Palliative care and involvement of anaesthesiology: current discussions

Onco-Anaesthesiology and palliative medicine: Opportunities and challenges

Global cancer burden is on the rise and many more patients present for surgery or other oncological diagnostic or therapeutic interventions requiring anaesthesia. Oncology therapy is unique as it requires a multidisciplinary team of surgical, medical and radiation oncologists apart from palliative medicine (PM) specialists, and anaesthesiologists. Anaesthetic management can affect the outcome of oncology treatment both by ensuring early return to oncology treatment and some anaesthetic techniques being innately associated with recurrence. Hence, the time has come for a separate super-speciality of onco-anaesthesiology to cater to the complex unmet needs of cancer patients. PM is the fourth dimension of oncology care and so mandatory education and training should be included in the undergraduate curriculum.

Palliative patients under anaesthesiological care: a single-centre retrospective study on incidence, demographics and outcome

BACKGROUND

While anesthesiologist's involvement in palliative care has been widely researched, extensive data on palliative patients under anesthesiological care in the operating room is missing. This study was performed to assess the incidence, demographics, and outcome of palliative patients under anesthesiological care.

METHODS

We conducted a single-center retrospective chart review of all palliative patients under anesthesiological care at a university hospital in 1 year. Patients were classified as palliative if they fulfilled all predefined criteria (a) incurable, life-threatening disease, (b) progression of the disease despite therapy, (c) advanced stage of the disease with limited life-expectancy, (d) receiving or being in need of a specific palliative therapy. Demographics, periprocedural parameters, symptoms at evaluation, and outcome were determined using different medical records.

RESULTS

Of 17,580 patients examined, 276 could be classified as palliative patients (1.57%). Most contacts with palliative patients occurred in the operating room (68.5%). In comparison to the non-palliative patients, procedures in palliative patients were significantly more often urgent or emergency procedures (39.1% vs. 27.1%., P < 0.001), and hospital mortality was higher (18.8% vs. 5.0%, P < 0.001). Preprocedural symptoms varied, with pain, gastrointestinal, and nutritional problems being the most prevalent.

CONCLUSIONS

Palliative patients are treated by anesthesiologists under varying circumstances. Anesthesiologists need to identify these patients and need to be aware of their characteristics to adequately attend to them during the periprocedural period.

Questions and answers on the Belgian model of integral end-of-life care: experiment? Prototype? : "Eu-euthanasia": the close historical, and evidently synergistic, relationship between palliative care and euthanasia in Belgium: an interview with a doctor involved in the early development of both and two of his successors

This article analyses domestic and foreign reactions to a 2008 report in the British Medical Journal on the complementary and, as argued, synergistic relationship between palliative care and euthanasia in Belgium. The earliest initiators of palliative care in Belgium in the late 1970s held the view that access to proper palliative care was a precondition for euthanasia to be acceptable and that euthanasia and palliative care could, and should, develop together. Advocates of euthanasia including author Jan Bernheim, independent from but together with British expatriates, were among the founders of what was probably the first palliative care service in Europe outside of the United Kingdom. In what has become known as the Belgian model of integral end-of-life care, euthanasia is an available option, also at the end of a palliative care pathway. This approach became the majority view among the wider Belgian public, palliative care workers, other health professionals, and legislators. The legal regulation of euthanasia in 2002 was preceded and followed by a considerable expansion of palliative care services. It is argued that this synergistic development was made possible by public confidence in the health care system and widespread progressive social attitudes that gave rise to a high level of community support for both palliative care and euthanasia. The Belgian model of so-called integral end-of-life care is continuing to evolve, with constant scrutiny of practice and improvements to procedures. It still exhibits several imperfections, for which some solutions are being developed. This article analyses this model by way of answers to a series of questions posed by Journal of Bioethical Inquiry consulting editor Michael Ashby to the Belgian authors.

