Palliative Care For The Geriatric Anesthesiologist: Allen N. Gustin JR,, Rebecca A. Aslakson

Download as pdf or txt
Download as pdf or txt
You are on page 1of 12

Palliative Care for the Geriatric Anesthesiologist

Allen N. Gustin Jr, ​MD​a​,​*​, Rebecca A. Aslakson, ​MD, PhD​b​,​c

KEYWORDS
​Geriatrics ​ ​Palliative care ​ ​Hospice ​ ​Do not resuscitate ​ ​Ethical dilemma ​ ​Palliative sedation ​ ​Physician-assisted
suicide ​ ​Perioperative palliative care

KEY POINTS

​The geriatric population is increasing, the number of chronic conditions within the geriatric population is rising, the use of palliative care and
hospice within geriatrics has dramatically risen, and patients with chronic illnesses and end-of-life issues will present to the oper- ating room
more frequently. ​ ​Palliative care and hospice are complementary and improve the patient’s and family’s
experience with chronic illness and end-of-life care, but differences exist. ​ ​Palliative care is not just care for those at “end of life”
but is appropriate for any patient at any age in any setting (including perioperative settings) with chronic health conditions.
Do-not-resuscitate (DNR) orders should not be automatically rescinded in the periopera- tive setting, but rather, conversations should occur to
establish alignment of the goals of care of the patient with goals of care of the anesthesia and the surgical procedure. ​ ​For actively dying
patients, refractory symptoms that do not respond to conventional ther- apies may require the addition of palliative sedation for management
of severe patient distress and suffering.

INTRODUCTION

The American population is aging. The percentage of the population older than age 65 was 9% in 1960 and is projected to reach
20% by 2050.​1,2 ​With increases in life ex- pectancy, the burden of serious illness among older adults has also increased with

Dr A.N. Gustin and Dr R.A. Aslakson have no financial or industrial relationships to disclose. ​a ​Department of Anesthesiology, Stritch School of Medicine,

Loyola University Medicine, 2160 South


​ 1st Avenue, Building 103, Room-3102, Chicago, IL 60153, USA; b​ ​Department of Anesthe- siology and Critical
Care Medicine, Palliative Medicine Program at the Kimmel Comprehensive Cancer Center at Johns Hopkins, The Johns Hopkins School of Medicine,
1800 Orleans Street, Meyer 289, Baltimore, MD 21287, USA; c​ ​Department of Health, Behavior, and Society, The Johns Hopkins Bloomberg School of
Public Health, 1800 Orleans Street, Meyer 289, Baltimore, MD 21287, USA * Corresponding author. Department of Anesthesiology, Loyola University
Medicine, 2160 South 1st Avenue, Building-103, Room-3102, Chicago, IL 60153. E-mail address: ​[email protected]

Anesthesiology Clin 33 (2015) 591–605 ​http://dx.doi.org/10.1016/j.anclin.2015.05.013 ​anesthesiology.theclinics.com 1932-2275/15/$ – see front matter ​©
2015 Elsevier Inc. All rights reserved.
Gustin Jr & Aslakson ​592

two-thirds of patients greater than 65 years old having multiple chronic conditions.​3 ​Moreover, providing high-quality end-of-life care
is challenging because of multiple factors, such as the increasing number of elderly patients, structural barriers to access of care
for older patients, and a fragmented health care system.​4 ​In a 1997 report that evaluated end-of-life care in the United States, the
Institute of Medicine described sig- nificant patient and family suffering related to end-of-life care and emphasized the need for
improvements​4 ​(​Box 1​). In the last decade and a half, hospice use has doubled and palliative care has made improvements with
the development of guide- lines and quality measures for the care of geriatric patients with chronic and/or severe illness.​5,6 ​A
follow-up Institute of Medicine report in 2014 revealed that more work is needed to improve the quality of care for patients at the
end of life, recognizing that palliative care services are underused and are too frequently unavailable, and that cur- rent providers
should seek out further training in palliative care–related skills​7 ​(see
Box 1 Institute of Medicine recommendations and challenges for providing quality end-of-life care in America

1997 Recommendations for End-of-Life Care

1. Raise the Issue. People should think about, talk about, and learn about decisions they may
face, as they or those they love approach death.

2. Raise Expectations. Dying people and their families should expect good, dependable care.
They should expect their beliefs and wishes to be respected.

3. Do What We Know Helps. Doctors, nurses, social workers, and others need to use what we
already know to prevent and relive pain and other symptoms.

4. Get Rid of Barriers to Good Care. Doing this often requires support of lawmakers, voters, the
media, and health care managers.

5. Build Knowledge. The National Institutes of Health and other public/private groups should
work together to find out more about end-stage disease and end-of-life care.

