In almost every room people were sleeping, but not like babies. This was not the carefree sleep that would restore them to rise and shine for another day. It was the sleep before — and sometimes until — death.
In some of the rooms in the hospice unit at Franklin Hospital, in Valley Stream on Long Island, the patients were sleeping because their organs were shutting down, the natural process of death by disease. But at least one patient had been rendered unconscious by strong drugs.
The patient, Leo Oltzik, an 88-year-old man with dementia, congestive heart failure and kidney problems, was brought from home by his wife and son, who were distressed to see him agitated, jumping out of bed and ripping off his clothes. Now he was sleeping soundly with his mouth wide open.
"Obviously, he's much different than he was when he came in," Dr. Edward Halbridge, the hospice medical director, told Mr. Oltzik's wife. "He's calm, he's quiet."
Mr. Oltzik's life would end not with a bang, but with the drip, drip, drip of an IV drug that put him into a slumber from which he would never awaken. That drug, lorazepam, is a strong sedative. Mr. Oltzik was also receiving morphine, to kill pain. This combination can slow breathing and heart rate, and may make it impossible for the patient to eat or drink. In so doing, it can hasten death.
Mr. Oltzik received what some doctors call palliative sedation and others less euphemistically call terminal sedation. While the national health coverage debate has been roiled by questions of whether the government should be paying for end-of-life counseling, physicians like Dr. Halbridge, in consultations with patients or their families, are routinely making tough decisions about the best way to die.
Among those choices is terminal sedation, a treatment that is already widely used, even as it vexes families and a profession whose paramount rule is to do no harm.
Doctors who perform it say it is based on carefully thought-out ethical principles in which the goal is never to end someone's life, but only to make the patient more comfortable.
But the possibility that the process might speed death has some experts contending that the practice is, in the words of one much-debated paper, a form of "slow euthanasia," and that doctors who say otherwise are fooling themselves and their patients.
There is little information about how many patients are terminally sedated, and under what circumstances — estimates have ranged from 2 percent of terminal patients to more than 50 percent. (Doctors are often reluctant to discuss particular cases out of fear that their intentions will be misunderstood.)
While there are universally accepted protocols for treating conditions like flu and diabetes, this is not as true for the management of people's last weeks, days and hours. Indeed, a review of a decade of medical literature on terminal sedation and interviews with palliative care doctors suggest that there is less than unanimity on which drugs are appropriate to use or even on the precise definition of terminal sedation.
Discussions between doctors and dying patients' families can be spare, even cryptic. In half a dozen end-of-life consultations attended by a reporter over the last year, even the most forthright doctors and nurses did little more than hint at what the drugs could do. Afterward, some families said they were surprised their loved ones died so quickly, and wondered if the drugs had played a role.
Whether the patients would have lived a few days longer is one of the more prickly unknowns in palliative medicine. Still, most families felt they and the doctors had done the right thing.
Mr. Oltzik died after eight days at the hospice. Asked whether the sedation that rendered Mr. Oltzik unconscious could have accelerated his death, Dr. Halbridge said, "I don't know."
"He could have just been ready at that moment," he said.
With their families' permission, Dr. Halbridge agreed to talk about patients, including Mr. Oltzik and Frank Foster, a 60-year-old security guard dying of cancer. He said he had come to terms with the moral issues surrounding sedation.
"Do I consider myself a Dr. Death who is bumping people off on a regular basis?" he asked. "I don't think so. In my own head I've sort of come to the realization that these people deserve to pass comfortably."