The anaesthesiologist and end of life care

Monday 5 June, 10h30-12h00, Room W

This three-part session on the final day of Euroanaesthesia 2017 looks at what the anaesthetist can bring in terms of skills and services to palliative care. In the first talk, Dr Gordon McGinn (Consultant in Anaesthesia and Pain Medicine, Queen Elizabeth University Hospital, Glasgow, UK) will ask “What can the anaesthesiologist offer in palliative care?”

The West of Scotland Interventional Cancer Pain Service is based in the regional cancer centre, servicing a population of 2.5 million.  This is a multi-professional service with input from 2 palliative care consultants, 4 consultant anaesthetists, specialist nurses, specialist physiotherapists and a psychologist.  It offers a two-stage multi-disciplinary assessment for those patients with pain that is either poorly managed utilising standard techniques and / or where adverse effects limit treatment effectiveness.

Of the nearly 400 patients referred, 300 were assessed, of which just under half went on to have an intervention.  Continuous intrathecal infusion is the most frequently undertaken intervention, with most patients having fully implanted pumps.  Other interventions include percutaneous radiofrequency cordotomy, coeliac plexus block / neurolysis, intrathecal neurolysis and a smaller number of miscellaneous procedures.  “Ensuring patient referral in a timely manner was an initial challenge, resolved by ongoing education,” says Dr McGinn.  “Such interventions are highly effective in both relieving pain and improving quality of life.  As such they should not be viewed as a last resort or reserved for the end of life.”

In the second presentation, Dr Vera Peuckmann-Post, based at University Clinic RWTH Aachen, Germany, will discuss non-opioid therapies in palliative care. Dr Peuckmann-Post is an anaesthesiologist who for the last three years has specialised in palliative care.

She says: “Besides general considerations around how to put ‘classical anaesthesiology issues’ into a palliative care perspective, the audience will learn about clinically highly relevant topics such as how to treat intractable pain at the end of life in addition to its management with opioids.”

She adds: “Topics will include lidocaine and ketamine treatment as well as non-pharmacological interventions such as “HIFU” therapy (high intensity focused ultrasound).  Evidence from the literature will be reviewed and case reports will highlight some special topics. Practical guidance in the daily palliative care setting will be given.”

The final presentation will be on “palliative sedation and the double effect theory”, delivered by Dr Nathalie Dieudonné-Rahm, Senior consultant in the Palliative care service, Bellerive Hospital, University Hospitals of Geneva, Switzerland.

According to the European Association for Palliative Care’s definition, palliative sedation refers to the monitored use of medications intended to induce a state of decreased or absent awareness, in order to relieve the burden of otherwise intractable suffering. Indications for palliative sedation are situations with intolerable distress due to physical symptoms or severe non-physical symptoms when death is likely within days. Moral justifications for sedation rely on last resort reasoning, respect of patient’s autonomy, sanctity of life, proportionality and the ‘Double Effect’ theory (DDE).

The origins of DDE can be found in Thomas Aquina’s Summa Theologica. This doctrine says that if doing something morally good has a morally bad side-effect it’s ethically OK to do it providing the bad side-effect wasn’t intended. This is true even if you foresaw that the bad effect would probably happen. For example, in cases where a doctor gives a patient close to death some strong pain killing drugs to relieve distressing symptoms, even though this may shorten their life. The doctor is not trying to kill the patient – the bad result of the patient’s death is a side-effect of the good result of reducing the patient’s pain.

Dr Nathalie Dieudonné-Rahm cautions: “The intentions of sedation may be difficult to validate externally. In addition, moral distinction between sedation’s intended and foreseeable consequences may be denied. Consequently, the DDE comes to be a controversial justification of palliative sedation. But although controversial, the DDE still has a prominent role in deontological models because it helps differentiate between palliative sedation and euthanasia.”