Opioids and benzodiazepines appear paradoxically to delay inevitable death after ventilator withdrawal.

The following statement was published in 1941: “The use of narcotics in the terminal cancer is to be condemned if it can possibly be avoided... morphine usage is an unpleasant experience to the majority of subjects because of undesirable side effects.” Although the focus of that article was addiction, it also listed respiratory depression (1). Stigmatization of morphine along with other opiates and opioids (collectively designated opioids) has a long history. In 1954, morphine and barbiturates further reduced ventilation in dyspneic, already hypoventilating patients during exacerbations of chronic obstructive pulmonary disease (COPD). Even though none of these patients then died, the authors presumed that opioids or sedatives would increase risk of premature death (2). This seemed logical, reinforcing a mind-set that continues to discourage many physicians from adequately palliating pain and/or dyspnea despite their ethical mandate to comfort (3). However, is this presumption really true? In a recent retrospective review of 75 patients—most with a low Glasgow coma scale (GCS), the overall median being GCS-3—terminal ventilator-withdrawal with opioids (morphine and fentanyl) did not hasten death, whereas benzodiazepine sedatives (midazolam and lorazepam) even delayed death (4). By contrast, this report focuses on a fully conscious man with postpolio syndrome who underwent self-requested ventilator-withdrawal with inevitable death apparently delayed when morphine and/or midazolam relieved dyspnea. I later observed four other patients (three being fully conscious) with ventilatory failure (excluding patients with hypoxemic respiratory failure) who also had inevitable deaths apparently delayed. Together, there is a significant correlation between weaning parameters unsedated and survival time sedated. Case Report 1