Part II Anaesthesia Refresher Course – 2020 12 University of Cape Town Palliative Care and the Role of the Anaesthetist Dr Marcelle Crowther Dept of Anaesthesia & Perioperative Medicine Groote Schuur Hospital University of Cape Town Introduction

Increased life expectancy coupled with life-prolonging treatment options through advances in medicine and technology has increased the complexity of our medical decision-making. End-of life decisions are ethically, legally and practically complex but increasingly common and therefore an important part of our practice. The mortality benefit of interventions should always be weighed against the potential for long-term suffering. We should ensure that patients die with dignity once medical therapy fails, treatment goals cannot be met and when the patient’s wishes are not congruent with organ support therapies.

Anaesthetists involvement in palliative care includes palliation in critical care units, anaesthesia for the palliative care patient presenting for palliative or emergency procedures and for pain and symptom control management at the end of life. Anaesthetists should equip themselves with general palliative care principles to enable them to understand medical futility, provide appropriate patient care as well as family guidance.

‘A doctor has neither a duty nor the right to prescribe a lingering death’ – Twycross RG

What is palliative care?

The World Health Organization defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

Palliative care is a form of multidisciplinary care with the purpose of relieving suffering and improving quality of life for both patients and families affected by critical illness or injury. Palliative care addresses physical, psychosocial and spiritual aspects of a patient’s care in a respectful and compassionate manner. Palliative care can be the sole treatment goal, or it can be offered in parallel with other medical treatment irrespective of prognosis. Advantages include the alleviation of physical and emotional distress, prioritizing the patient’s dignity, allowing patients and their family/carers to continue living life and helping to avoid unnecessary procedures with their associated costs. This requires the skill, time and collaboration of a multidisciplinary team that includes the patient and their family in decision-making. Management decisions should be based on the patient’s wishes, past and projected future quality of life, evidence based medical practice, severity and prognosis of illness, age as well as ethical reasoning. Decision-making is often complicated by differences of opinion or belief systems and causes emotional distress to all involved. Continuous reassessment of treatment goals is essential.

Common misconceptions about palliative care

• It is only for oncology patients • It hastens death • The administration of morphine hastens death • Patients who stop eating die of starvation • Palliative care can not be provided outside of a hospital • Children should not be allowed to talk about death and dying • Pain is a part of dying • The use of pain medication does leads to addiction • Palliative care implies doctors have given up hope. • Care is withdrawn

Palliative care and the role of the anaesthetist Dr M Crowther

Ethical considerations of palliative care

Clinical decision should aim to balance the four principles of Beauchamp and Childress, namely autonomy, beneficence, non-maleficence and justice.

A four quadrants approach could assist with decision-making: • Medical indications – will the treatment have an overall benefit? • Quality of life – how will the patient’s quality of life be impacted? • Patient preferences – does the patient want the treatment? • Contextual features – is the treatment available? Is treatment cost justifiable?

There are several ethical considerations pertaining to palliative care that are briefly summarised in the table below.

Ethical consideration Example Autonomy and non-maleficence Respect advanced directives Proxy informed consent Do-not-resuscitate (DNR) orders Withdrawing or withholding life-sustaining treatment Beneficence Achieved quality of life post treatment Distributive justice Equality of access to best available care Decisional capacity and consent Paediatric patient Intensive Care Unit (ICU) patient Dignity Dignified death Honesty/truth telling Augments patient participation in decision making Privacy and confidentiality Patient’s wishes regarding privacy to be respected

Patients can refuse treatment but doctors are not obliged to provide life-sustaining treatment that is deemed futile or not in the best interest of the patient. These ethical considerations will be discussed further in the text below.

The need for palliative care

There is a high need for palliative care. A point prevalence survey of the need for palliative care in inpatients at 11 public sector hospital in Cape Town showed that 16,6% of all inpatients and 54,8% of medical inpatients met the criteria for palliative care.

