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A Dosage of Opioids Should Never Exceed What Is Necessary to Relieve Symptoms

We read with great interest the Official American Thoracic Society Clinical Policy Statement: Palliative Care for Patients with Respiratory Diseases and Critical Illnesses (1). This statement describes how palliative care can be integrated into curative and/or restorative care for patients with respiratory diseases and critical illnesses. The authors describe the possibility of treating dyspnea with opioids and the need for titration of the opioid dosage in dyspnea treatment. However, the authors suggest that in Oregon and some European countries the use of dosages of opioid that exceed what is necessary to relieve symptoms is legal, in contrast to other countries. We assume that the authors refer to the possibility of self-assisted suicide or euthanasia in, for example, Oregon, Belgium, or The Netherlands (2, 3). However, the use of excessive dosages of opioids is not part of the currently available guidelines for symptom management, nor are such dosages justified with the intention to terminate life in self-assisted suicide or euthanasia. In fact, an excessive dosage of an opioid is probably not appropriate for hastening death (4). An excessive dosage of an opioid may cause delirium, and dying in a terminal delirium should always be avoided (5).

Daisy J. A. Janssen

Proteion Thuis
Horn, The Netherlands

Martijn A. Spruit

Centre for Integrated Rehabilitation of Organ Failure (CIRO)
Horn, The Netherlands

Jos M. G. A. Schols

University Maastricht
Maastricht, The Netherlands

Emiel F. M. Wouters

University Hospital Maastricht
Maastricht, The Netherlands
and
Centre for Integrated Rehabilitation of Organ Failure (CIRO)
Horn, The Netherlands

FOOTNOTES

Conflict of Interest Statement: None of the authors has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

REFERENCES

1. Lanken PN, Terry PB, Delisser HM, Fahy BF, Hansen-Flaschen JH, Heffner JE, Levy M, Mularski RA, Osborne ML, Prendergast TJ, et al., on behalf of the ATS End-of-Life Care Task Force. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;178:912–927.
2. Sullivan AD, Hedberg K, Fleming DW. Legalized physician-assisted suicide in Oregon: the second year. N Engl J Med 2000;342:598–604.[Abstract/Free Full Text]
3. Deliens L, van der Wal G. The euthanasia law in Belgium and the Netherlands. Lancet 2003;362:1239–1240.[Medline]
4. van der Heide A, Onwuteaka-Philipsen BD, Rurup ML, Buiting HM, van Delden JJ, Hanssen-de Wolf JE, Janssen AG, Pasman HR, Rietjens JA, Prins CJ, et al. End-of-life practices in the Netherlands under the Euthanasia Act. N Engl J Med 2007;356:1957–1965.[Abstract/Free Full Text]
5. White C, McCann MA, Jackson N. First do no harm ... terminal restlessness or drug-induced delirium. J Palliat Med 2007;10:345–351.[CrossRef][Medline]

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