AGONIA. - From ἀγωνία = struggle, anxiety, anguish; “the extreme struggle of the body against death” (cf. Vocab. lingua ital. della R. Accad. d'Ital., s.v.). It presents differing aspects in duration and violence, according to the duration of the illness, the organism’s resistance, and the patient’s age. It is rapid and intense in violent injuries, poisonings, and acute infections; prolonged, sometimes for days, when the organism has almost adapted itself to difficult living conditions through slow, chronic wasting (tuberculosis, tumours, long-standing heart diseases); it is entirely absent in cases of sudden death, in which the cause is so violent or sudden as to extinguish life at once, without the possibility of struggle. Given such a variety of manifestations, it may be difficult, especially for one who is not a physician, to determine its onset and course; on the other hand, it is of great importance for the priest to understand these extreme conditions of the patient in order to provide special assistance in «articulo mortis». The state of agony may best be revealed by observation of the organism’s three principal functions: two of vegetative life, respiration and circulation; and one of relational life, the activity of the nervous system.
Respiration, which has already varied considerably in its characteristics during the course of the illness, undergoes at the onset of agony its gravest alterations in frequency, intensity, and rhythm; the latter in particular marks the time and undergoes the most profound modifications as death approaches. The so-called Cheyne-Stokes periodic breathing is characterized by a group of respiratory movements that first increase in intensity to a maximum and then gradually become more superficial until they cease; this is followed by a more or less prolonged pause of apnea (up to many seconds), and then by a new group of respiratory movements with the same characteristics of increase and decrease. During the pause of apnea the patient wholly or partly loses consciousness, the pupils contract and no longer react to light, the eyes close, the pulse becomes smaller and more frequent, the head falls back, and the individual assumes the appearance of one dead; the resumption of a new cycle of respiratory movements causes this complex of signs to recede, while the patient regains consciousness and, as if awakening from sleep, resumes the interrupted speech, attempts to sit up in bed, and becomes agitated in anxiety at an end which he feels to be near, imploring help from those around him. The definitive cessation of breathing, corresponding to the transition to death, coincides with one of these pauses. Although Cheyne-Stokes breathing may in particular cases last for days or even weeks, and sometimes cease completely, it should ordinarily be regarded as a sign of the utmost gravity, followed by death within a few hours. In agony respiration often assumes a noisy, gurgling character (tracheal rattle), owing to the passage of air through catarrhal secretions accumulated in the trachea and in the pharyngo-laryngeal region; the frequency, which increases during the illness in relation to rising fever, toxic condition, and possible bronchopulmonary complications, becomes slow and the act laborious.
Circulation can provide important signs of the onset and progress of the agonal state. As the heart weakens, the pulse becomes smaller (that is, it beats with less force beneath the palpating finger) and more frequent; thus, as the patient’s condition worsens, it exceeds 110–120 beats per minute, reaching 130–140 in the final moments, often almost imperceptible to palpation or perceptible only in less peripheral arteries and therefore nearer to the heart (the temporal artery, in front of the tragus of the ear; the external carotid, beneath the angle of the jaw, along the anterior margin of the sternocleidomastoid muscle). A high pulse rate has significance only when accompanied by the other signs of the patient’s grave condition, since there are disturbances of cardiac rhythm in which an exceedingly high rate (180–250 beats per minute) may occur transiently and be accompanied by normal conditions of health in the individual. Irregularity of the pulse (arrhythmia, intermittence), if associated with the other signs of deterioration and especially if it replaces a previous regularity, has a grave significance.
Peripheral circulatory insufficiency brings about cooling of the extremities (hands, feet, tip of the nose, ears), which assume a pale, more or less bluish coloration (cyanosis), owing to the concomitant respiratory insufficiency.
