A few days ago, the headlines swept through the media: “Sweden: Infected old men are offered a lethal cocktail instead of therapy?”, “Active euthanasia instead of COVID-19 treatment?” Disturbing reports from Sweden »and a dozen others citing an article that appeared in the Swedish daily Dagens Nyheter. In an interview with Medonet, Dr. Tomasz Grądalski, a specialist in palliative medicine and geriatrician, explains when and in what cases patients are given morphine, which was listed as one of the ingredients of the “deadly cocktail”.
- Morphine, in addition to its analgesic effect, also reduces the feeling of breathlessness. However, it should be administered skillfully – orally and starting with small doses
- “The wider use of this drug in medicine is associated with the emergence of a new specialty in the 60s, which is palliative care, and the demonstration that morphine can be successfully used orally.” It was a breakthrough for millions of sick people
- “The problem limiting the use of morphine in our country are irrational fears, even phobias, unfortunately also affecting some doctors”
- “Palliative care excludes euthanasia in its assumptions, but uses in therapy the same, potent drugs that could (if used inappropriately) take the patient’s life”
Magda Zmna, Medonet: How is it with this morphine? Why was the reliever medication used in the context of ‘inhibition of breathing’?
Dr. med. Tomasz Grądalski, specialist in palliative medicine and geriatrician: Morphine, in addition to its analgesic effect, also reduces the feeling of breathlessness, among others. affecting the respiratory center in the brain and slowing down the frequency of breathing. This effect is advantageous in the case of gradual increase in doses of morphine administered systematically, starting with minimal amounts of the drug, by the oral route. The slowing down of excessively accelerated breathing is accompanied by an improvement in the oxygenation of the blood and tissues. Obviously, unskillful, inconsistent with medical art, the use of too high doses of morphine from the beginning, especially by injection, may result in excessive “respiratory depression” and, consequently, also death.
What are the indications for the administration of morphine? What are the benefits for the patient?
The main indication for the use of morphine is severe pain. For this purpose, it is administered not only to patients with advanced neoplastic disease, but also to people suffering from other diseases (e.g. chronic obstructive pulmonary disease, heart failure). The wider use of this drug in medicine is associated with the emergence of a new specialty in the 60s, which is palliative care and showing that morphine can be successfully administered orally, which has not been practiced before. It was a breakthrough for millions of sick people. Like every drug, morphine has its limitations: not all pain can be alleviated, and the side effects observed during therapy are also known.
The problem limiting the use of morphine in our country are irrational fears, even phobias, unfortunately also affecting some doctors. These include the unjustified fear of a patient’s physical or mental dependence, the risk of a deterioration in his intellectual performance, and even the fear of shortening his life. Many years of clinical experience with the correct use of morphine do not support any of these concerns. For example, patients who receive this medication to alleviate suffering often live longer and in better comfort, and in situations where treatment has to be discontinued, it is possible to safely and gradually discontinue the medication.
According to the article quoted by the Polish media, which appeared in the daily Dagens Nyheter, many seniors in nursing homes in Sweden are given morphine instead of COVID-19 treatment, which inhibits breathing and contributes to premature death. The journal quotes geriatrics professor Yngve Gustafson: Instead, many elderly people with pneumonia are routinely given morphine and midazolam to inhibit breathing. This is active euthanasia, if not worse.
According to Medexpress, the Swedish health authority launched an investigation after concerns were raised about the ethical behavior of elderly people infected with the SARS-CoV-2 coronavirus. The investigation will be conducted between June 1 and June 21 and will cover all 21 administrative regions in the country. Combining morphine with ‘active euthanasia’ can have detrimental effects for those who use palliative care.
Can administering morphine to a patient be considered a treatment discontinuation? This is how it is presented by the daily Dagens Nyheter, quoted by other media.
The fundamental ethical duty of a doctor is to save the life of a sick person, and when this is not possible, to bring relief from suffering – which is what palliative medicine deals with. So you can never tell a sick person that nothing can be done for him or that he will not be treated at all. However, each stage of the disease has different goals of therapy. At the end of life, treatment is aimed at improving comfort, including by relieving troublesome symptoms such as pain, shortness of breath, anxiety and others. For this purpose, various treatments and drugs are used, also from the group of opioids (synthetic opium derivatives), which include morphine. Thus, administering morphine to a patient is not an expression of cessation of treatment, but an example of an active, scientifically and effective therapy aimed at alleviating suffering..
Our country, when it comes to the use of opioids, is still below the European average, which is not beneficial for patients, and information such as the one from Sweden does not help.
Why did morphine appear in this context of “active euthanasia”?
Euthanasia is an action aimed at ending a patient’s life at his / her request. Such actions are not ethically – and in our country also legally – permissible. In countries where euthanasia is permitted by law, several drugs are usually used together at doses well in excess of those defined as lethal. One of these drugs may also be one of the opioids. However, a clear distinction should be made between administering opioid drugs, including morphine, in dosages and in a manner that alleviates suffering to a level where the patient can live actively despite severe illness, from administering lethal doses of the drug to take life.
Medical publications describing the use of legal euthanasia indicate that physical symptoms that are not always difficult to control are the main motive for demanding it to be performed in terminally ill patients. Increasingly, the lack of satisfaction with life or the loss of hope is emphasized as sufficient reason to carry it out. Some of such procedures are performed in nursing homes, often without the patient’s informed consent, relying only on a previously submitted declaration of will.
It is difficult to refer to the recent media information from nursing homes in Sweden about the intentionally resignation of physicians from actually available oxygen or ventilator therapy and, instead, consciously choosing euthanasia. If it concerns patients who have a potential chance to improve their health and recover from coronavirus infection – it is ethically reprehensible and unacceptable action.
Palliative care excludes euthanasia in its assumptions, but uses in therapy the same, potent drugs that could (if used inappropriately) take the patient’s life. The key to avoid misinterpretation of specific medical activities by relatives who do not have medical education is to ensure good communication from the beginning of the therapy. Reliable and tailored to the expectations, gradual transfer of unfavorable information to the patient and his relatives is a necessary condition for obtaining good satisfaction with the treatment.
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