The SPICT tool (see annexure A) can be used to identify patients with life threatening illnesses. Early identification and incorporation of palliative care principles in parallel to other clinical management is important.

The lack of palliative care results in underuse of effective therapy, overuse of aggressive therapy and misuse of several other therapies. Palliative care has been shown to improve patient and family

12 - 2 Palliative care and the role of the anaesthetist Dr M Crowther member symptom scores, decrease health care utilization and costs, without negatively impacting survival time. It is for these reasons that it should be an integral component of patient care.

End of life care in the Intensive Care Unit

Patient’s needs in the ICU Family’s needs in the ICU • Pain and symptom control • Honest information • Human connection • Privacy • Relieving the burden on family/friends • Being listened to • Avoidance of unwanted life support • Respect of family member’s wishes • Continuity of care • Sensitivity to their cultural traditions • Communication • Decision making burden needs to be • Trust in treating physician addressed

Comprehensive care of the critically ill should include palliative care regardless of prognosis. Palliative care helps to manage suffering and addresses the needs of patients and their families without interfering with the goals of critical care (reduce morbidity and mortality, maintain organ function and restore health). Integration of palliative care in the ICU can improve the quality of end-of-life care. It is unlikely that patients will return to their baseline life trajectory (physical and psychological) post ICU admission and palliative care helps to better prepare patients and their families for this. Pain assessment and management is the most consistent application of palliative care in the ICU whilst other aspects of palliative care are performed inconsistently and infrequently. ETHICUS 2 compares end-of-life practice between 1999-2000 vs 2015-2016 and it showed that limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently in 22 European ICU’s.

Essential components of ICU palliative care

Multidisciplinary team palliative care assessment

A palliative care assessment should be done prior to admission to avoid invalid assumptions and recognize the dying patient. This will include: • Pain and symptom assessment • Cultural and spiritual assessment • Advance care planning o Discussion about future care between an individual and their care providers o This could include: patient's concerns, wishes, important values and patient’s wishes regarding interventions, organ support and resuscitation • Advance directives • Identify patient’s mandated proxy or medical decision-maker to make decisions on the patient’s behalf if the patient is no longer able to • Prognostication- likely outcomes of ICU stay o It is important to discuss prognosis with patients to allow them to have realistic treatment goals, focus on important life goals and unfinished business. It is not possible to make an exact prediction and this inherent uncertainty should be communicated to patients. Do not give exact dates or numbers but rather talk about days, weeks, months or years • Family assessment and Facilitated Values History o The Facilitated Values History approach helps to assist surrogate decision makers to understand incapacitated patients' values and to apply these values during decision- making

Communication – physician and critical care nurse

Communication is used as a quality of care marker in the ICU. It is highly valued by families. Compassionate truth telling is advised when having end-of-life discussions. Communication should always allow for shared decision-making. All discussions and decisions should be clearly documented. This conversation should not focus on what you cannot do but rather on what we still can do which includes symptom management, good communication and being available.

12 - 3 Palliative care and the role of the anaesthetist Dr M Crowther

Breaking of bad news should, where possible, be done by the most senior clinician available. The clinician should be accompanied by the nurse caring for the patient. This is best approached by using the SPIKES protocol of breaking bad news.

S – Situation/Setting: Private relative interview room P – Perception: Open ended questions to try and understand what the family understand I – Invitation: Obtain families invitation to give them more information K – Knowledge: Honest account of history, current condition and prognosis. Discuss future care plan, DNR, autopsy or organ donation and comfort care plan options. E – Emotions/Empathy – Allow for emotional responses, be empathetic S – Summary/Strategy – Follow-up

Withholding and withdrawing of organ support systems (‘life support’)

Consensus definitions as per the WELPICUS study:

• Withdrawing life-sustaining treatment: decision to actively stop a life-sustaining intervention presently being given • Withholding life-sustaining treatment: decision not to start or increase a life-sustaining intervention

In clinical practice we can withhold and/or withdraw futile medical treatments when we are in the presence of death. This is different to active euthanasia and assisted suicide. Medical futility should be assessed prior to withholding and/or withdrawing treatments such as vasopressors, ventilator support, cardiopulmonary resuscitation, clinically assisted nutrition or hydration and other medical therapies. When confronted with a potentially futile situation we should ask ourselves whether quantitative, qualitative, physiological, imminent demise or overall futility applies and then direct care accordingly. The answers aren’t always clear and clinicians must be comfortable dealing with uncertainties. The patient should be at the centre of all decisions and decision-making should always include the family.

