Palliative Care: Another Role For ‘Titrationologists’?

Perry Fine, MD, believes anesthesiologists should play a role in the delivery of palliative care.

“We as anesthesiologists are perfectly aligned to spend more of our time, knowledge and skills involved with patients who are facing end-of-life issues or are actively suffering,” the professor of anesthesiology at the University of Utah and strategic advisor to Capital Caring, Washington D.C., told the audience gathered for the R.W. Robertazzi Memorial Panel during the 68th New York State Society of Anesthesiologists’ PostGraduate Assembly (PGA).

“It is by virtue of our expertise that we are obligated ethically to become involved,” he added.

Dr. Fine and Amy Alvarez-Perez, MD, a palliative care physician in the Department of Supportive and Palliative Care, Roswell Park Cancer Institute, Buffalo, N.Y., discussed the ethical and legal issues surrounding the provision of palliative care—and the potential role for anesthesiology therein—during a unique debate format entitled, “Current Controversies in the Art and Science of Anesthesiology.” Other topics discussed during the event included the role of etomidate in the hemodynamically unstable patient and safety trends in the delivery of anesthesia.

According to the Institute of Medicine, palliative care focuses on providing patients with relief from the symptoms, pain and stress of a serious illness. It is not limited to the terminally ill and can be provided along with curative treatment. The primary goals of palliative care are improving and supporting the best quality of life for both the patient and the patient’s family and preventing and relieving the patient’s suffering. Dr. Alvarez-Perez added that hospice care is a type of palliative care for people in the final months of life.

The Brittany Maynard Case

On this latter application for palliative care, Dr. Alvarez-Perez, a former anesthesiologist who retrained in palliative care, said that current approaches by the medical establishment to prevent prolonged and painful dying include do not resuscitate orders; the termination of life-sustaining treatments (sometimes called passive euthanasia, which is a misnomer); and the administration of large doses of opioids (sometimes called indirect euthanasia). All of these treatment paths are accepted legally and ethically. The issue of physician assistance in dying or the “death with dignity” movement made national headlines last year with the case of Brittany Maynard. Ms. Maynard was diagnosed with terminal brain cancer in 2013 and decided that she would end her life when the suffering from her disease became unbearable. She relocated from California to Oregon because of the latter state’s death with dignity provision, which allows for physician-assisted dying in those with a confirmed terminal diagnosis. Ms. Maynard died in November 2014, at the age of 29, after taking a legal, lethal dose of secobarbital prescribed by a physician.

“She did not want to have someone else decide how or when she would die and she did not want to suffer to the point of needing palliative sedation,” Dr. Alvarez-Perez told the audience at the PGA.

Both speakers said palliative care is an important part of the provision of contemporary health care. Where they differ is on the issue of which specialists should be involved in its delivery. Although Dr. Fine sees a role for anesthesiologists as an important and integral member of palliative care teams—given their expertise in pharmacologic and interventional pain treatment and titrated reduction of consciousness and awareness—Dr. Alvarez-Perez holds strongly to the idea that palliative care is a specialty unto itself.

“Palliative care should be the standard of care for all seriously ill patients and their families,” she said. “And that means palliative care should be done by those who practice and preferably are board certified in palliative care, not anesthesiologists.”

Dr. Fine, however, argued that there is still room for anesthesiologists to “competently apply their technical skills to provide total analgesia for intractable pain or palliative sedation to eliminate existential suffering”; however, those opting to do so must confront potential barriers, including what he described as the “complex” ethical and legal questions surrounding indications for these interventions. He noted that, much like in criminal law, what is permissible often centers on the issue of “intent” in applying potentially life-limiting treatments. Often, there is no clear, distinct line between the health care professionals’ moral and ethical obligations to provide relief to patients who are experiencing intolerable suffering and their obligation to “do no harm.”

“There is a deeply established ethical standard that the intended action must not be intrinsically wrong, whether we’re talking about a very potent analgesic or palliative sedation—the agent must only intend the ‘good’ effect and not the ‘bad’ effect,” he explained. “And the ‘bad’ effect must not be a means of achieving the ‘good’ effect. In other words, intentionally killing to stop all pain is not viewed as a proportional response to the problem since we have other means to address it. Proportionality and intent is key to determining ethical actions in all medical decision making, especially where the possibility of hastening death looms large.”

According to Dr. Fine, consensus guidelines for palliative sedation cover everything from categories of agents that can be used as well as indications for when they can be implemented (i.e., in those suffering from severe, intractable pain not responsive to the “usual” pharmacologic options, or regional anesthesia, or surgical/radiotherapeutic interventions, and in those who suffer emotional anguish or exhaustion that has not responded to reasonable attempts at addressing their underlying causes of existential distress). Dr. Fine also published an updated approach to treating cancer pain that includes palliative sedation as a final step in treating intolerable pain based on the seminal protocol developed by the World Health Organization, which promoted stepwise and progressive use of increasingly more potent (opioid) analgesics to address the worldwide problem of undertreated cancer pain.

The field of anesthesiology has historically been at the forefront, Dr. Fine noted, of developing myriad and novel formulations and approaches for safely and effectively delivering pharmacotherapy to patients in a variety of dire circumstances, including those facing end-of-life decisions. He added that many of the treatment decisions made in the palliative care setting mirror those made by anesthesiologists in the critical care and/or surgical settings. Classes and specific drugs available for sedation include barbiturates, benzodiazepines, opioids, neuroleptic agents, etomidate, propofol and, most recently, dexmedetomidine.

“You have expertise in these agents, it’s simply a matter of applying it in a different setting,” Dr. Fine said. “Titration is everything, and if there is one thing that can be said of anesthesiologists it is that we are really ‘titrationologists.’ Serious pain is our domain. Preventing and relieving it is what we’re good at, so how can we not take a leadership role?”