Management of dyspnea at the end of life: Relief for patients and surgeons

I first met John, a 72-year-old retired professor, in the trauma room where he was brought after a motor vehicle crash while driving to his physician's office. He was in severe respiratory distress with obvious chest trauma, multiple fractures, and an oxygen saturation of 86% on oxygen mask. He was intubated and placed on mechanical ventilation with minimal improvement in his oxygen saturation. His workup revealed multiple rib fractures, pneumothorax, pulmonary contusion, and traumatic brain injury. I spoke with his family during his resuscitation when they told me of his severe chronic obstructive pulmonary disease. He had been intermittently on steroids and home oxygen during the last 6 months. I was dismayed to hear the news, because I could already foresee a long complicated intensive care course for John if he survived, with a high likelihood that he would become ventilator dependent. John's family mentioned an advance directive, which stated his wishes that he would not want to be ventilator dependent at the end of his life. During the first few days of his hospitalization I hoped that some of his pulmonary injury would be treatable and reversible, allowing him to be weaned from the ventilator. But after 10 days there was little progress or improvement. He became hypoxemic and tachypneic when the ventilator was weaned. I discussed John's condition with his family again, and they brought the advance directive; John's wishes were clear, he would not want a prolonged course on mechanical life support. His primary care physician concurred that he and John had several discussions about mechanical ventilation for his pulmonary disease and that he would not want to be ventilator dependent. After a family conference in which consensus was reached unanimously, John's ventilatory support was withdrawn after intravenous administration of lorazepam and morphine. To everyone's surprise, John did not die right away. He lingered in the intensive care unit for 2 days in comatose state with labored, spontaneous breathing. While all those concerned recognized John's wishes were appropriately honored by withdrawal of the ventilatory support, they became increasingly distraught. "Doctor, is he suffocating off the respirator? I can't watch him suffer like that. Can't you do something?" I was conflicted. It was difficult to tell whether he was suffering from suffocation. He did have fast labored breathing, but he was also comatose and therefore unaware of discomfort. Should I treat him with high-dose morphine just in case, and make the respiratory signs go away, even if it may hasten his death? If that happens, will I have performed euthanasia?