General anaesthesia in end‐of‐life care: extending the indications for anaesthesia beyond surgery

Abstract

Summary In this article, we describe an extension of general anaesthesia – beyond facilitating surgery – to the relief of suffering during dying. Some refractory symptoms at the end of life (pain, delirium, distress, dyspnoea) might be managed by analgesia, but in high doses, adverse effects (e.g. respiratory depression) can hasten death. Sedation may be needed for agitation or distress and can be administered as continuous deep sedation (also referred to as terminal or palliative sedation) generally using benzodiazepines. However, for some patients these interventions are not enough, and others may express a clear desire to be completely unconscious as they die. We summarise the historical background of an established practice that we refer to as ‘general anaesthesia in end‐of‐life care’. We discuss its contexts and some ethical and legal issues that it raises, arguing that these are largely similar issues to those already raised by continuous deep sedation. To be a valid option, general anaesthesia in end‐of‐life care will require a clear multidisciplinary framework and consensus practice guidelines. We see these as an impending development for which the specialty should prepare. 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.

General anaesthesia in end‐of‐life care: extending the indications for anaesthesia beyond surgery

“…I read the article by Takla et al. [1] with great interest and thank them for bringing attention to this subject. Important questions on the ethics and practicalities of the use of sedative drugs to achieve unconsciousness at the end of life cannot advance without stakeholders agreeing on fundamental definitions.…”

General anaesthesia and euthanasia: difficulties defining the difference in end‐of‐life care

“…The correspondence offers two different perspectives related to our article [1] on general anaesthesia at the end of life (GAEL). Morfey's thoughtful analysis and conclusion [2], that anaesthetists should engage more with the ethical dimensions of inducing unconsciousness, is consistent with the message of our article.…”

“…Following the British Medical Association (BMA) vote to change its position on proposals to legalise physician‐assisted dying in the UK [2], there is a risk that advocating for a shift towards providing general anaesthesia in end‐of‐life care in the presence of the ongoing debate could be misinterpreted as support for physician‐assisted dying. While the authors stress they do not advocate euthanasia [1], we feel it is important to acknowledge the potential crossover and difficulties in distinguishing between the two in end‐of‐life care.…”

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We read with interest the article by Takla et al [1] discussing the potential use of general anaesthesia in palliative medicine. Following the British Medical Association (BMA) vote to change its position on proposals to legalise physician-assisted dying in the UK [2], there is a risk that advocating for a shift towards providing general anaesthesia in end-of-life care in the presence of the ongoing debate could be misinterpreted as support for physician-assisted dying.

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“…Palliative care physicians have extensive expertise and experience in supporting patients (and their families) as they approach the end of life. The sparsity of reported cases of patients requiring low‐dose propofol to prevent suffering in the context of the population makes the need questionable [1], particularly as the authors give no details of other methods used to control symptoms before resorting to the use of propofol. The authors state that “ Terminally ill patients should have a right to the option of anaesthesia as they approach the end of their life ,” but provide no information about workforce issues, particularly as most hospices are in the charitable sector with independent governance processes.…”