Anesth Analg 2005;100:183-188
© 2005 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000141061.74294.DE
SPECIAL ARTICLE
The Evolving and Important Role of Anesthesiology in Palliative Care
Perry G. Fine, MD
Department of Anesthesiology, Pain Management Center, University of Utah, Salt Lake City, Utah
Address correspondence and reprint requests to Perry G. Fine, MD, Department of Anesthesiology, Pain Management Center, Ste. 200, 615 Arapeen Dr., University of Utah, Salt Lake City, UT 84109. Address e-mail to fine{at}aros.net
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Abstract
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A small but clinically significant proportion of dying patients experience severe physically or psychologically distressing symptoms that are refractory to the usual first-line therapies. Anesthesiologists, currently poorly represented in the rapidly evolving specialties of hospice and palliative medicine, are uniquely qualified to contribute to the comprehensive care of patients who are in this category. Anesthesiologists’ interpersonal capabilities in the management of patients and families under duress, their knowledge and comfort level with the application of potent analgesic and consciousness-altering pharmacology, and their titrating and monitoring skills would add a valuable dimension to palliative care teams. This article summarizes the state of the art and means by which anesthesiologists might contribute to improvements in the important end-of-life outcome of safe and comfortable dying.
IMPLICATIONS: Safe and comfortable dying at the end of a progressive, life-limiting illness are key outcome measures in end-of-life care and are high priorities voiced by patients and their families. Anesthesiologists have unique skills that could greatly improve these critically important outcomes.
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Introduction
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Distressing symptoms are common with progressive, life-limiting chronic diseases, such as cancer, heart failure, emphysema, and neurodegenerative disorders, especially in their far-advanced stages (1). Causes for suffering include disease-mediated symptoms, such as pain, dyspnea, and fatigue. Depression, anxiety, and loss of a sense of purpose in living (feelings of uselessness) often accompany those with end-stage diseases (2). Finally, and more difficult to quantify, are the existential or spiritual dimensions of suffering. Progressive loss of function and dramatic changes in previously held status and roles within family and social or occupational domains can cause an overwhelming sense of despair. It is only within the last several years that clinical studies have illuminated and detailed the incidence, prevalence, and severity of distressing conditions among the dying (3).
It has been widely recognized that there is room for significant improvement in end-of-life care in the United States (4,5). Professional education programs, undergraduate and graduate curriculum expansion, increased access to hospice care, and development of inpatient palliative medicine services are all areas where some progress is taking place (6–8). Treatment of cancer pain was the initial focus of palliative care efforts spearheaded by the World Health Organization (WHO) (9). A relatively easy-to-follow generic approach to cancer pain management, the WHO three-step ladder, has been validated as being useful for most patients with cancer-related pain in many settings, but a subset of patients remains for whom this approach does not lead to effective pain relief (10). Additional recommendations, elaborations, and refinements to this original basic guideline have been published and widely disseminated by governmental bodies, such as the (former) Agency for Healthcare Policy and Research (now the Agency for Healthcare Research and Quality) and professional organizations such as the American Society of Anesthesiologists, American Pain Society, and American Geriatrics Society (11–13).
From the limited data available, it appears that the vast majority of patients could experience comfort and relief from most distressing symptoms were available guidelines and principles of interdisciplinary palliative care conscientiously applied (14). In other words, not only have we identified a serious and ubiquitous public health problem, but we also have ample means at our disposal, if we implement them, to effectively manage this problem for most patients. What appears equally evident is that there are some patients for whom these usually relatively simple and straightforward modalities of supportive and pharmacological therapy do not provide ample relief from pain or other types of suffering. Few studies have quantified the use of anesthesiology pain specialists to remedy the prevalent public health problem of insufficient pain control in those with far-advanced disease. One survey in Scotland suggests that, of the 8%–20% of cancer patients who have indications for treatment by anesthesiology pain specialists, few patients are ever referred for specialty pain consultation (15).
