Skip to main content
PMC home page
Journal of Medical Ethics logoLink to Journal of Medical Ethics
. 2002 Jun;28(3):164–169. doi: 10.1136/jme.28.3.164

The agony of agonal respiration: is the last gasp necessary?

R Perkin 1, D Resnik 1
PMCID: PMC1733591  PMID: 12042401

Abstract

Gasping respiration in the dying patient is the last respiratory pattern prior to terminal apnoea. The duration of the gasping respiration phase varies; it may be as brief as one or two breaths to a prolonged period of gasping lasting minutes or even hours. Gasping respiration is very abnormal, easy to recognise and distinguish from other respiratory patterns and, in the dying patient who has elected to not be resuscitated, will always result in terminal apnoea.

Gasping respiration is also referred to as agonal respiration and the name is appropriate because the gasping breaths appear uncomfortable and raise concern that the patient is suffering and in agony. Enough uncertainty exists about the influence of gasping respiration on patient wellbeing, that it is appropriate to assume that the gasping breaths are burdensome to patients. Therefore, gasping respiration at the end of life should be treated.

We propose that there is an ethical basis, in rare circumstances, for the use of neuromuscular blockade to suppress prolonged episodes of agonal respiration in the well-sedated patient in order to allow a peaceful and comfortable death.

Full Text

The Full Text of this article is available as a PDF (98.0 KB).