2014 Challenges for Providing Quality End-of-Life Care in America

1. Increasing number of elderly Americans, including those with some combination of frailty,
significant physical and cognitive disabilities, multiple chronic illnesses, and functional limitations.

2. Growing cultural diversity of the US population, which makes it ever more important for
clinicians to approach all patients as individuals, without assumptions about the care choices they might make.

3. Structural barriers in access to care that disadvantage certain population groups.

4. A mismatch between the services patients and families need most and the services they can
readily obtain.

5. Availability of palliative care services has not kept pace with the growing demand.

6. Wasteful and costly systemic problems, including perverse financial incentives, a fragmented care delivery system, time pressures that limit
communication, and a lack of service coordination across programs.

7. The resulting unsustainable growth in costs of the current health care delivery system over
the past several decades.

Data from Institute of Medicine. Approaching death: improving care at the end of life. Wash- ington, DC: National Academic Press; 1997; and Institute of
Medicine. Dying in America: improving quality and honoring individual preferences near the end of life. Washington, DC: National Academies Press;
2014.
Palliative Care for the Geriatric Anesthesiologist ​593
Box 1​). Palliative care approaches and skills benefit geriatric patients, their families, and their providers not only in the
course of general care but also in the perioperative setting.
PALLIATIVE CARE
The term “palliative care” was first coined in 1975 by a Canadian physician, Dr Balfour Mount, who was introducing
“hospice-like” services into Canadian hospitals​8​; since then the definition has evolved​7,9–12 ​(​Table 1​). In brief, palliative
care involves (1) aggressive and expert symptom management, (2) psychosocial support of the patient and family,
and (3) careful discussion about the patient’s goals of care for his or her medical treatments.
In working toward these three goals, palliative care focuses on providing patients and their families with relief from the
symptoms, pain, and stress of serious illness— whatever the diagnosis and whatever the outcome. The ultimate goal
is to improve the quality of life for the patient and the family. Palliative care can begin early in the course of treatment
of any serious illness and may be delivered in several ways across the continuum of health care settings, including the
home, nursing home, long-term acute-care facility, acute-care hospital, intensive care unit (ICU), perioperative setting,
or outpatient clinic.​7 ​Palliative care should be available when life-prolonging therapy begins, after life-prolonging
therapy is withheld or withdrawn, and even for the pa- tient’s family after the patient’s death​10 ​(​Fig. 1​). ​Fig. 1​A depicts
the traditional model of palliative care where a patient first receives life-prolonging therapy until it fails, then palliative
care is provided. ​Fig. 1​B depicts the overlapping model where palliative care gradually increases while the patient
receives a gradual decrease in life-prolonging therapy. ​Fig. 1​C depicts the integrated model where palliative medicine
is delivered at the onset of the illness and concurrently along with life-prolonging therapy. The in- tensity of palliative
care increases and decreases depending on the preferences of the patient and the family. ​Fig. 1​D depicts the ICU
individualized integrated model where the patient receives palliative care along with ICU care. In the ICU, hospice
care is not integrated into critical care because, though palliative care can be provided concur- rent to critical care,
hospice cannot. One should note that life-prolonging care ends
Table 1 Definitions for palliative care
World Health
Organization, 1990
Active total care for the patient whose disease process is not
responsive to cure. World Health
Organization, 1993
The study and management of patients with acute, progressive far advanced disease for whom the prognosis is limited and the focus of care
is quality of life. National Consensus
Project, 2004
The prevention and relief of suffering and the support of the best possible quality of life for patients and the family regardless of the state of
disease. World Health
Organization, 2007
Palliative care as a pathway to improve the quality of life for
patients and families with palliation and relief of suffering. Institute of Medicine,
2014
The care that provides relief from pain and other symptoms,
supports quality of life, and focuses on patients with serious advanced illnesses and their families. Center to Advance Palliative Care
The specialized medical care for patients with serious illness.
Data from Refs.​7,9–12
594
Fig. 1. (A) Traditional dichotomous model. (B) Overlapping model of palliative care. (C, D) Indi- vidualized integrated model of palliative care.
(Adapted from Lanken PN, Terry PB, DeLisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for pa-
tients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;177:914.)
Palliative Care for the Geriatric Anesthesiologist ​595

