What if you die in your sleep

Coma - falling asleep gently: one in four people is put into a coma before death

Falling asleep gently: one in four people is put into a coma before death

Medication enables dying people in Switzerland to fall asleep peacefully. But that is not discussed enough - there is a risk of abuse.

Asleep peacefully. This is how dying is often described in obituaries. Such an end of life is comforting for the relatives. Nowadays relatives sometimes even say that he fell asleep peacefully when the patient died of a lung disease and in the end suffocated.

Because there are drugs that enable a gentle death, such as the active ingredient midazolam, which has a sleep-inducing, anxiety and antispasmodic effect. The dying person is sedated, i.e. put into deep sleep. "In many cases it is a blessing that this is available for the last hours of life," says Markus Zimmermann, professor of theological ethics at the University of Freiburg and president of the national research program "End of Life", whose findings were published yesterday. If a dying person is completely desperate, delirious or has difficulty breathing, sedation makes sense so that he can die in peace. Sedation is rarely used because of severe pain: this can be relieved with medication that is less impairing to consciousness.

But sedation can also be abused. The authors of the study “Medical Decisions at the End of Life” are observing developments critically.

Death becomes a decision

In Switzerland, 71 percent of all deaths do not happen suddenly or unexpectedly. This is because medicine can keep people alive longer and longer. “If we can do more and more, then we have to say more and more often: Now we'll leave it anyway,” says Zimmermann. The doctors must therefore decide together with the patient and their relatives whether treatment should be continued or not. In Switzerland, such decisions are made in four out of five unsurprising deaths.

And more and more often those involved are opting for end-of-life sedation: Every fourth dying person today does not experience death consciously, but in deep sleep. In 2001 it was only one in twenty. “This reality is little known to the public, but it should be,” says Zimmermann. “As an ethicist, I also think that one should take a closer look: Was the sedation done properly? Was it discussed? Was it appropriate? "

The risk that sedation is not carried out properly exists in departments in hospitals where patients rarely die or in old people's and nursing homes. A common mistake is simply increasing the dose of morphine for sedation. In high doses, morphine also clouds consciousness, but it has strong side effects.

It would be legally incorrect to sedate a patient who would live for several weeks or months, but who is no longer able to live. "Then it would be assisted suicide," says Zimmermann, "and more of a case for exit." Sedation is also not appropriate if it only happens because it makes the situation easier for the relatives or the nursing staff, believes the ethicist.

There is more talk in Switzerland

In the first study on the end of life from 2001/02, five other European countries took part in addition to Switzerland. It was found that people in Switzerland talk more about the end of life than in other countries. While in Switzerland doctors today talk to dying people and relatives about imminent death and the possibility of discontinuing treatment in around 60 percent of all cases, this only happens in 20 percent of all cases in Italy. Study leader Markus Zimmermann says: “In Switzerland, firstly, doctors are more willing to make a decision. Second, there is more talk about it, this is the only way that decisions are made more often than simply waiting and continuing as before. " (kus)

Relief from delirium

Georg Bosshard, co-author of the study and doctor at the Geriatrics Clinic at the University Hospital Zurich does not quite share this view: “It is not uncommon for a person to fall into delirium in the last hours of life and become very restless Example to stand up, although he no longer has the strength to do so and would injure himself. Sedation helps. In the past, you might have just given a different calming cocktail that had a similar effect. " Bosshard sees the reason for the sharp increase in so-called terminal sedation in the fact that doctors are simply more aware that it is one. And: "There is more talk about it," says Bosshard. "That's a good sign. A surprising number of dying people have often heard of it and explicitly want it. "

Bosshard and Zimmermann believe that the most important thing is to talk about it beforehand. The study found that in three-quarters of all deaths, the doctor discussed the decision with the patient if the patient was considered to be competent. In half of the other cases, the doctors talked to the relatives or knew the wishes of the dying. And in the rest? The study authors suspect that some doctors missed timely and open discussions with their patients about dying or did not seek at all.

Where does euthanasia begin?

The National Fund has approved this group of authors from the “End of Life” research program to continue their study on the subject of “Terminal sedation - palliative care or slow euthanasia?”. Because sedation as an act is a borderline case, says Zimmermann. And Bosshard also finds it ethically sensitive: “It is a profound decision if someone says that at time X I will be put into a coma until death. He says goodbye to the relatives and ends his conscious life. "

But this is not the only reason why sedation into death has the taste of assisted suicide: the decision is often made not to give a sedated dying person any more food or fluid. So the person dies, if death does not occur earlier anyway, after a week at the latest.

Bosshard does not fundamentally criticize that. But he says: "You have to talk about it, just as people talk about assisted suicide today." The study closes with the conclusion: This is another challenging area at the end of life that has been largely ignored in the medical guidelines for palliative care. It should be possible to clearly distinguish sedation until death from decisions that may shorten life.