Anesthesiologists, because of their combination of skills, are uniquely qualified to care for dying patients. These skills include knowledge of analgesic and sedative pharmacology for the management of pain; awareness of perceptual alterations, along with well honed skills in drug titration; and experience with critically ill and highly anxious, often agitated, patients (and family members) under stressful circumstances. This topic has few citations in the literature and has none from the United States. A study performed in Italy described a newly established "Pain and Palliative Care Unit" staffed by anesthesiologists (16). It documented 460 admissions in its first full year of operation. Although no specific comparative outcomes were described, it may be inferred, because these patients were referred for care and received expert-level interventions, that they received a qualitatively better level of care than they otherwise would have received.
The purpose of this article is to characterize the type of patient in whom anesthesiologists’ particular skills may contribute to improvements in end-of-life care. It is time to bridge the best of modern-day anesthesiology and palliative care with our most cherished traditional values and duties of physicianhood.
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Intractable Symptoms
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There are many symptom complexes that are often experienced by patients with far-advanced diseases of all types, but the burdens of illness have been studied and categorized most thoroughly in cancer patients (10). These distressing symptoms are often interrelated and include pain, dyspnea, nausea/vomiting, pruritus, skin lesions, diarrhea, fatigue, depression, anxiety, and agitation. When usual and familiar means of managing these signs and symptoms of progressive, life-limiting disease are not adequate, dying becomes an onerous process for the patient, family members, and professional caregivers. The opportunity for a "good death" and any opportunity for "dying well" is replaced with an oppressive and dismal sense of fatality and horror. This can, and does, lead to various degrees of abandonment because witnessing such suffering, and feeling helpless to relieve it, can be torturous. Family members and other loved ones are then burdened by immutable memories of this suffering, which can lead to pathologic and protracted grief. A wish for a premature death—by patients who are in the throes of these experiences or by those who fear this type of egregious situation as their own lives progress—is a tragic, but real, consequence of untreated extreme suffering (17).
Clearly, disease-mediated physical symptoms have an emotional effect, and one’s psychological state affects sensory perceptions. The International Association for the Study of Pain definition of pain, for example, takes this into account, elaborating pain as a sensory and emotional experience. Furthermore, an interdisciplinary approach to assessment and management that understands, respects, and attends to the complex biopsychosocial and spiritual nature of human beings confronted by terminal disease leads to better outcomes (e.g., patient preferences are acknowledged and met, anxiety is assessed and effectively reduced through nonpharmacological and/or pharmacological means, and pain is controlled to a patient’s level of comfort) compared with more traditional medical models (14). Nonetheless, it is practical to divide seemingly intractable symptoms into two distinct categories—physical and emotional/existential—although treatment paths may converge.
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Intractable Pain and Total Analgesia
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To most effectively deal with all patients with pain, a modification of the traditional WHO stepladder is necessary (Fig. 1). This modification takes into account the role of additional pain management interventions when rational trials and upward titration of antiinflammatory drugs, pain-modulating/-attenuating drugs (adjuvant analgesics), and opioid analgesics do not effectively control pain or when adverse effects add more burden than benefit.
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Figure 1. Modification of the World Health Organization stepladder approach to pain control. NSAID = nonsteroidal antiinflammatory drug.
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When clinical circumstances preclude any other reasonable or practical alternatives, especially specific or targeted pain-reducing interventions, or when death is imminent, inducing a state of "total analgesia" may be indicated. In this context, total analgesia (differentiated from anesthesia) is heretofore defined as a state of minimal or absent pain perception in the face of a potent neuropathic or nociceptive pain stimulus without intentional alteration in situational awareness. In these circumstances, the therapeutic goal is pain relief—not sedation, amnesia, or unconsciousness. Currently, the most useful drug available for this purpose is ketamine, administered in subanesthetic doses (18).