at death, whereas palliative care peaks at death and continues after death to address the bereavement needs of the patients
family.​10 ​Indeed, even in the ICU, expert state- ments recommend concurrent palliative and life-prolonging care with the emphasis
varying with the patient’s condition and care goals. Palliative care is appropriate at any age (pediatric to geriatric), at any stage in a
serious illness, and can be provided concurrent with curative or life-prolonging therapies.​13
Although palliative care is increasingly integrated into the continuance of geriatric care, it is still underused.​13 ​Despite
national efforts to improve end-of-life care, proxy reports of pain and other alarming symptoms in the last year of life have
increased over the last 10 years.​14 ​Moreover, advances in health care have transformed many previ- ously lethal diseases (human
immunodeficiency virus and AIDS, heart failure, chronic obstructive pulmonary disease, end-stage renal disease, and dementia)
into chronic conditions with a frequent significant physical and psychological burden for patients and their families. To meet
growing needs for palliative care, hospital, home-based, hospice-based, and community-based palliative care programs are
increasing in number each year.​15 ​However, there are still not enough trained palliative care pro- viders to meet demand; the
Center to Advance Palliative Care highlights that there is approximately one cardiologist for every 71 patients experiencing a heart
attack, one oncologist for every 141 newly diagnosed patients with cancer, and only one specialized palliative care physician for
every 1200 persons living with serious or life-threatening illness.​10

END-OF-LIFE CARE AND HOSPICE

End-of-life care refers generally to the process of addressing the medical, social, emotional, and spiritual needs of people who are
nearing the end of life. End-of-life care may include a range of medical and social services, including disease-specific interventions
and palliative and hospice care for those with advanced serious condi- tions who are near death.​7 ​More specific than palliative
care, hospice is for dying pa- tients. Although palliative care and hospice are complementary, differences do exist. Palliative care is
based on patient and family need, whereas hospice care is based on patient prognosis. Palliative care can be provided with efforts
related to restoring health regardless of any life-sustaining treatment (including ICU care). Hospice care, however, tends to focus
on the patient’s goals of care at the end of life and cannot typically be provided concurrent with aggressive curative or
life-prolonging treatment options. Palliative care can be provided with no limitations to care—even with the use of cardiopulmonary
resuscitation (CPR).​7 ​Hospice tends to discourage life-sustaining options that do not support the patient’s goals of care.

PALLIATIVE CARE–RELATED PERIOPERATIVE ISSUES Cardiopulmonary Resuscitation/Do-Not-Resuscitate


Orders/Anesthesiology

CPR is provided approximately 800,000 times annually in the United States and is the only medical intervention for which no
consent is required and where an explicit physi- cian order is necessary for it to be withheld.​16 ​In 1983, the President’s Commission
for the Study of Ethical Problems in Medicine clarified that patients had a right to expect CPR as the standard of care in all
situations of cardiac arrest unless a patient’s wish was clearly documented to have it withheld.​17 ​From the 1980s to 1991, patient’s
do- not-resuscitate (DNR) orders were routinely rescinded on entering the operating room because anesthesiologists and
surgeons believed that routine anesthesia and surgical care in the operating room (eg, volume resuscitation and use of vasoactive
medica- tions) would be considered “resuscitation.”​18,19 ​However, in the last two decades,
Gustin Jr & Aslakson ​596

opinions have evolved such that some patients and providers believe that DNR orders should only apply to CPR in the event of an
actual cardiac arrest and all the medical treatment before cardiac arrest is not CPR (and so should not be affected by a DNR
order).​20 ​Moreover, studies still support variation in practice concerning management of DNR orders for perioperative patients. In
one study, anesthesiologists were twice as likely as either internists or surgeons to assume DNR patients would suspend their
DNR order in the operating room and, compared with these other providers, were less likely to discuss the implication of a DNR
order with their patients, more likely to refuse to provide care for DNR patients, and more likely to ignore a patient’s DNR request
even if the patient made wishes explicit after an informed discussion.​21 ​The Patient Self Determination Act of 1990 established as
US law that a patient’s right to self-determination was the supreme standard in medical ethics, taking prece- dence over
beneficence.​9,22 ​Because of this act, routine suspension of the DNR orders in the perioperative period is considered a violation of
the patient’s right of self-deter- mination.​23–25 ​As a result, the American Society of Anesthesiologists’ practice guide- lines refute
required rescission of a DNR during the perioperative period and instead support the “required reconsideration” of a patient’s DNR
status before proceeding with surgery.​26 ​In that discussion with a patient, the anesthesiologist or surgeon should address the
patient’s goals and values in the context of the anesthesia and the surgical procedure.​18 ​In our estimation, four possible outcomes
of this DNR dis- cussion exist (​Box 2​). Clinical care should be discussed with the patient while keeping the patient’s goals of care
as the centerpiece of the discussion. The health care team is not ensuring a particular outcome, but rather ensuring that care is
designed around the patient’s individual goals and values, and is medically consistent with standards of care.​18
Based on the previous discussion, patients with DNR orders can have a portion or all of their DNR wishes maintained in the
operating room and perioperative period. Managing patients with care limitations and/or end-of-life issues can be psycholog- ically
and ethically challenging for some health care providers. An anesthesiologist may be presented with a clinical situation where he or
she feels ethically uncomfort- able to provide intraoperative care for geriatric hospice or palliative care patients at the end of life. In
those circumstances, the American Medical Association Code of Ethics states that clinicians should not be compelled to perform
procedures they view as inconsistent with their personal values but should involve a second anesthe- siologist who is willing to
comanage the patient by performing the desired proce- dure.​27 ​Consistent with this guidance, the anesthesiologist can refuse to
provide care for a patient when he or she has fundamental ethical concerns, but the