The ethical equivalence of withholding and withdrawal of life sustaining treatment is debated. The two are equivalent if a treatment is disproportionately burdensome for the patient (will not offer clinical improvement and/or may prolong suffering) because regardless of whether the treatment is stopped (withdrawal) or not started (withheld), the principle (preventing prolonged patient suffering via a non-beneficial therapy) is regarded as the same. This is supported in the guidelines of most critical care societies and medical regulatory bodies.

There are variable definitions of medical futility but essentially it is the unacceptable likelihood of achieving an effect that the patient has the capacity to appreciate as a benefit. It has both a quantitative and qualitative component. Quantitative futility refers to the likelihood that treatment will confer patient benefit is unacceptably low and this is a medical decision. Qualitative benefit refers to the quality of the resulting patient benefit that is unacceptably low and this is a family/patient value-based decision.

Futility can also be thought of as physiological, imminent demise and clinical/overall futility. • Physiological futility: intervention is not expected to produce its desired physiologic effect • Imminent demise futility: medical condition is irreversible, and the patient is expected to die before discharge and not recover interactive capacity before death • Clinical or overall futility: intervention will not restore the patient’s capacity to interact with the environment and continue human development i.e. poor-quality outcome

Medical futility itself is not a widely accepted term as it implies pointlessness or uselessness. It creates the impression that nothing further can be done and although this might be true when considering cure this is not the case for overall care.

The withdrawal process requires multidisciplinary team involvement including social workers and religious/spiritual leaders. All treatments need to be critically evaluated to determine whether they are positively contributing to the care of the dying patient. All non-essential, non-beneficial procedures and medication should be continued. 12 - 4 Palliative care and the role of the anaesthetist Dr M Crowther

Medication for pain and symptom control can be given per os, continuous subcutaneous or intravenous routes depending on the patient and clinical scenario e.g. are they able to swallow?

Examples from Providing Palliative Care in South Africa During the COVID-19 Pandemic

Pain and symptom control

Symptom Management Total pain - physical, social, emotional and • Pharmacological spiritual pain o Opioids • Advantages o Paracetamol o Negates unwanted systemic effects o NSAIDs o Improves functional capacity o Ketamine o Manages suffering of the patient o Cannabinoids and their family o Neuropathic pain medication • Pain assessment with standard methods • Interventional can be difficult in the dying patient o Destructive • Misconceptions ▪ Alcohol or phenol o Pain management and comfort care ▪ Radiofrequency can cause adverse haemodynamic ▪ Surgical and respiratory consequences o Non-destructive o Aggressive pain management in the ▪ Peripheral blocks ICU can lead to opioid addiction • Somatic • Sympathetic

12 - 5 Palliative care and the role of the anaesthetist Dr M Crowther

▪ Central blocks ▪ Local anaesthetics or steroids • Non-pharmacological or complementary therapy o Social, emotional and spiritual care o Acupuncture. Massage, reflexology, aromatherapy, homeopathy etc.

