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I think that the spike of brain activity prior to death (which is fairly proven with near death studies) speaks to the need for opiates and speedy palliative extubation. Certainly if these patients become more alert just before death, they could experience pain and fear, as well as more pleasant emotions. Our job is to be sure that these patients don't suffer when their family makes a difficult decision to focus on comfort oriented care.

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I agree completely with regard to pain. I am deeply uncomfortable with the idea of creating any kind of 'restrictive' or conservative approach to palliative opioids and benzodiazepines after extubation. I am open to the idea of permitting more consciousness in selected patients, whose family are at their side continuously providing love, touch, connection. I don't know whether it is also our duty and role to eliminate all fear just prior to death, if that means rendering everyone insensate and stuporous (thereby also eliminating the possibility of more positive feelings of connection to family, humanity, one's life history, etc). But because we lack any reliable way of knowing how much someone is suffering, and the possibilities of insufficient palliation seem horrifying, I personally believe we should always lean to the side of more palliation, rather than less. Thank you for writing.

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