Question: A 95 year old relative died alone during the night in a hospital. She had suffered a fall which worsened a back injury and had to be admitted to hospital. She was administered regular morphine which seemed to me to work quite well in alleviating her pain. I was told that she was terminal and that once her BP fell below a certain level all medications except comfort measures would be ceased. This is what happened. She also lost her appetite and starting drinking very little. In the last two days of her life she had nothing to eat or drink at all and couldn't talk. It is uncertain as to whether she could register anything that was said to her. However, she died with her eyes opened and I don't know the significance of this is. I doubt that she died in pain and she didn't seem to have a grimace, although she wore top dentures which were not in place at the time and this made it difficult to determine her facial expression. Is there any evidence that people who die with their eyes open are in some sort of discomfort (but not necessarily pain) or fear at the time of death. She had tachycardia but was taken off the medication. Is it possible that the heart rate increased so much before her pulse rate crashed that this could have awakened her? Please don't be diplomatic about this. I need to know the truth.

Thank you Dr. Divakara for the benefit of your expertise. I appreciate the difficulty in answering my questions, especially since you weren't even present at the time. I remember that after the relative was taken off her beta-blocker her geriatrician said that she had developed tachycardia (although I don't know the exact HR at the time) and she was not in pain then. However, for all I know, the tachycardia could have become worse just before she died. Her systolic BP had previously fallen between 80 and 90. I don't know whether it would have remained like that or gone back up since observations were ceased. However, the morphine seemed to do a good job of alleviating severe back pain (although she was stationary in bed) and I wonder whether, if it could do that, there is a reasonable probability that she wouldn't have experienced pain if the tachycardia became worse at the very end. Of course, I appreciate that there are other forms of discomfort besides pain. During her last two days she only fully opened her eyes on a small number of occasions and I thought it was odd that her eyes were fully open at the time she died. You have, however, told me that this of itself does not always indicate pain or discomfort, but may just indicate that the patient was conscious. She did not have any other serious medical conditions before she died, although she would have been dehydrated (n/s was ceased days earlier and she had nothing at all to eat or drink for two days). If you were to have an informed guess based upon your expertise and experience and the overall information that I have provided, would you be inclined to think it was more or less likely that she was in pain at the time of death? As it is not possible for you to know, this may be an unfair question to ask of you. Also, although morphine is used to treat pain, can it also have the effect of diminishing other sensations such as any discomfort caused by tachycardia? Unfortunately, I do not know when she had her last administration of regular morphine.