IV or subcutaneous administration is most reliable and readily titrated, starting with a bolus dose of ketamine 0.1 mg/kg. An IV or subcutaneous continuous infusion is initiated at a rate determined by the total dose and duration of effect of bolus doses. For example, if a patient gets sufficient pain relief for 15 min from 5 mg of ketamine, then an infusion of 20 mg/h would be appropriate. In patients who have been receiving large-dose opioids, it has been found that it is often possible (and desirable) to immediately reduce the opioid dose by 25%–50% and then slowly titrate downward, depending on the patient’s pain reports and cognitive/behavioral status. In so doing, undesirable large-dose opioid effects, such as sedation or myoclonus, can be avoided. In reports of this subanesthetic dosing technique for analgesia, typical effects of anesthetic doses of ketamine (e.g., salivation, sedation, loss of airway reflexes, and hallucinosis) do not pose problems (18,19). IV or subcutaneous lidocaine infusion also has been described as useful for neuropathic pain conditions intractable to other conventional modalities, although there are no comparative studies of efficacy, safety, or outcomes (20,21). With these techniques, alone or in combination, it has been my experience and that of other investigators and clinicians that the most excruciating pain-producing disorders in patients with terminal disease can be effectively treated to the extent that a calm, comfortable dying can occur.
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Existential Exhaustion and Total Sedation
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Various expressions have been used to describe the state of mind of some patients with far-advanced disease, when consciousness becomes oppressive and they desire to absent themselves from awareness. These terms include intractable suffering, existential exhaustion, life fatigue, terminal despair, and demoralization syndrome (22). The term total sedation was invoked to describe the clinical process of eliminating awareness or consciousness in distressed or exhausted patients with far-advanced disease who are not expected to live very long (23). This time period is not crisply defined, but a range of days to weeks is the intended frame of reference. Use of this updated terminology distinguishes this palliative intervention from the more ambiguous older term terminal sedation, which implied a life-ending intervention.
The request for deep sedation by the patient (or proxy) may or may not be accompanied by a wish to "end it all," but for ethical and legal reasons it is important to clarify and define the goals of therapy. To outline a care plan whose goal is to relieve the suffering caused by awareness is ethically and legally distinct from one whose purpose is to cause or hasten death (24). This is a critical ethical and legal distinction that lays the foundation for clear communications and treatment objectives among all stakeholders (patient, family, nurses, doctors, clergy, and others). The incidence of this intervention, at least as reported in the literature, has a broad range (from <1% to 30% of dying patients). The reasons for this wide degree of variation in practice are not well described (25,26).
Various routes of administration and different classes of drugs can be used to induce a state of total sedation. To effect total sedation with safety and efficacy, parenteral routes (subcutaneous or IV infusion) are the most reliable and predictable, allowing for rapid dose titration according to each individual patient’s needs, circumstances, and changes in clinical condition (23). No adequately controlled clinical trials have compared various classes of drugs in terms of effectiveness or safety, so the choice must be made on the basis of the treating physician’s experience with these drugs and the patient’s clinical circumstances and setting (Table 1).
The use of deep sedation as a respite measure in chronically ill patients who are not expected to die soon, but who may be experiencing the same degree of emotional fatigue as their more gravely ill counterparts, has not been addressed to the same degree in the medical ethics community. It is anticipated that deep sedation as a therapy in and of itself, independent of providing relief from a painful or distressing medical or surgical procedure, would be extremely controversial. Use of such an intervention could have great salutary benefit but might also have substantial abuse potential and carry associated risks. However, in light of the increasing numbers of patients experiencing multiple debilitating chronic conditions that are not imminently lethal but are emotionally exhausting, it may be time to open this topic in the rapidly evolving field of palliative medicine ethics.
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Conclusion
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Palliative care programs that meet physical, emotional, and spiritual needs effectively address the chief concerns voiced by those facing life-limiting illness (32,33). There is a subset of patients for whom conventional approaches to pain and symptom management do not provide adequate comfort. In these cases, immediate consultation with someone who has expertise in the management of these more complicated patients would be consistent with the referral/consultation paradigm followed in all other areas of medical practice. Anesthesiologists, by virtue of their unique training, should logically serve in this capacity. To meet this challenge, grounding in both the pragmatic and ethical issues of end-of-life care is necessary. In providing such grounding, we can assure all patients (and those who care about them and for them) that they need not fear a torturous end to their lives. There is always something that can be done—safely, ethically, and legally—that coincides with our duty to cure when possible and provide comfort always.