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Alpers A. Criminal act or palliative care? Prosecutions involving the care of the dying. J Law Med Ethics. 1998 Winter;26(4):308-31, 262. doi: 10.1111/j.1748-720x.1998.tb01678.x. [DOI] [PubMed] [Google Scholar]
  2. Carlson G. Neuromuscular blockade administration to end suffering: an ethical dilemma. Crit Care Nurs Q. 1999 Nov;22(3):39–44. doi: 10.1097/00002727-199911000-00007. [DOI] [PubMed] [Google Scholar]
  3. Daly B. J., Thomas D., Dyer M. A. Procedures used in withdrawal of mechanical ventilation. Am J Crit Care. 1996 Sep;5(5):331–338. [PubMed] [Google Scholar]
  4. Enck R. E. Terminal sedation. Am J Hosp Palliat Care. 2000 May-Jun;17(3):148–149. doi: 10.1177/104990910001700301. [DOI] [PubMed] [Google Scholar]
  5. Foley K. M. Competent care for the dying instead of physician-assisted suicide. N Engl J Med. 1997 Jan 2;336(1):54–58. doi: 10.1056/NEJM199701023360109. [DOI] [PubMed] [Google Scholar]
  6. Furrow B. R. Pain management and provider liability: no more excuses. J Law Med Ethics. 2001 Spring;29(1):28–51. doi: 10.1111/j.1748-720x.2001.tb00038.x. [DOI] [PubMed] [Google Scholar]
  7. Galloway K. S., Yaster M. Pain and symptom control in terminally ill children. Pediatr Clin North Am. 2000 Jun;47(3):711–746. doi: 10.1016/s0031-3955(05)70234-0. [DOI] [PubMed] [Google Scholar]
  8. Ghoneim M. M. Awareness during anesthesia. Anesthesiology. 2000 Feb;92(2):597–602. doi: 10.1097/00000542-200002000-00043. [DOI] [PubMed] [Google Scholar]
  9. Glasser R. L., Tippett J. W., Davidian V. A., Jr Cerebellar activity, apneustic breathing, and the neural control of respiration. Nature. 1966 Feb 19;209(5025):810–812. doi: 10.1038/209810b0. [DOI] [PubMed] [Google Scholar]
  10. Guntheroth W. G., Kawabori I. Hypoxic apnea and gasping. J Clin Invest. 1975 Dec;56(6):1371–1377. doi: 10.1172/JCI108217. [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Latham S. R. Aquinas and morphine: notes on double effect at the end of life. DePaul J Health Care Law. 1997 Spring;1(3):625–644. [PubMed] [Google Scholar]
  12. Luce J. M., Alpers A. Legal aspects of withholding and withdrawing life support from critically ill patients in the United States and providing palliative care to them. Am J Respir Crit Care Med. 2000 Dec;162(6):2029–2032. doi: 10.1164/ajrccm.162.6.1-00. [DOI] [PubMed] [Google Scholar]
  13. Manning H. L., Schwartzstein R. M. Pathophysiology of dyspnea. N Engl J Med. 1995 Dec 7;333(23):1547–1553. doi: 10.1056/NEJM199512073332307. [DOI] [PubMed] [Google Scholar]
  14. Matzo M. L., Balkstra C. R., Zugcic M. Dyspnea near the end of life: an excerpt from the upcoming RNS 11th Annual Conference. Heart Lung. 2001 Mar-Apr;30(2):164–165. doi: 10.1067/mhl.2001.114983. [DOI] [PubMed] [Google Scholar]
  15. McHaffie H. E., Lyon A. J., Fowlie P. W. Lingering death after treatment withdrawal in the neonatal intensive care unit. Arch Dis Child Fetal Neonatal Ed. 2001 Jul;85(1):F8–F12. doi: 10.1136/fn.85.1.F8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Meisel A., Snyder L., Quill T., American College of Physicians--American Society of Internal Medicine End-of-Life Care Consensus Panel Seven legal barriers to end-of-life care: myths, realities, and grains of truth. JAMA. 2000 Nov 15;284(19):2495–2501. doi: 10.1001/jama.284.19.2495. [DOI] [PubMed] [Google Scholar]
  17. Melzack R. The tragedy of needless pain. Sci Am. 1990 Feb;262(2):27–33. doi: 10.1038/scientificamerican0290-27. [DOI] [PubMed] [Google Scholar]
  18. Orr R. D., Bishop L. Why psychiatrists should not participate in euthanasia and physician-assisted suicide. Am J Forensic Psychiatry. 1998;19(1):35–48. [PubMed] [Google Scholar]
  19. Poets C. F., Meny R. G., Chobanian M. R., Bonofiglo R. E. Gasping and other cardiorespiratory patterns during sudden infant deaths. Pediatr Res. 1999 Mar;45(3):350–354. doi: 10.1203/00006450-199903000-00010. [DOI] [PubMed] [Google Scholar]
  20. Quill T. E., Byock I. R. Responding to intractable terminal suffering: the role of terminal sedation and voluntary refusal of food and fluids. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians-American Society of Internal Medicine. Ann Intern Med. 2000 Mar 7;132(5):408–414. doi: 10.7326/0003-4819-132-5-200003070-00012. [DOI] [PubMed] [Google Scholar]
  21. Quill T. E., Dresser R., Brock D. W. The rule of double effect--a critique of its role in end-of-life decision making. N Engl J Med. 1997 Dec 11;337(24):1768–1771. doi: 10.1056/NEJM199712113372413. [DOI] [PubMed] [Google Scholar]
  22. Quill T. E., Lee B. C., Nunn S. Palliative treatments of last resort: choosing the least harmful alternative. University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel. Ann Intern Med. 2000 Mar 21;132(6):488–493. doi: 10.7326/0003-4819-132-6-200003210-00011. [DOI] [PubMed] [Google Scholar]
  23. Quill T. E. The ambiguity of clinical intentions. N Engl J Med. 1993 Sep 30;329(14):1039–1040. doi: 10.1056/NEJM199309303291414. [DOI] [PubMed] [Google Scholar]
  24. Rich B. A. An ethical analysis of the barriers to effective pain management. Camb Q Healthc Ethics. 2000 Winter;9(1):54–70. doi: 10.1017/s0963180100901063. [DOI] [PubMed] [Google Scholar]
  25. Rollin B. E. Pain and ideology in human and veterinary medicine. Semin Vet Med Surg (Small Anim) 1997 May;12(2):56–60. doi: 10.1016/s1096-2867(97)80002-3. [DOI] [PubMed] [Google Scholar]
  26. Rousseau P. The ethical validity and clinical experience of palliative sedation. Mayo Clin Proc. 2000 Oct;75(10):1064–1069. doi: 10.4065/75.10.1064. [DOI] [PubMed] [Google Scholar]
  27. Rushton C. H., Terry P. B. Neuromuscular blockade and ventilator withdrawal: ethical controversies. Am J Crit Care. 1995 Mar;4(2):112–115. [PubMed] [Google Scholar]
  28. Saito Y., Hashimoto T., Iwata H., Takahashi K., Fukumizu M., Sasaki M., Hanaoka S., Sugai K. Apneustic breathing in children with brainstem damage due to hypoxic-ischemic encephalopathy. Dev Med Child Neurol. 1999 Aug;41(8):560–567. doi: 10.1017/s0012162299001188. [DOI] [PubMed] [Google Scholar]
  29. Sandin R. H., Enlund G., Samuelsson P., Lennmarken C. Awareness during anaesthesia: a prospective case study. Lancet. 2000 Feb 26;355(9205):707–711. doi: 10.1016/S0140-6736(99)11010-9. [DOI] [PubMed] [Google Scholar]
  30. St-John W. M., Paton J. F. Characterizations of eupnea, apneusis and gasping in a perfused rat preparation. Respir Physiol. 2000 Nov;123(3):201–213. doi: 10.1016/s0034-5687(00)00177-8. [DOI] [PubMed] [Google Scholar]
  31. Sulmasy D. P., Pellegrino E. D. The rule of double effect: clearing up the double talk. Arch Intern Med. 1999 Mar 22;159(6):545–550. doi: 10.1001/archinte.159.6.545. [DOI] [PubMed] [Google Scholar]
  32. Tobin M. J. Dyspnea. Pathophysiologic basis, clinical presentation, and management. Arch Intern Med. 1990 Aug;150(8):1604–1613. doi: 10.1001/archinte.150.8.1604. [DOI] [PubMed] [Google Scholar]
  33. Truog R. D., Burns J. P., Mitchell C., Johnson J., Robinson W. Pharmacologic paralysis and withdrawal of mechanical ventilation at the end of life. N Engl J Med. 2000 Feb 17;342(7):508–511. doi: 10.1056/NEJM200002173420712. [DOI] [PubMed] [Google Scholar]

Articles from Journal of Medical Ethics are provided here courtesy of BMJ Publishing Group

RESOURCES