Agony

AGONY. - From ἀγωνία = struggle, anxiety, anguish; "the final struggle of the body against death" (cf. Vocab. lingua ital. della R. Accad. d'Ital., s.v.). It presents a different aspect in length and in violence, according to the duration of the illness, the organic resistance, the age of the sick person. Rapid and burning in violent traumas, poisonings, acute infections; long, at times lasting for days, when the organism has almost become accustomed to difficult living conditions through a slow, chronic wearing down (tuberculosis, tumors, long-running heart disease); it is completely absent in cases of sudden death, in which the cause is so violent or so sudden as to snuff out life at a stroke, without any possibility of struggle. Given such a variety of pictures, it can be difficult, particularly for one who is not a physician, to establish its onset and its course; on the other hand, it is of great importance for the priest to realize such extreme conditions of the sick person in order to provide particular assistance in "articulo mortis." The state of agony can best be revealed by the observation of the three principal functions of the organism: two of the vegetative life, respiration and circulation; one of the life of relation, the activity of the nervous system.

Respiration, which already in the course of the illness has varied considerably in its characteristics, undergoes at the onset of agony the most serious alterations in frequency, in intensity, in rhythm; particularly the latter marks the tempo and undergoes the most profound modifications as death approaches. The so-called Cheyne-Stokes periodic respiration is characterized by a group of respiratory acts that first increase in intensity up to a maximum and then gradually become more shallow until they die away; there follows a pause of apnea more or less long (up to many seconds) and then a new group of respiratory acts with the same characteristics of crescendo and diminuendo; in the pause of apnea the patient loses consciousness completely or in part, the pupils contract and no longer react to light, the eyes close, the pulse becomes smaller and more frequent, the head falls back reclined and the individual takes on the appearance of a dead person; the resumption of a new cycle of respiratory acts causes this complex of signs to recede, while the sick person regains consciousness and, as if waking from sleep, takes up the interrupted word, strains to sit up in bed, becomes agitated in the anxiety of an end that he feels is near, imploring help from those around him. The definitive cessation of breathing, which corresponds to the passage into death, coincides with one of these pauses. Cheyne-Stokes, although in particular cases it can last for days or even weeks and at times cease completely, is ordinarily to be considered a sign of high gravity, which death follows within a few hours. Respiration often takes on in agony a sonorous gurgling character (tracheal rattle) because of the passage of air through the catarrh accumulated in the trachea and in the pharyngo-laryngeal tract; the frequency, which increases in the course of the illness in relation to the rise of fever, to the toxic state, to possible broncho-pulmonary complications, becomes slow and the act labored.

Circulation can give us important signs as to the onset and the progression of the agonal state. The pulse, with the weakening of the heart, becomes smaller (that is, it beats with less energy under the finger that palpates it) and more frequent, so that, with the worsening of the sick person's condition, it exceeds 110-120 pulsations per minute, reaching in the final moments 130-140, often almost imperceptible to palpation or perceptible only on less peripheral arteries and therefore closer to the heart (temporal, in front of the tragus of the ear; external carotid, beneath the angle of the mandible, close to the anterior margin of the sternocleidomastoid muscle). The elevated frequency of the pulse has value only if accompanied by the other signs of gravity of the sick person, since there exist disturbances of cardiac rhythm in which there may be a very high frequency (180-250 pulsations per minute), transitory and accompanied by normal conditions of health of the individual. Irregularity of the pulse (arrhythmia, intermittence), if joined with the other signs of worsening and particularly if it replaces a previous regularity, has a grave significance.

Peripheral insufficiency of the circulation brings about the cooling of the extremities (hands, feet, tip of the nose, ears), which take on a pale color more or less bluish (cyanosis) because of the contemporaneous respiratory insufficiency.