Dyspnoea • Opioids • Common • Benzodiazepines • Opioids suppress respiratory awareness; • Alcohol does not hasten death • Barbiturates • If bronchodilation required o Β2-agonists o Methylxanthines

Cough • Opioids • Potassium iodide

Delirium • Haloperidol • Environmental measures • Medication to reduce agitation

Secretions • Hyoscine • Glycopyrrolate

Nausea and vomiting • Anticholinergics - hyoscine • 5HT3- antagonists - ondansetron • H1 antihistamines - promethazine • Neuroleptics - haloperidol • Prokinetics - metoclopramide • NK1- receptor antagonists – aprepitant • Adjuvants – dexamethasone, cannabinoids and benzodiazepines

Anxiety or distress • Benzodiazepines • Propofol • Opioids

Sedation • Methylphenidate CNS stimulants • Amphetamines • Modafinil

Other aspects of comfort care

• Assess patient and family resources and needs • Determine preferred place of death • Temperature control • Wound care • Pressure care • Clinical assisted hydration and nutrition – provide sips of water and comfort feeding o Withdrawal of hydration and nutrition is emotive and debated o Too little or too much can be harmful. Individualise patients and take family’s wishes into account o Mechanisms of providing hydration and nutrition can be distressing and uncomfortable e.g. nasogastric tube

12 - 6 Palliative care and the role of the anaesthetist Dr M Crowther

Other ethical and complex issues pertaining to palliative care in the ICU

• Terminal Sedation o Terminal sedation aims to relieve intolerable and refractory symptoms in the terminally ill. It should not be confused with euthanasia where the goal is to hasten death. There is no evidence to support that sedation is associated with shorter survival. • Euthanasia o Deliberate intervention undertaken with the intention of ending a life in order to relieve intractable suffering ▪ Non- voluntary: killing of a patient who does not have capacity to request or withhold consent. This is considered murder ▪ Voluntary euthanasia/assisted suicide: • Illegal in RSA • Pharmacological paralysis • Balance treating the patient with treating the family • Presence of family members during resuscitation

Practicalities related to dying on the intensive care unit

Administration

A death certificate can be completed for a patient deemed to have died of natural causes. All unnatural deaths should get an autopsy as per the Inquest Act. If there is any doubt it should be discussed with the forensic pathologist on call.

Organ donation

Organ donation to be considered in the brain-dead patient or for donation after circulatory death if imminent cardiac arrest anticipated after withdrawal of life-sustaining treatment.

Family support and bereavement

Families should be assisted during this difficult time through relaxing unit policies to accommodate the family where possible, good communication, counselling and religious support.

It is important to establish trust prior to anticipated loss. Communication of bad news can have lasting consequences in survivors. Bereavement is determined by circumstances of loss, personality and social circumstances. Make use of available hospital services for assistance.

Kübler-Ross Grief Cycle

• Denial • Anger • Depression • Bargaining • Acceptance

Care team self-care

End-of-life care is associated with burnout, moral distress, cumulative grief, counter transference and compassion fatigue. Teamwork, self-care (physical, mental and social), bereavement counselling and spiritual support to care providers are essential.

12 - 7 Palliative care and the role of the anaesthetist Dr M Crowther

Perioperative

Anaesthetists will be involved in palliative care when they are involved in critical care units, anaesthesia for palliative surgery, and for pain and symptom control management at the end of life. Palliative care is yet another example of the ever expanding role of anaesthetists as perioperative physicians.

Preoperative period

Anaesthetists are in a unique position to help with the early identification of patients in need of palliative care. Surgery should be preceded by a multidisciplinary team discussion taking into account not only the overall prognosis but also the potential and impact of postoperative complications, deterioration and long hospital stay on the patient’s quality of life. Anaesthetists could provide generalist palliative care or advocate for specialist palliative care.

Advanced directives

Advanced care discussions about the patient’s wishes, priorities and values should take place prior to high risk surgery. Discuss advanced directives, do not resuscitate (DNR) status and establish mandated proxy or preferred surrogate decision maker. The patient’s wishes and preferences should be clearly documented. Advanced directives may change as circumstances change. In South Africa advanced directives are not legally binding but they are especially helpful and can guide decision- making if the perioperative course is complicated and the patient loses his/her capacity.