The condition of the nervous system is of great importance in determining the seriousness of the patient’s state, whether one considers higher nervous activity (the specific sensibility of the sense organs, consciousness, mental clarity) or lower activity (general sensibility, reflex activity of vegetative life). At the onset of agony, the first function to be impaired is that of certain sense organs; first of all sight, which weakens until it is extinguished. Hearing activity, however, persists, though with individual variations: sometimes it becomes duller, at other times it retains all its strength or even becomes extremely acute; a fact to be borne well in mind when speaking in the presence of seriously ill persons who apparently lack consciousness. The behaviour of consciousness varies from case to case: while there are patients who are entirely unconscious from the very onset of agony, others remain perfectly lucid until almost the final moments. Not infrequently the patient is disturbed by delusional ideas.
From a practical point of view, it would be highly important to know whether the dying person, even when giving the impression of being completely cut off from the external world by the functional « deficit » of his sense organs, nevertheless retains the inner clarity of his thought and in some way still remains in relation with the external environment, having some sensation of what occurs around him, although unable to communicate his ideas to those nearby and to manifest his will through actions. The problem is of the greatest interest from the affective, juridical, and theological points of view. In discussing it, let us consider separately in man sensibility, intelligence, and consciousness, faculties which in normal conditions coexist and cooperate. Whereas sensibility and intelligence presuppose consciousness, that is, the knowledge which the soul has of its own acts, the question arises whether consciousness, in the condition of mixed nature proper to man, can exist without the sensibility and intelligence by which man is capable of knowing the relations of correlation that facts bear to ideas and ideas to one another. We must admit as certain that in man, given his particular mixed nature, even the highest operations of the spirit are impossible without the anatomical and functional integrity of the nervous centres. In all those cases, therefore, in which we have clear signs of grave lesion or grave functional impairment of the nervous system (of which we may become aware in view of the complete « deficit » of general and specific sensibility and reflex activity), we may hold as certain the extinction not only of intelligence but also of the individual’s consciousness. On the other hand, in those cases in which, although the patient appears devoid of intelligence and unconscious, signs of some activity of the central nervous system persist (automatic movements, moaning, reflexes whose processing centres are in the encephalic portion of the nervous system: coughing, sneezing, sucking, swallowing, blinking), we cannot exclude some elementary activity of the cerebral hemispheres and, correspondingly, a glimmer of inner consciousness such as still to enable the patient to derive benefit from the affectionate and religious assistance of those around him.
Apart from the symptoms detectable through examination of the respiratory and circulatory states and of the nervous system, the agonizing person already presents, at first sight, a posture of the body and an appearance of the face that clearly indicate the approach of death. Hippocrates was the first to describe this in a portrait that still bears his name («Hippocratic facies»): a sharp and cold nose, with drooping wings that move with the respiratory acts; hollow temples and prominent cheekbones; sunken eyes with half-open eyelids, clouded cornea, wandering gaze; dry and cold ears; half-open mouth, with dry, sooty lips; the skin of the forehead and of the entire face taut, pale yellowish or bluish in color, covered with cold, clammy sweat.
If the agonizing person is, for human charity, a most pitiable object of extreme care, he is for the Catholic priest an affectionate object of religious assistance; after the last sacraments, the priest still offers the dying person the final aid of the prayers for the agonizing, while «mysterious relations between brain and consciousness and between the soul and God unfold in the moments when death itself becomes smiling, when it is accompanied by the illumination of the soul sinking into the bosom of God» (A. Carrel, p. 331).
A misguided pity for the sick person, now deemed to have no hope of recovery, in the desire to spare him the terror and suffering of a., advocates the practice of «euthanasia» (v.) intended to extinguish his life prematurely in a painless manner, or at anesthesia (v.) capable of completely abolishing in him not only sensitivity to pain but also consciousness. This is condemned both by natural law and by positive divine law, since it constitutes direct killing, or at least deprives the sick person of the possibility of receiving the aid provided by supernatural means until his final moments, denying him the expiatory benefit of suffering.
In view of the uncertainty we may entertain regarding the possible persistence of consciousness in the agonizing person, and in any case regarding his potentiality for it, it is a duty to attend to the dying person’s social obligations (settlement of unlawful situations) and religious obligations (administration of the sacraments) before he enters agony.
For the religious aspect, V. ANIMA, raccomandazione della.