Abstract
Dear Editor:
This journal recently published an article entitled “Pathophysiologies of Dyspnea Explained: Why Might Opioids Relieve Dyspnea and Not Hasten Death?” 1 My mentor and colleague, the late Dr. Miles Edwards, published an article covering similar ground back in 2005, entitled “Opioids and Benzodiazepines Appear Paradoxically to Delay Inevitable Death after Ventilator Withdrawal.” 2
I was distressed to note that your recent article did not even honor Dr. Edwards with the respect of a citation, much less directly acknowledge his prior insights. Dr. Edwards was a man of singular humility and grace. I am quite certain he would have felt no distress at this oversight. At most, he might smile with avuncular understanding as a younger generation ignored the wisdom of their elders.
Dr. Edwards had an extraordinary wisdom based on years spent in careful observation at the bedside. Yet, in his understated way, in his article he ventures only the following suggestion: “Palliative care physicians might consider as credible an alternative logic, that palliating dyspnea by carefully providing opioids and/or benzodiazepines should reduce work of breathing thereby protecting against premature death from fatigue.”
The JPM article, on the other hand, speculates about the pathophysiology of dyspnea, using the ill-considered term “suffocation dyspnea.” This, in turn, appears to have led a journal reader to the horrifying suggestion that “perhaps from pathophysiologic inference, abandoning the practice of terminally extubating…is the most appropriate way of avoiding distress in patients who are prone to dyspnea. The avoidance of dyspnea…could outweigh the perceived benefit of treatment withdrawal to shorten the dying process and therefore the suffering.” 3
In 1992 Dr. Edwards wrote of an experience with terminal extubation in a fully conscious patient. 4 He reported that his fears of causing immediate “suffocation” and severe “visceral panic” were unfounded. He medicated the patient skillfully for dyspnea with opioids. He observed that the patient “exchanged smiles with his daughter, appeared comfortable and relaxed…and did not struggle further,” until inevitable death 45 minutes later.
In this case report Dr. Edwards considered it “cruel” to delay his patient's request to be extubated for even an additional five hours. Even as placid a man as Dr. Edwards might take umbrage at a clinical guideline that would condemn ventilated patients to a protracted cardiovascular death because of our mistaken fears of uncontrolled “suffocation dyspnea.” Dyspnea can be, and should be, effectively palliated with opioids.
I remember Dr. Edwards's grace and equanimity when yet another journal rejected his manuscript and his gratitude when it was finally accepted at a small journal. Dr. Edwards could have proclaimed his insights with the force of a zealot and perhaps attracted the attention of a major journal. But his humble spirit would only allow his text to read that his insights were “not new,” and that clinicians “might consider” changing their practice. Perhaps this explains why his contributions have been overlooked and ignored.
Though he would be embarrassed to hear me say this, I will proclaim that Dr. Edwards's seminal paper should be required reading for all palliative care clinicians.