Box 2 Outcomes of discussions with perioperative patients with DNR orders

1. Maintain the DNR status unaltered.

2. Fully rescind the DNR status in the perioperative period.

3. Accept certain resuscitative measures but refuse others, with all changes being fully
documented.

4. Elect to the anesthesiologist or surgeon the right to determine which interventions are
appropriate and which are not in accordance with the patient’s stated wishes.

Data from Margolis JO, McGrath BJ, Kussin PS, et al. Do not resuscitate (DNR) orders during sur- gery: ethical foundations for institutional policies in the
united states. Anesthesia Analgesia 1995;80(4):806–9.
Palliative Care for the Geriatric Anesthesiologist ​597

anesthesiologist cannot abandon the patient and is required to promptly find another anesthesiologist who would be willing to
provide the care. Similar to management of other patients with care limitations (ie, Jehovah’s witness patients who refuse blood
transfusions), anesthesia care practices may wish to develop individual practice guidelines to support and facilitate care of patients
who wish to maintain DNR orders throughout the perioperative period.

Noninvasive Ventilation

DNR and do-not-intubate decisions to limit active treatments are taken immediately on hospital admission to protect patients from
interventions that both contradict their preferences and values and also which could deprive them from communication with their
families, particularly during the last moments of their lives.​28 ​The problem is determining when the clinical practice of noninvasive
ventilation (NIV) support may be appropriate or futile.​29 ​Indeed, some perioperative patients with treatment limita- tions may refuse
endotracheal intubation outside the operating room but may accept NIV because it may forego intubation while potentially
providing relief from suffering caused by some forms of dyspnea. Some caution that NIV may be inappropriate in the context of any
end-stage disease because of an increased use of medical re- sources, prolongation of the dying process, and intensification of
suffering.​30 ​Yet, NIV may be beneficial for patients with progressive dyspnea and the use of NIV should be tailored to each
patient’s situation and each patient’s goals of care.

Hydration and Artificial Nutrition

Cultural and religious variations among patients can create conflict between goals of care and the concerns about hydration and
artificial nutrition at the end of life. The American Academy of Hospice and Palliative Medicine (AAHPM) endorses the ethi- cally
and legally accepted view that artificial nutrition and hydration, whether delivered parenterally or though the gastrointestinal tract
via a tube (including nasogastric tubes), is a medical intervention.​31 ​The AAHPM recognizes that some faiths and tradi- tions may
consider artificial nutrition and hydration as basic sustenance or as symbolic importance, apart from any measurable benefit or the
patient’s physical well-being. Such views should be explored, understood, and respected, in keeping with patient and family
values, beliefs, and cultures.​31 ​Members of the Roman Catholic faith view the removal of artificial nutrition and hydration as passive
euthanasia.​32 ​Family members can also feel distressed when nutrition is withheld because they may believe that the patient “is
starving to death.” Thus, there may be equally good, ethical, and valid reasons for patients, particularly at the end of life, to either
pursue or not to pur- sue palliative hydration and artificial nutrition. Moreover, anesthesiologists may care for these patients in the
operating room for placement of feeding tubes and other pro- cedures for providing enteral nutrition. Consequently, involvement in
these proce- dures typically is aided by careful discussion of care plans and goals with the entire clinician team as well as with the
patient.

ONGOING CONTROVERSIES IN PALLIATIVE MEDICINE Palliative Sedation, Physician-Assisted Suicide, and


Euthanasia

The concept of palliative sedation was introduced in the literature in 1991 to describe the practice of drug-induced sedation for
terminally ill patients for management of otherwise refractory symptoms leading to unmitigated patient suffering.​33 ​Critics claimed
this sedation was “slow euthanasia” or mercy killing in disguise.​34 ​Recom- mendations, guidelines, and standards for the
appropriate implementation have
Gustin Jr & Aslakson ​598

