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Anesthesiology in Palliative Care

By February 21, 2020 No Comments

Caring for seriously ill or geriatric patients often means caring for patients who have chronic, painful symptoms or who are approaching the end of life.1 Because of the higher risk of perioperative morbidity and mortality in patients with serious illness, clinicians must consider palliative care strategies before, during and after a procedure for such a patient.1 Palliative care aims to prevent and relieve suffering of patients with life-threatening illnesses and their families.2 This includes treatment of physical pain, psychological issues and spiritual dilemmas, without intending to hasten or postpone death.2 Palliative care is an interdisciplinary effort, involving multiple types of clinicians, patients’ families and the patients themselves.1,3 The anesthesia provider plays a critical role in palliative care and general pain management throughout the perioperative period.3 As a large portion of the world’s population grows older, anesthesiology professionals should familiarize themselves with their part in palliative care and effective ways to provide such care.

Anesthesiology is closely linked to palliative care. While anesthesiology is the practice of medicine dedicated to pain relief and perioperative care, palliative medicine aims to improve a patient’s quality of life by managing pain and other symptoms of a serious illness.3 Thus, the two disciplines share common practices and values.3 Additionally, anesthesia providers are uniquely equipped to provide quality palliative care through their interpersonal skills, experience managing distressed patients and their families, knowledge of analgesic and sedative drugs and ability to monitor vital signs.4 Historically, anesthesia providers’ main motivation was to reduce perioperative mortality as much as possible. However, modern improvements in education, monitoring technologies and anesthetic drugs have allowed surgical intervention for seriously ill or frail patients, making anesthesiologists’ role more complex.3 Contemporary anesthesiology professionals attend to these patients in a way that is more layered than simply avoiding perioperative complications.3 Preoperative preparation with palliative care strategies involves determining if the surgery is appropriate and aligns with the patient’s ultimate goals.5 Intraoperatively, the anesthesia provider’s duty is to make sure the surgery goes as safely as possible. The focus of postoperative care for a terminally ill patient is managing pain and symptoms, getting the patient home or to hospice as soon as possible and reducing complication rates.5 In order to help anesthesia providers prepare for the symptom management and difficult conversations that palliative care entails, Hospice and Palliative Medicine has become a specialty option for anesthesiologists6 and certified registered nurse anesthetists (CRNAs).7 Clearly, anesthesia providers are well-positioned to reduce the suffering of seriously ill patients and their families throughout the perioperative period or in inpatient units.

Anesthesia providers can use a variety of pharmacologic agents to provide palliative care. For example, research shows that ketamine has been effective in opioid-resistant postoperative pain control.8 It is also commonly used for metastatic cancer pain, and can be helpful in improving end-of-life care for cancer patients.9 Additionally, many researchers cite the usefulness of propofol in palliative and terminal care. In a study by Moyle, propofol was more effective than benzodiazepines in sedation for terminally ill patients who were severely agitated or delirious.10 Meanwhile, Lundström et al. found that propofol was able to effectively sedate and reduce vomiting in patients in a palliative inpatient unit who did not respond to benzodiazepines.11 McWilliams et al. also found that propofol was useful for end-of-life sedation when other drugs had failed.12 Though data is limited on regional anesthesia for palliative care in children,13 research by Anghelescu et al. found that epidural and peripheral nerve blocks can provide analgesia and reduce opioid requirements in children who have terminal cancer.14 Wohlt and Fine suggest that dexmedetomidine, a sedative and analgesic drug, may help patients in hospice and palliative care settings whose symptoms do not respond to usual therapies.15 Evidently, a variety of anesthetic and analgesic medications can be applied to the palliative care arena.

Anesthesiology professionals may have a vital role in palliative care, given their skills in communication with patients and families, pain management and medication administration. The anesthesia provider can give palliative care solutions to terminally ill patients during the perioperative period or in inpatient settings. Drugs such as ketamine, propofol, nerve blocks and dexmedetomidine may provide adequate sedation and symptom reduction for patients who are at the end of life. Future research should include nonpharmacologic analgesic solutions for palliative care, such as electroacupuncture. Additionally, studies on anesthesia-related palliative care interventions should be standardized in order to adequately compare their efficacies.16

1.         Gustin AN. Palliative Care for the Anesthesia Provider. In: Reves JG, Barnett SR, McSwain JR, Rooke GA, eds. Geriatric Anesthesiology. Cham: Springer International Publishing; 2018:481–491.

2.         World Health Organization. WHO Definition of Palliative Care. Cancer 2020; https://www.who.int/cancer/palliative/definition/en/.

3.         Fine PG, Davis MS, Muir JC, Byas-Smith M. Anesthesiology and Palliative Care: Past, Present, and Future. Anesthesia & Analgesia. 2018;127(1):12–14.

4.         Fine PG. The evolving and important role of anesthesiology in palliative care. Anesthesia & Analgesia. 2005;100(1):183–188.

5.         Forner K. Palliative Care and the Perioperative Surgical Home. ASA Newsletter. 2015;79(11):28–30.

6.         Gebauer S. Hospice and Palliative Medicine as a Specialty Option for Anesthesiologists. ASA Newsletter. 2016;80(10):8–9.

7.         Faircloth AC. Anesthesia Involvement in Palliative Care. Annual Review of Nursing Research. 2017;35(1):135–158.

8.         Fine PG. Ketamine: From anesthesia to palliative care. AAHPM Bulletin. Spring 2003;3(3):1.

9.         Kurdi MS, Theerth KA, Deva RS. Ketamine: Current applications in anesthesia, pain, and critical care. Anesthesia, Essays and Researches. 2014;8(3):283–290.

10.       Moyle J. The use of propofol in palliative medicine. Journal of Pain and Symptom Management. 1995;10(8):643–646.

11.       Lundström S, Zachrisson U, Fürst CJ. When Nothing Helps: Propofol as Sedative and Antiemetic in Palliative Cancer Care. Journal of Pain and Symptom Management. 2005;30(6):570–577.

12.       McWilliams K, Keeley PW, Waterhouse ET. Propofol for Terminal Sedation in Palliative Care: A Systematic Review. Journal of Palliative Medicine. 2010;13(1):73–76.

13.       Rork JF, Berde CB, Goldstein RD. Regional Anesthesia Approaches to Pain Management in Pediatric Palliative Care: A Review of Current Knowledge. Journal of Pain and Symptom Management. 2013;46(6):859–873.

14.       Anghelescu DL, Faughnan LG, Baker JN, Yang J, Kane JR. Use of epidural and peripheral nerve blocks at the end of life in children and young adults with cancer: The collaboration between a pain service and a palliative care service. Pediatric Anesthesia. 2010;20(12):1070–1077.

15.       Jackson KC, Wohlt P, Fine PG. Dexmedetomidine: A Novel Analgesic with Palliative Medicine Potential. Journal of Pain & Palliative Care Pharmacotherapy. 2006;20(2):23–27.

16.       Aslakson R, Cheng J, Vollenweider D, Galusca D, Smith TJ, Pronovost PJ. Evidence-Based Palliative Care in the Intensive Care Unit: A Systematic Review of Interventions. Journal of Palliative Medicine. 2014;17(2):219–235.