Perioperative Do Not Resuscitate order

Cardiopulmonary resuscitation is standard of care for cardiac arrest. It can only be withheld based on a physician’s do not resuscitate (DNR) order or clear documentation of the patient’s wishes.

Advanced directives and DNR orders are not routinely suspended perioperatively that presents challenges that include: • Cardiac arrest can occur as a complication of surgery/anaesthesia as opposed to the patient’s natural progression of disease • Endotracheal intubation could be indicated for a specific surgical procedure • Vasopressors may be indicated for brief periods to negate the effects of anaesthetic agents It is for these reasons that conditional suspensions or waivers can be negotiated and clearly documented for the perioperative period. Negotiation outcomes can include maintaining DNR status, waiver of DNR status perioperatively, accept certain measures but refuse others or delegate to anaesthetist/surgeon to decide on appropriateness of interventions

In the scenario where full DNR status must be honoured perioperatively, the patient should be informed about the implications thereof. The physician can medically object to providing treatment deemed inconsistent with standards of care or morally object on personal grounds. If a physician

12 - 8 Palliative care and the role of the anaesthetist Dr M Crowther objects on moral grounds the patient’s treatment must not be delayed as a consequence and an alternative willing treating team should be arranged.

Consent

Valid consent should be obtained. The patient should be aware of all risks, potential complications and medical alternatives available to them.

The consent process may be complicated in the terminally ill if they lack decisional capacity. There are variable definitions of capacity as various role players (social, political, practitioners, public health) view capacity differently based on age, individual, context and the evolution thereof. Legal capacity consists of both age and decisional capacity. The age of full legal capacity is 18 in South Africa. It is presumed that adults have decisional capacity and that minors lack decisional capacity. A patient with decisional capacity has the ability to understand relevant information, appreciate the consequences (risks and benefits), reason and make decisions about treatment. Capacity can be decision specific and fluctuate over time.

It is difficult to assess decisional capacity. A patient’s reasoning process is assessed rather than the actual choice made. The four generally accepted decision-making abilities that constitute capacity are: understanding, expressing a choice, appreciation and reasoning. There are unvalidated adult assessment tools available but there aren’t agreed upon standards and criteria. Careful documentation of this process is essential.

Patients who lack decisional capacity should always remain involved in their management if possible. Honour advanced directives if appropriate to the clinical context and there is no reason to believe the patient has subsequently changed their mind. In the absence of an advanced directive or an irrelevant advanced directive a surrogate will make decisions on the patient’s behalf. In order of precedence the surrogate can be a patient’s mandated proxy, person authorised by law or court order, spouse or partner, parent, grandparent, adult child or a sibling. In the absence of a surrogate the healthcare professional will be expected to act on the patient’s behalf adhering to the best interest principle.

Chronic medication

It would not be uncommon for these patients to be on multiple agents both for disease management as well as pain and symptom control. The impact of these drugs perioperatively should be taken into account e.g. chemotherapy, chronic opioids etc.

Intraoperative

Patients will commonly present for palliative or emergency procedures.

This particular group of patients could have increased opioids requirements and increased risk of postoperative delirium.

Postoperative

Total pain and symptom control management – see ICU

Conclusion

Palliative care should be practiced in parallel to other aspects of care. The demand for palliative care outweighs the availability of palliative care physicians and it is therefore up to us to equip ourselves with generalist palliative care skills to provide this service to our patients.

Anaesthetists as perioperative care physicians are uniquely positioned to assist with the early identification of patient’s in need of palliative care, provide appropriate symptom and pain control management and to be advocates of patient’s wishes perioperatively.

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“You matter because you are you. You matter to the last moment of your life and we will do all we can not only to help you die peacefully but to live until you die” – Dame Cicely Saunders – founder of the first modern hospice

With special thanks to Dr Rene Krause, Dr John Turner and the Groote Schuur ICU consultant body for sharing resources and providing input during my preparation of these lecture notes.

References

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Annexure A

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