been issued by national and international organizations.​8 ​Supporters note palliative sedation to be “the intentional administration of
sedative drugs in dosages and in com- binations required to reduce the consciousness of a terminally ill patient as much as
necessary to adequately relieve one or more refractory symptoms.”​20 ​In contrast to physician-assisted suicide or euthanasia, the
intent of palliative sedation is to relieve symptoms, not to end the patient’s life​8​; the intent of actions is the crux of care. Palli- ative
sedation has critical ethical and legal considerations that require a foundation of clear communications and treatment objectives
among all stakeholders (patient, fam- ily, nurses, doctors, clergy, and others). The incidence of palliative sedation is difficult to
estimate (ranges from <1% to 30%) given the wide variation in definitions.​35 ​Many groups advise that proportionality is a key
concept for palliative sedation with the depth of sedation recommended to be proportional to the severity of the symptoms.​8 ​The
AAHPM consensus statement regarding palliative sedation recognizes that palliative care seeks to relieve suffering (pain and
distress) associated with disease but that, unfortunately, not all symptoms associated with advanced illness can be controlled with
pharmacologic or other interventions.​36 ​Palliative sedation is defined by the AAHPM as the use of sedative medication at least in
part to reduce patient awareness of distressing symptoms that are insufficiently controlled by symptom- specific therapies. The
level of sedation is proportionate to the patient’s level of distress, and alertness is preserved as much as possible.​36 ​The AAHPM
also defines “palliative sedation to unconsciousness.” This occurs when the administration of sedation is to the point of
unconsciousness and can be considered when less extreme sedation has not achieved sufficient relief of distressing symptoms.
This practice is used only for the most severe, intractable suffering at the very end of life.​36
Currently, the ethical debates support palliative sedation for the management and relief of refractory or intractable
symptoms.​37,38 ​The key ethical features are (1) the clinician’s intent to relieve suffering, (2) the degree of sedation being
proportional to the severity of suffering, and (3) that the patient (or surrogate) should give informed consent.​39 ​The American
Medical Association Statement on the End of Life Care states that patients should have “trustworthy assurances that physical and
mental suffering will be carefully attended to and comfort measures intently secured.”​40 ​Palliative sedation is legal in every state in
the United States and has been supported by the US Supreme Court in ​Vacco v Quill ​(521 US 793; 1997) and ​Washington v
Glucksberg ​(521 US 702; 1997).​41 ​Anesthesiologists may wish to familiarize them- selves with the ethical issue of palliative
sedation because the drugs used for this practice include common anesthetics, such as ketamine, propofol, or barbiturates, and
because the use of these agents in some hospitals may be restricted to anes- thesia practitioners.

INTEGRATING PALLIATIVE CARE AND PERIOPERATIVE CARE FOR OLDER ADULTS Palliative Care and the Surgical Intensive
Care Unit

As ICU survivors increase in number and are studied beyond their ICU stay, the bur- dens of survivorship are coming into clearer
view.​42,43 ​A broad array of physical and psychological symptoms (along with impairments in function and cognition) continue to
impair the quality of a patient’s life during and after the ICU.​14 ​Patients may have functional and neurocognitive deficits after
surviving an ICU admission.​44–49 ​Not only are the patients experiencing symptoms of survivorship, the family members of critically ill
patients can exhibit signs of anxiety and depression, along with compli- cated grief and posttraumatic stress disorder.​44,45 ​A “post
intensive care syndrome” has been described for patients and their family members.​42
Palliative Care for the Geriatric Anesthesiologist ​599

Many ICU patients are unable to participate in shared decision-making with the ICU team and decisions must be made
instead by surrogates.​50,51 ​These discussions may be particularly difficult because surrogates may respond to interactions with ICU
staff by focusing on details rather than the larger picture, relying on personal instincts or beliefs, and sometimes rejecting
prognostic information.​52 ​The need for specialist palliative care consultation is sometimes justified. Indeed, members of the ICU
team should provide basic palliative care at all times. However, given that ICU personnel do not follow patients outside of the unit,
specialized palliative care involvement can aid in care continuity for these patients inside and outside of the ICU (through recov-
ery, discharge, and at home).
Unique barriers may exist for implementation of palliative care in any ICU. These barriers include unrealistic
expectations for intensive care therapies for the patient by the patient, family, or ICU clinician; misperception that palliative care
and critical care are not complementary and concurrent approaches; conflation of palliative care with end-of-life or hospice care;
concern the institution of palliative care will has- ten death; competing demands on ICU clinician effort; no adequate reward for
pallia- tive care excellence; and failure to apply effective approaches for system or culture change to improve palliative care.​13
Despite these barriers, palliative care is increas- ingly accepted as an essential component of comprehensive care for critically ill
pa- tients, regardless of diagnosis or prognosis.​14
Implementation of palliative care in a surgical ICU can be uniquely challenging. Some evidence suggests that surgeons
may have an exaggerated sense of account- ability for patient outcomes and thus tend to do everything possible to avoid patient
death.​53 ​Surgeons may believe that they enter into a “covenantal” relationship with the patient (and by extension, the family) and
that patients and their families may consciously or unconsciously cede decision-making to that surgeon, particularly related to
goals of care.​53 ​In a national survey, many surgeons described conflict with intensive care physicians and ICU nurses with respect
to appropriate goals of postoperative care.​54 ​Also, surgeons described difficulties in managing clinical as- pects of poor outcomes,
communicating with the family and the patient about such outcomes, and coping with their own discomfort about these outcomes.​53
Given the strong sense of responsibility for patient outcomes, surgeons may be resistant to integrated palliative care in the ICU
and may require encouragement from other specialties (including anesthesiologists) to consider palliative care options for patient
care.​13,55
As the longer-term impact of intensive care on those surviving acute critical illness is increasingly documented, palliative
care can help to prepare and support patients and families for challenges after ICU discharge.​13 ​Key quality markers for palliative
care measures have been identified and implemented in the ICU. The Care and Communi- cation Bundle was developed and
tested as part of national performance improve- ment by the Voluntary Hospital Association. The bundle is triggered by time and
involve identifying the medical decision-maker and resuscitation status before Day 2 in the ICU, offering social work and spiritual
care support before Day 4, and con- ducting an interdisciplinary family meeting not later than Day 5.​56 ​Anesthesiologists can
advocate for more engagement of palliative care services for perioperative pa- tients within the surgical ICUs of their institutions.

