular blockers to suppress extended periods of painful respiration and allow a peaceful and comfortable death. Even though these drugs necessarily lead to death, since they block the patient’s breathing, the authors claimed that hastening death is an unintended consequence and the difference between “hastening death” and “intending death” is a difference of degree, not of kind.

However, according to Dr. Laura Hawryluck, a U of T physician who specializes in end-of-life and ethical issues, once neuromuscular blockers are administered to dying patients, there is no return, and that is where lines become blurred between euthanasia and a doctor’s attempt to relieve suffering.

“The solution lies in healthcare providers having open discussions of what families and loved ones can expect to see during the dying process, and how pain and distress (including shortness of breath) will be palliated,” said Hawryluck. It is probably more painful for the family surrounding the deathbed watching their loved one die than it is for the patient. These final-hour scenarios often leave family members with the belief that their loved one did not die peacefully.

“Death is a part of life and, similar to birth, our bodies undergo a series of changes, including changes in the way we are seen to breathe,” said Hawryluck. “These changes are normal, yet we rarely prepare families for what they will see. It is always very hard to lose someone you love—last moments with them will always be etched in our memories.” Instead of sanitizing death, she advises, “Sharing our fears, concerns, questions and grief will avoid us being haunted by thoughts of our loved ones’ last moments being filled with pain and suffering.”