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Case Studies
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Intractable Pain and Total Analgesia
A 38-yr-old woman with metastatic adenocarcinoma of the cervix had severe pain in her pelvis, low back, and lower extremities that was due to tumor-induced compressive lumbosacral radiculopathy. She had undergone surgical resection, chemotherapy, and palliative radiation therapy. Because of pain and weakness, she was bedridden. She was cachectic, intermittently agitated, and unable to focus on anything but her pain because of its excruciating and constant nature. As a result, her husband and school-age children were unable to interact with her, and this caused great emotional distress for all of them. She was brought under the care of a hospice team upon recognition that she was in the terminal phase of this disease. Attempts to relieve her pain with opioids, antiinflammatory drugs, tricyclic antidepressants, and antiepilepsy drugs (adjuvant analgesics) had been unsatisfactory, causing confusion and obtundation without comfort. Regional analgesic/anesthetic techniques (e.g., spinal opioid analgesia) were contraindicated because of chronic anticoagulation therapy for recurrent deep venous thrombosis. A trial dose of ketamine 0.1 mg/kg was administered via "butterfly" IV catheter; this provided almost 1 h of near-complete relief of all pain. She was able to undergo personal care (bed-bath and skin massage) comfortably. She was quite sleepy, so the decision was made to reduce her current subcutaneous hydromorphone dose by 50% and to start ketamine at an initial rate of 0.1 mg · kg–1 · h–1 through her subcutaneous administration site after a repeat bolus dose. Over the course of the next several days, she was able to spend several minutes at a time hugging her children and relating with her husband, reporting her pain to be barely noticeable. She stated that she felt somewhat "spacey," but it was not unpleasant or distressing to her compared with her previous pain. The hospice staff inquired about "bad dreams," but the patient did not recount any. She continued to have no interest in food or fluid intake, and she became oliguric and then comatose after several days. She died 10 days after the initiation of ketamine therapy, appearing comfortable, with her family at the bedside.
Existential Exhaustion and Total Sedation
A 52-yr-old electrician had been in decline from amyotrophic lateral sclerosis over several months and had been admitted for 2 hospitalizations because of aspiration pneumonia that required intubation and ventilation. He had lost all motor control of his extremities and required total care. His family was able to provide this, but the patient had made the decision, after much psychiatric and pastoral counseling, that he did not want to be ventilator-dependent, nor did he want a gastric feeding tube placed (this had been recommended to deal with his dysphagia and progressive malnutrition). He was being treated with lamotrigine and small-dose oral morphine concentrated solution, which effectively controlled pain and dyspnea. He had been on several different trials of selective serotonin reuptake inhibitor antidepressants for treatment of depression over the previous year. With the help of a counselor and in the company of his wife, he created an advance directive, stating that he did not want any further attempts at resuscitation or hospitalization, nor did he want the use of means to prolong his dying. He expressly conveyed that when the time came that he was no longer able to communicate at all, he would like to go to bed and discontinue all non–symptom-control medical interventions, including oxygen therapy and ingestion of any food or fluids. He wanted to go to sleep and not wake up. His religious beliefs proscribed suicide, and he clearly differentiated this from wanting to be relieved of his suffering caused by being constantly aware of his grievous circumstances. His family and doctors stated that they would abide by his wishes, bringing in a home-based hospice team familiar with the management of cases such as his. The hospice provided psychosocial support to the family and continued to evaluate and treat the patient for depressed mood and other distressing symptoms. Spiritual care was coordinated with the family’s minister. When the patient was no longer able to effectively communicate except with grunts and indicated that he wanted total sedation, this was provided at home by using an infusion of IV midazolam and morphine and was titrated to maintain sleep and absence of dyspnea through the patient’s appearance of comfort. Oral and skin care was maintained. The patient died in apparent comfort after 3 days, with his family in attendance.
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Footnotes
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This article is adapted from the 22nd Annual John J. Bonica Lecture, presented at the University of Washington, Seattle, WA, September 23, 2003.
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Accepted for publication July 16, 2004.
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Abstract
Introduction