Palliative Care Consultation and Mechanical Circulatory Support Devices

Mechanical circulatory support (MCS) for patients with advanced heart failure re- fractory to medical therapy has made
tremendous progress in the past 15 years.​57 ​Thousands of patients have had MCS devices inserted successfully as
Gustin Jr & Aslakson ​600

improvements in patient selection, surgical technique, and postoperative manage- ment have occurred.​57 ​MCS devices broadly
include devices implanted to improve cardiac output on a temporary basis (extracorporeal membrane oxygenation) or for longer
periods of support (the left ventricular assist device being the most com- mon).​58–60 ​Compared with medical therapy alone, the
placement of an MCS device improves survival, quality of life, and functional status in appropriately selected pa- tients with
advanced heart disease.​61 ​For a subset of patients with advanced heart failure, MCS device placement can be performed until a
heart transplant is avail- able (referred to as a “bridge to transplant”).​57 ​Some patients may recover their heart function without ever
needing a heart transplant (ie, recovery from viral myocarditis or postpartum cardiomyopathy) where the MSC device can be suc-
cessfully explanted without further issue (referred to as “bridge to recovery”).​57 ​For patients who are ineligible for cardiac
transplantation (patient preference, age, or comorbidities), an MSC device can be placed with the intent that the device will remain
in place for the duration of the patient’s life (referred to as “destination therapy”).​57
Because MSC devices are now used more and more as destination therapy, place- ment is no longer restricted to the supply
of transplantable hearts. Moreover, destina- tion therapy adds particular complexity to the patient’s treatment options and
decision-making during the course of the MSC device as the patient approaches the end of life.​57 ​Several analyses have concluded
that, in patients with an MSC device for destination therapy, the patients’ goals of care often are undefined.​62,63 ​Without clearly
defined goals or advanced directives, destination therapy may merely maintain circulation in a moribund patient, a situation
sometimes glibly referred to as “destina- tion nowhere.”​64 ​Although the continuous-flow devices (ie, Heart Mate II or Heart Ware)
have shown improved morbidity and mortality, hospitalizations are still frequent for bleeding episodes (usually gastrointestinal),
arrhythmias, infections (especially of the driveline), respiratory failure, renal failure, right heart failure, and cerebrovascular
events.​65 ​These adverse events may significantly affect a patient’s morbidity and qual- ity of life.​66,67 ​Because patients have the
right to exercise autonomy, patients or family members may elect for deactivation of the MSC device if they believe that their goals
of care are no longer achieved with the MSC device. Death related to deactivation of the MSC device is considered to be caused
by heart failure, not from stopping the device.
Given these complexities, experts and practitioners have suggested that proactive perioperative palliative care may benefit
patients considering MSC device placement and a study has shown feasibility of proactive palliative care in “preparedness plan-
ning” for MSC patients.​56,61,68 ​Indeed, the 2013 International Society for Heart and Lung Transplantation Guidelines published
practice guidelines recommending specialist palliative care involvement in the care of patients being considered for an MCS
device. The summary recommended that specialized palliative care be a compo- nent of the treatment of patients with end-stage
heart failure during the evaluation phase for an MSC and that goals and preferences for end-of-life should be discussed with all
patients receiving MCS as destination therapy.​57 ​In addition, the International Society for Heart and Lung Transplantation
recommended that palliative care special- ists be involved in the in-hospital management of all MSC patients.​57 ​Accordingly, an-
esthesiologists and the cardiac anesthesiologist should recognize greater involvement with palliative care specialists in the
management of patients with MSC devices and can use these palliative care specialists more frequently when perioperative needs
arise.
Palliative Care for the Geriatric Anesthesiologist ​601

