Does general anaesthesia have a role in end‐of‐life care?

Morgan Liotta

27/04/2021 5:00:49 PM

A new study suggests palliative care patients have a right to be unconscious when they are dying. But what is involved?

Palliative care patient being comforted.
General anaesthesia should be considered as another option to ensure patients are comfortable at the end of their lives, according to experts.

Often regarded as a complex, controversial and overlooked area, the potential role of general anaesthesia in end-of-life care is being explored further.
With no primary care framework currently in the Australian setting, palliative sedation ­– including administration of general anaesthesia to a dying patient – requires examination of the associated ethical, medico-legal, emotional and practical implications, according to experts.
These include patient autonomy, informed consent, hastening of death, cost, religious beliefs, and therapy options.
New research from anaesthesia and medical ethic experts at the Murdoch Children’s Research Institute (MCRI), and the Universities of Melbourne and Oxford claim that general anaesthesia should be more widely available for patients at the end of their lives.
Published in Anaesthesia, the findings review the current role of sedation in end-of‐life care, and whether general anaesthesia is an extension of existing practices in the UK. General anaesthesia in end-of-life care has been used and described in the UK since 1995, with the authors identifying international trends show an increased use of general anaesthesia in this context.
Professor Dimity Pond, a GP with a special interest in aged and palliative care, told newsGP although the study presents an interesting approach ‘well-worth the debate’, there is still a lot to consider.
‘There’s no doubt that general anaesthesia could help dying patients slip away in their sleep. But I’m in two minds about this,’ she said.  
‘I’ve watched a few people dying … and when people are struggling you do want to be able to give them some comfort. Some people will be in great pain and not as well controlled as we’d like, and this would offer an option for those people.
‘It might not just be for pain, but for shortness of breath, and as we’ve seen with COVID, this is very uncomfortable and anxiety-inducing, so anaesthesia could assist with that.
‘On the other hand, many people are also excluded from current assisted dying procedures because they can’t consent, for example people with cognitive impairment and dementia. So they would most likely be excluded from this [approach] as well.’
The study authors emphasise that general anaesthesia in end‐of‐life care is not a form of assisted dying or euthanasia, rather to have more options available to ensure patients are comfortable at the end of their lives. 
Associate Professor Joel Rhee, Chair of RACGP Specific Interests Cancer and Palliative Care, told newsGP that the term ‘general anaesthesia’ needs to be clarified in this context.
‘It is not general anaesthesia requiring intubation [as used for surgery]. Rather, they are describing the use of anaesthetic induction agents, such as propofol, to achieve a state of sedation/anaesthesia that does not require airway support,’ he said.
Associate Professor Rhee cautions that this type of anaesthesia is a ‘potent’ form of palliative sedation, requiring inpatient care and anaesthetics expertise.
‘It’s a highly specialised treatment that should be guided by specialist palliative care teams with experience in using this form of treatment,’ he said.
Pain medication is commonly given to patients who are dying, but the authors say that some terminal or palliative patients will want to be certain they are unconscious and unaware as their final moments arrive, or at least have the option available.
‘For some patients, these common [pain medication] interventions are not enough,’ Professor Julian Savulescu, co-author, Chair of Practical Ethics at the University of Oxford and Visiting Professor at MCRI, said.
‘Other patients may express a clear desire to be completely unconscious as they die. Some dying patients just want to sleep. Patients have a right to be unconscious if they are dying. We have the medical means to provide this and we should.’
Recent findings from a separate UK survey found a high level of support for access to deep sedation in dying patients, with 88% of those surveyed saying they would like the option of a general anaesthetic if they were dying. Nearly two thirds said they would personally choose to have an anaesthetic at the end of life.
But a clear framework needs to be put in place for the Australian setting, according to Professor Pond.
‘I can’t see that we’ve yet got the medical means to provide it to everyone. I think that’s a resource issue,’ she said.
‘And assessing when we need to do this – perhaps not for cases where the existing medications and palliative care processes are sufficient – to avoid the person being in great distress.

‘But [if] basic criteria are needed, then you’re doing these assessments to meet those criteria.’
Associate Professor Joel Rhee says the highly specialised treatment should be guided by specialist palliative care teams. 

It is well known that GPs involved in palliative and end-of-life care have a clear-cut role in supporting these patients and helping to facilitate their wishes.
‘Having an early conversation with the patients is really important,’ Associate Professor Rhee said.
‘Through the process of advance care planning, the patient’s wishes regarding end-of-life care can be discussed, including the possibility of inpatient admissions when necessary to ensure comfort and symptom control.
‘This could avoid a tricky situation of a patient documenting in their advance care directive statements such as, “I do not wish to go to the hospital”, then several months later developing refractory symptoms causing suffering that could be better managed in inpatient settings.’
Cost is another issue when it comes to the option of general anaesthesia, Professor Pond says.
‘Can we as a society afford this? GPs would need extra effort to administer the anaesthesia which can be expensive, so we need the resources in place first,’ she said.
‘My other question is, would this option be only for people who can afford it? That’s another whole set of issues, and potentially deepens the inequalities in our society.
‘Our healthcare system is very stretched at the moment and there are arguably higher priorities to consider.’
The study authors conclude that to be a valid option, general anaesthesia in end‐of‐life care is an ‘impending development’ requiring a ‘clear multidisciplinary framework and consensus practice guidelines’.
‘General anaesthesia in end‐of‐life care raises an important debate about the possible role of anaesthesia in the relief of suffering beyond the context of surgical/diagnostic interventions,’ they wrote.
Professor Pond agrees.
‘As a society, we need to think more about dying because it’s one of those things that happens to 100% of people, but we often prefer not to [think or talk about it],’ she said.
‘We need to gain that space and have a really vibrant, active debate about how we want to preserve people’s dignity [when they are dying].
‘So to have more options available is definitely something to keep in mind.’
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Dr Graham James Lovell   28/04/2021 8:46:01 AM

The AJGP in 12/2019 has a thorough article on Palliative sedation by a hospital based Palliative Care team. However,it is again from a hospital based perspective. The community based GP experience using the standard available medications is in the same journal in 3/2020. This documents over decades of Palliation just how effective the standard drugs are for achieving end of life sedation in home and RACFs. Currently we can’t get patients into our small palliative care units and the demand for their services will only increase. This article highlights the “Elephant in the room “ , that there is a huge need to fund both upskilling of GPs in Palliative care skills, and provide appropriate funding for them to use these skills in home and community settings. Palliative care services are a consultancy, and GPs are still needed for the day to day care of end of life patients.