title: Ethical reflections on end-of-life signs and symptoms in the intensive care setting: a place for neuromuscular blockers?
abstract: The death of a loved one is often an ordeal and a tragedy for 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, end-of-life signs, such as agonal gasps, can be an almost unbearable "sight" because the physical manifestations are hard to watch and can lead to subjective interpretation and irrational fears. Ethical unease arises as the dying patient falls prey to death throes and to the manifestations of ebbing life and the physician can only stand by and watch. From this point on, medicine can put an end to suffering by the use of neuromuscular blockade, but in so doing life ceases at the same time. It is difficult, however, not to respond to the distress of loved ones and caregivers. The ethical problem then becomes the shift 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, expressed through movement and sound? Because there cannot be any simple and unequivocal answer to this question, the SRLF Ethics Commission is offering ethical reflections on end-of-life signs and symptoms in the intensive care setting, and on the use of neuromuscular blockade in this context, with presentations on the subject by two philosophers and members of the SRLF Ethics Commission, Ms Lise Haddad and Prof Dominique Folscheid. The SRLF Ethics Commission hopes to provide food for thought for everyone on this topic, which undoubtedly calls for further contributions, the aim being not to provide ready-made solutions or policy, but rather to allow everyone to ponder this question in all conscience.
authors.affiliation: SRLF Ethics Commission, la Maison de la Réanimation, Paris F-75010, France ; Department of Medical Intensive Care, CHU Caen, service de Réanimation Médicale, avenue Cote de Nacre Caen, 14033 cedex, Caen F-14000, France.
authors.forename: Cédric
authors.initials: C
authors.lastname: Daubin
authors.affiliation: SRLF Ethics Commission, la Maison de la Réanimation, Paris F-75010, France ; CHU Saint-Louis, Consultation Douleur, Paris F-75010, France.
authors.forename: Lise
authors.initials: L
authors.lastname: Haddad
authors.affiliation: SRLF Ethics Commission, la Maison de la Réanimation, Paris F-75010, France ; Institut Hannah Arendt, Université Paris-Est Marne-la-Vallée, Marne-la-Vallée F-77454, France.
authors.forename: Dominique
authors.initials: D
authors.lastname: Folscheid
authors.affiliation: SRLF Ethics Commission, la Maison de la Réanimation, Paris F-75010, France ; Department of Medical Intensive Care, CHU Pellegrin Tripode, Bordeaux F-33076, France.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Boyer
authors.affiliation: SRLF Ethics Commission, la Maison de la Réanimation, Paris F-75010, France ; Department of Medical Intensive Care, Institut Gustave Roussy, Villejuif F-94805, France.
authors.forename: Ludivine
authors.initials: L
authors.lastname: Chalumeau-Lemoine
authors.affiliation: SRLF Ethics Commission, la Maison de la Réanimation, Paris F-75010, France ; Department of Medical Intensive Care, CHU Bordeaux Hôpital Saint-André, Bordeaux F-33075, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Guisset
authors.affiliation: SRLF Ethics Commission, la Maison de la Réanimation, Paris F-75010, France ; Department of Pediatric Medical Intensive Care, CHU Necker Enfants Malades, Paris F-75743, France.
authors.forename: Philippe
authors.initials: P
authors.lastname: Hubert
authors.affiliation: SRLF Ethics Commission, la Maison de la Réanimation, Paris F-75010, France ; Department of Medical Intensive Care, CH de la Côte Basque, Bayonne F-64109, France.
authors.forename: Jérôme
authors.initials: J
authors.lastname: Pillot
authors.affiliation: SRLF Ethics Commission, la Maison de la Réanimation, Paris F-75010, France ; Department of Medical Intensive Care, CHU Poitier, Poitier F-86021, France.
authors.forename: René
authors.initials: R
authors.lastname: Robert
authors.affiliation: SRLF Ethics Commission, la Maison de la Réanimation, Paris F-75010, France ; Service de réanimation médicochirurgicale, CHU Louis Mourier, Université Paris Diderot, Sorbonne Paris Cité, UMRS 722, F-92701 Colombes cedex, F-75018 Paris France.
authors.forename: Didier
authors.initials: D
authors.lastname: Dreyfuss
keywords: Critical care; End of life; Ethics; Gasps