Table 4 Current areas of Controversy

   Neuromuscular blockers mask the clinical signs of pain and suffering delineated above. When possible, the withholding and withdrawal of life support should be started after their effects wear off in order to permit Intensivists to assess as accurately as possible the patient's pain and suffering and ensure good palliative care. If neuromuscular blockers were not in use, they should not be started in order to hide patient distress. The intent and justifications of Intensivists who fail to wait for neuromuscular blockers to wear off or who fail to reverse them must be carefully documented. Since patients in persistent vegetative states are deemed incapable of feeling pain or anxiety, sedatives and narcotics are usually not required during the withholding/withdrawal of life support. The family's perceptions of pain and suffering, however, may play a role in the use of narcotics and sedatives in these patients.

Terminal Sedation

   Terminal sedation, defined in the literature as sedation with continuous IV narcotics and/or sedatives until the patient becomes unconscious and death ensues from the underlying illness, is palliative care, not euthanasia. Since terminal sedation may arguably make the detection of euthanasia/assisted suicide more difficult, the intent of the Intensivist is crucial.

Intent

   The intention of the Intensivist administering narcotics/sedatives to palliate dying patients can be assessed by careful documentation in the chart of: 1) the patient's medical condition and reasons leading to the initiation of palliative care, 2) the goal, which is to relieve pain and suffering, 3) the way pain and suffering will be evaluated, and 4) the way in which drugs will be increased and why. Intensive care units should develop guidelines governing the process of withholding and withdrawal of life support and Intensivists should justify and document any need to deviate from the policy and the anticipated modifications. The administration of drugs without any palliative benefit, e.g. lethal doses of potassium chloride or neuromuscular blockers, suggests an intent to euthanize/assist in the suicide of an individual patient.

Principle of Double Effect

   If the amount of narcotics/sedatives required to relieve pain and suffering at the end-of-life may foreseeably cause hastening of death, although the physician's intent is solely to relieve suffering, this should be considered palliative care.

Distinction between Palliative Care and Euthanasia

   The intent of the physician administering narcotics and sedatives to the dying patient is the most crucial distinction between palliative care and assisted death (euthanasia/assisted suicide). In order to avoid any misinterpretations, Intensivists must clearly document, in the patient's chart, their intentions and justify their actions during the withholding/withdrawal process.