[Palliative care oriented therapy for all patients : recommendations of an expert circle]

BACKGROUND

Since 2011 palliative care has been a compulsory part of the German medical study course (so-called Q13 palliative and pain medicine). Palliative care content does not, however, as often taught, have to focus only on patients in the so-called palliative stages of disease. The aim of this investigation was to encourage a discussion concerning the integration of palliative care aspects into general medical treatment.

METHODS

For data collection an open discussion of the main topics by experts in palliative medical care was used. The main outcome measures and recommendations included responses regarding current practices related to expert opinions, national and international literature and one case report. The literature search was performed using the databases "PubMed", "Medline" and "Google" (1990-2011).

RESULTS

As an important consensus, the following recommendations for optimization of inpatient and outpatient care were: (1) integration of aspects of palliative care into medical curricula of all disciplines, (2) palliative care content should be extended to the general optimization of therapy for all patients, (3) palliative medicine should be part of the everyday medical practice in all disciplines and (4) palliative medicine should not be isolated as "death medicine" or medicine of the dying patient.

CONCLUSIONS

Palliative care treatment is increasingly becoming integrated into medical education and into medical curricula of all disciplines. Palliative ideas and goals are focussed on patients in the so-called palliative stages of disease. Furthermore, palliative medicine is often described as the medicine of dying patients. As a result of this study it seems to make sense to extend palliative care aspects to all patients and to all patient care. The extent to which such opportunities exist and such health care is economically feasible remains to be the subject of further clinical studies.

Review of palliative sedation and its distinction from euthanasia and lethal injection

Palliative sedation evolved from within the practice of palliative medicine and has become adopted by other areas of medicine, such as within intensive care practice. Clinician's usually come across this practice for dying patients who are foregoing or having life support terminated. A number of intolerable and intractable symptom burdens can occur during the end of life period that may require the use of palliative sedation. Furthermore, when patients receive palliative sedation, the continued use of hydration and nutrition becomes an issue of consideration and there are contentious bioethical issues involved in using or withholding these life-sustaining provisions. A general understanding of biomedical ethics helps prevent abuse in the practice of palliative sedation. Various sedative drugs can be employed in the provision of palliative sedation that can produce any desired effect, from light sedation to complete unconsciousness. Although there are some similarities in the pharmacotherapy of palliative sedation, euthanasia, physician-assisted suicide, and lethal injection, there is a difference in how the drugs are administered with each practice. There are some published guidelines about how palliative sedation should be practiced, but currently there is not any universally accepted standard of practice.

[Anesthesiology and palliative medicine. Structured results of a prospective questionnaire-based survey in German hospitals]

BACKGROUND

Anesthesiology departments were often integrated into the primary formation of palliative activities in Germany. The aim of this study was to present the current integration of anesthesiology departments into palliative care activities in Germany.

METHODS

The objective was to determine current activities of anesthesiology departments in in-hospital palliative care. A quantitative study was carried out based on a self-administered structured questionnaire used during telephone interviews.

RESULTS

A total of 168 out of 244 hospitals consented to participate in the study and the response rate was 69%. In-hospital palliative care activities were reported for most of the surveyed hospitals. Only two hospitals in the maximum level of care reported no activities. Participation in these activities by anesthesiology departments was described in up to 92%. Historically, most activities are due to the commitment of individuals, whereas the development of palliative care of cancer pain services and hospital support teams took place in the university hospitals by 2005.

CONCLUSIONS

Until 2005 many university palliative care activities had their origins in cancer pain services. These were often integrated into anesthesiology departments. Currently, anesthesiology departments work as an integrative part of palliative medicine. However, it appears from the present results that there is a domination of internal medicine (especially hematology and oncology) in palliative activities in German hospitals. This allows the focus of palliative activities to be formed by subjective specialist interests. Such a state seems to be reduced by the integration of anesthesiology departments because of their neutrality with respect to faculty-specific medical interests. Advantages or disadvantages of these circumstances are not considered by the present investigation.