SUMMARY

Palliative care and hospice programs are expanding. Palliative care and hospice meet the physical, emotional, and spiritual needs
of geriatric patients quite effectively, and have addressed many of the chief concerns voiced by those patients facing life- limiting
illness.​69 ​Subsets of patients exist for whom conventional approaches to pain and symptom management by anesthesiologists and
surgeons do not provide adequate comfort.​33 ​In these cases, immediate consultation with a palliative care specialist who has
expertise in the management of these complicated patients and their symptoms is appropriate.​33 ​There is usually something that
can be done safely, ethically, and legally that coincides with our duty to patient care.​33 ​Despite palliative medicine and hospice
being in their infancy just a few decades ago, significant strides have been made. Palliative care and hospice have assisted in
shifting the focus of pa- tient care from a practitioner-centered and institution-centered practice toward a family-centered,
patient-centered, and evidence-based practice.​7,21,70 ​Palliative care can provide aggressive symptom management in geriatric
patients in the periop- erative setting, even when patients choose curative or life-prolonging therapies.​18 ​For patients who are at the
end of life, palliative care and hospice can allow the patient to die in peace rather than in a piecemeal fashion.​32 ​For those who are
not at the end of life, this approach to patient care offers the same hope: to live in peace, not piece- meal.​71 ​Palliative medicine is
consistent with our duty as physicians to help cure, pro- vide relief, and offer comfort. “​Gue ́rir quelquefois, soulager souvent,
consoler toujours​” (cure sometimes, relieve often, comfort always).

REFERENCES

1. He W, Sengupta M, Velkoff VA, et al. 65​+ ​in the United States. 2005. Available at:
http://www.census.gov/prod/2002pubs/censr-4.pdf​. Accessed February 20, 2015. 2. Bureau of the Census. Projections of the
population by age and sex for the United States: 2010 to 2050. 2008. Available at: ​http://www.census.gov/prod/2010pubs/
p25-1138.pdf​. Accessed February 20, 2015. 3. Centers for Disease Control and Prevention (CDC). The state of aging and health
in America—2013. 2013. Available at: ​http://www.cdc.gov/features/ agingandhealth/state_of_aging_and_health_
in_america_2013.pdf​. Accessed February 20, 2015. 4. ​Institute of Medicine. Approaching death: improving care at the end of life.
Wash-
ington, DC: National Academic Press; 1997​. 5. ​Teno JM, Gozalo PL, Bynum JP, et al. Change in end-of-life care for
Medicare beneficiaries: site of death, place of care, and health care transitions in 2000, 2005, and 2009. JAMA 2013;309:470–7​.
6. ​NIH State-of-the-Science Conference Statement on improving end-of-life care.
NIH Consens State Sci Statements 2004;21(3):1–26​. 7. ​Institute of Medicine. Dying in America: improving quality and
honoring individual preferences near the end of life. Washington, DC: National Academies Press; 2014​. 8. ​ten Have H, Welie JV.
Palliative sedation versus euthanasia: an ethical assess-
ment. J Pain Symptom Manage 2014;47(1):123–36​. 9. ​Mahler DA, Selecky PA, Harrod CG, et al. American College of
Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease. Chest
2010;137(3):674–91​.
Gustin Jr & Aslakson ​602