The state of the nervous system is of great importance for determining the conditions of gravity of the sick person, whether one considers the higher nervous activity (specific sensibility of the organs of sense, consciousness, mental lucidity) or the lower (general sensibility, activity of the reflexes of vegetative life). With the establishment of agony, the first to be damaged is the activity of certain organs of sense; in the first place sight, which grows faint until it is extinguished; the activity of hearing, on the other hand, persists, though with individual variations, so that while at times it becomes more dull, at others it retains all its strength or even becomes extremely acute; a fact to be kept well in mind when speaking in the presence of gravely ill persons apparently deprived of consciousness. The behavior of consciousness varies from case to case, so that while there are sick persons who already at the onset of agony are completely unconscious, there are others who are fully lucid almost to the final moments. Not rarely the sick person is agitated by delirious ideas.

It would be very important from the practical point of view to be able to know whether the dying person, even if he gives the impression of being completely separated from the external world because of the functional "deficit" of his organs of sense, nevertheless retains the internal lucidity of his own thought and in some manner remains still in relation with the external environment, having some sensation of what is happening around him, even though he cannot communicate his own ideas to those around him and manifest his will by acts. The problem is of the greatest interest from the affective, juridical, and theological point of view. In order to discuss it, let us consider separately in man sensibility, intelligence, and consciousness, faculties that, under normal conditions, are coexistent and cooperating. While sensibility and intelligence presuppose consciousness, that is, the knowledge that the soul has of its acts, the doubt arises whether consciousness, in the condition of mixed nature proper to man, can exist without the sensibility and the intelligence with which man is able to know the relations of correlation that facts have with ideas and these among themselves. We must admit as certain that in man, given his particular mixed nature, even the highest operations of the spirit are not possible without the anatomical and functional integrity of the nervous centers. In all those cases, therefore, in which we have clear signs of grave lesion or grave functional suffering of the nervous system (of which we can become aware having regard to the complete "deficit" of general and specific sensibility and of reflex activity), we can hold as certain the extinguishing not only of the intelligence, but also of the consciousness of the individual. On the other hand, in those cases in which, although the sick person appears deprived of intelligence and unconscious, there persist signs of some activity of the central nervous system (automatic movements, moaning, reflexes whose centers of elaboration are in the encephalic portion of the nervous system: cough, sneeze, sucking, swallowing, blinking), we cannot exclude some elementary activity of the cerebral hemispheres and correspondingly a glimmer of internal consciousness such as still to permit the sick person to derive an advantage from the affective and religious assistance of those around him.

Apart from the symptoms detectable through examination directed at the state of respiration, circulation, and the nervous system, the dying person presents, even simply at first glance, a posture of the body and an appearance of the face that clearly betray the approach of death. Hippocrates was the first to describe this in a picture that still goes by his name ("Hippocratic facies"): sharp and cold nose with flaring nostrils that move with the acts of respiration; hollow temples and prominent cheekbones; sunken eyes with half-open eyelids, clouded cornea, wandering gaze; dry and cold ears; half-open mouth, with dry and sooty lips; skin of the forehead and of the whole face taut, of a pale yellowish or bluish hue, covered with cold, clammy sweat.

If the dying person represents for human charity a most pitiable object of extreme care, he is a loving focus of religious assistance for the Catholic priest who, after the last sacraments, still offers the dying man the final aids of the prayers of the dying, while "mysterious relations between brain and consciousness and between the soul and God unfold in the moments in which death itself becomes smiling, when it is accompanied by the illumination of the soul that plunges into the bosom of God" (A. Carrel, p. 331).

A misguided pity for the sick person, judged by now without hope of recovery, in the desire to spare him the terror and suffering of agony, advocates the practice of "euthanasia" (v.) aimed at extinguishing his life ahead of time in a painless manner or at least the use of an anesthesia (v.) such as to abolish in him completely not only sensitivity to pain but also consciousness. This is condemned both by natural law and by positive divine law, representing a direct killing, or at least depriving the sick person of the possibility of the succor provided by supernatural means up to the final moments, depriving him of the expiatory benefit of suffering.

Given the uncertainty we may harbor about the possible persistence of consciousness in the dying person, in any case about its potentiality, it is a duty to provide for the social obligations (settling of illegal situations) and religious obligations (administration of the sacraments) of the dying person before he enters into agony.

For the religious part, v. ANIMA, raccomandazione della.

Giuseppe de Ninno