Anesthesia in End-of-Life Care

In an April 2021 review article in Anaesthesia, Oxford University ethicists and anesthesiology experts called for the expanded use of general anesthesia in end-of-life care. For patients experiencing exceptionally challenging symptoms at the end of life, palliative sedation is a well-established alternative to administering high doses of analgesia,¹ with studies indicating that it has been used in 15 to 30 percent of terminally ill patients.² While gradual sedation that lessens intense suffering is generally accepted within palliative care, there has historically been more opposition to deliberately inducing full unconsciousness at the end of life. However, a recent survey of British public opinion by the Oxford researchers reports that 88 percent of individuals would like to have the option of unconsciousness in end-of-life care, a practice known as “terminal anesthesia,” prompting calls to widen this practice.³

In the review article, the authors write that wishes to eliminate experiences of physical or mental suffering are understandable. Physicians frequently recognize this in other circumstances by accommodating patients’ requests for general anesthesia for minor surgeries, such as tooth extractions, where mild sedation is sufficient to eliminate pain.¹ The literature surrounding palliative sedation is already robust: in the early 1990s, Nathan Cherny and Russell Portenoy described how sedation can be used for patients experiencing “refractory symptoms,” such as pain, delirium, distress, or dyspnea that cannot be adequately controlled. Their algorithm for determining the appropriate use of sedation has since been adopted and refined by other researchers.⁴

In 1995, anesthetist and palliative care physician John Moyle developed a protocol for infusing propofol in end-of-life care to induce full unconsciousness. He described the protocol’s use in two patients who died peacefully after four and nine days of continued administration. Roughly 25 publications, case series, and reviews since Moyle’s article have described using propofol infusions at the end of life. These publications have a broad scope, ranging from reports on the demonstrated efficacy of the practice,² its ability to be incorporated into certified registered nurse anesthetists’ areas of expertise,⁴ and its applications for use in terminally ill children.⁵ The authors of the Anaesthesia review article argue that the Moyle protocol can be refined for widespread use in the modern era. In 2016, France passed a law that gave terminally ill patients the right to continuous sedation and established broad principles for how to achieve this state, if the patient is believed to be within 14 days of death.⁶

In the United States, palliative sedation is legal, with the Supreme Court supporting the right of informed patients to pursue relief of suffering even if doing so may unintentionally hasten death,⁴ as can be the case with high doses of analgesia.¹ Nonetheless, other ethical concerns exist, including patients’ conflicting definitions of pain, their autonomy at the end of life, and their continued feeding and hydration. Similarly, there is significant debate on physician-assisted dying,⁴ which is largely illegal in the United States (only 10 U.S. jurisdictions have “death with dignity” legal statuses), and distinctions between it and terminal anesthesia.⁷

Whether the ASA will actively support the practice remains to be seen. In Britain, at least, over half of those surveyed believe that terminal anesthesia and euthanasia are distinct from each other. Two-thirds believe that doctors should be allowed to induce unconsciousness in dying patients, and roughly the same number indicated that they would potentially desire this at the end of their own lives.³

References

1. Takla A, Savulescu J, Wilkinson DJC, Pandit JJ. General anaesthesia in end-of-life care: extending the indications for anaesthesia beyond surgery. Anaesthesia. Published online 2021. doi:10.1111/anae.15459
2. Lundström S, Zachrisson U, Fürst CJ. When nothing helps: propofol as sedative and antiemetic in palliative cancer care. J Pain Symptom Manage. 2005;30(6):570-577.
3. Takla A, Savulescu J, Kappes A, Wilkinson DJC. British laypeople’s attitudes towards gradual sedation, sedation to unconsciousness and euthanasia at the end of life. PLoS One. 2021;16(3):e0247193.
4. Wolf MT. Palliative sedation in nursing anesthesia. AANA J. 2013;81(2):113-117.
5. Miele E, Angela M, Cefalo MG, et al. Propofol-based palliative sedation in terminally ill children with solid tumors: A case series: A case series. Medicine (Baltimore). 2019;98(21):e15615.
6. McCall B. Widen use of general anesthesia in end-of-life care, say experts. Medscape. Published April 23, 2021. https://www.medscape.com/viewarticle/949894
7. Death with dignity acts. Death With Dignity. Published November 6, 2015. https://deathwithdignity.org/learn/death-with-dignity-acts