10. ​Lanken PN, Terry PB, Delisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for
patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008;177(8):912–27​. 11. World Health
Organization. WHO Definition of Palliative Medicine. Available at: ​http://www.who.int/cancer/palliative/definition/en/​. Accessed on
February 20, 2015. 12. Center to Advance Palliative Care. What is palliative care? Available at: ​http://
getpalliativecare.org/whatis/​. Accessed February 20, 2015. 13. ​Aslakson RA, Curtis JR, Nelson JE. The changing role of
palliative care in the ICU.
Crit Care Med 2014;42:2418–28​. 14. ​Singer AE, Meeker D, Teno JM, et al. Symptom trends in the last year of life from
1998 to 2010: a cohort study. Ann Intern Med 2015;162(3):175–83​. 15. Center to Advance Palliative Care (CAPC) Hospice
and Palliative Care. Available at: ​www.capc.org/topics/hospice-and-palliative-care/​. Accessed February 20, 2015. 16. ​Rubulotta F,
Rubulotta G. Cardiopulmonary resuscitation and ethics. Rev Bras Ter
Intensiva 2013;25(4):265–9​. 17. ​President’s Commission of the study of ethical problems in medicine and biomed- ical and
behavior research. Deciding to forgo life sustaining treatment: ethical, medical, and legal issues in treatment decisions.
Washington, DC: Library of Congress; 1983​. 18. ​Scott TH, Gavrin JR. Palliative surgery in the do not resuscitate patient: ethics and
practical suggestions for management. Anesthesiol Clin 2012;30:1–12​. 19. ​Clemency MV, Thompson NJ. “Do not
resuscitate orders” (DNR) in the perioper- ative period—a comparison of the perspectives of anesthesiologists, internists, and
surgeons. Anesth Analg 1994;78(4):651–8​. 20. ​Knipe M, Hardman JG. Past, present, and future of ‘do not attempt resuscitation’
orders in the perioperative period. Br J Anaesth 2013;111(6):861–3​. 21. ​Broeckaert B, Nunez Olarte JM. Sedation in
palliative care: facts and concepts. In: ten Have H, Clark D, editors. The ethics of palliative care: European perspec- tives. Facing
Death series. Berkshire (United Kingdom): Open University Press; 2002​. 22. ​Panetta L. Omnibus budget conciliation act of 1990.
United States House of Rep-
resentatives; 1990​. 23. ​Cohen CB, Cohen PJ. Do-not-resuscitate orders in the operating room. N Engl J
Med 1991;325(26):1879–82​. 24. ​Truog RD. “Do-not-resuscitate” orders during anesthesia and surgery. Anesthesi-
ology 1991;74(3):606–8​. 25. ​Walker RM. DNR in the OR. Resuscitation as an operative risk. JAMA 1991;
266(17):2407–12​. 26. American Society of Anesthesiologists. Available at: ​http://www.asahq.org/for-
members/medica/for%20members/documents/Standards%20Guidelines %20stmts/
ethical%20guidelines%20for%20the%20anesthesia%20care%20of%20patients. ashx​. Accessed February 20, 2015. 27. ​AMA
Council on Ethical and Judicial Affairs. Physician objection to treatment and individual patient discrimination. CEJA report 6-a-07.
Chicago: AMAPress; 2007​. 28. ​Azoulay E, Demoule A, Jaber S, et al. Palliative noninvasive ventilation in patients
with acute respiratory failure. Intensive Care Med 2011;37(8):1250–7​. 29. ​Carlucci A, Guerrieri A, Nava S. Palliative care in COPD
patients: is it only an end-
of-life issue? Eur Respir Rev 2012;21(126):347–54​.
Palliative Care for the Geriatric Anesthesiologist ​603

30. ​Curtis JR, Cook DJ, Sinuff T, et al. Noninvasive positive pressure ventilation in crit- ical and palliative care setting:
understanding the goals of therapy. Crit Care Med 2007;35(3):932–9​. 31. American Academy of Hospice and Palliative Medicine.
Consensus statement on artificial nutrition and hydration near the end of life. Available at: ​http://aahpm.org/ positions/anh​.
Accessed February 20, 2015. 32. ​Brody H, Hermer LD, Scott LD, et al. Artificial nutrition and hydration: the evolu-
tion of ethics, evidence, and policy. J Gen Intern Med 2011;26(9):1053–8​. 33. ​Enck RE. Drug-induced terminal sedation for
symptom control. Am J Hosp Palliat
Care 1991;8:3–5​. 34. ​Claessens P, Menten J, Schotsman P, et al. Level of consciousness in dying pa- tients. The role
of of palliative sedation: a longitudinal prospective study. Am J Hosp Palliat Care 2012;29(3):195–200​. 35. ​Fine PG. The evolving
and important role of anesthesiology in palliative care.
Anesth Analg 2005;100:183–8​. 36. American Academy of Hospice and Palliative Medicine. Consensus statement on
palliative sedation. Available at: ​http://aahpm.org/positions/palliative-sedation​. Accessed February 20, 2015. 37. ​Carvalho TB,
Rady MY, Verheijde JL, et al. Continuous deep sedation in end-of- life care: disentangling palliation from physician-assisted death.
Am J Bioeth 2011;11(6):60–2​. 38. ​Broeckaert B. Palliative sedation, physician-assisted suicide, and euthanasia:
“same, same but different”? Am J Bioeth 2011;11(6):62–4​. 39. ​Homsi J, Walsh D, Rivera N, et al. Symptom evaluation
in palliative medicine: patient report vs. systematic assessment. Support Care Cancer 2006;14(5): 444–53​. 40. American Medical
Association. AMA statement on end-of-life care. Available at:
http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/about-
ethics-group/ethics-resource-center/end-of-life-care/ama-statement-end-of-life- care.page? ​Accessed February 20, 2015. 41.
Bruce SD, Hendrix CC, Gentry JH. Palliative sedation in end-of-life care. J Hosp
Palliat Nurs 2006;8(6):320–7​. 42. ​Needham DM, Davison J, Cohen H, et al. Improving long-term outcomes after
discharge from intensive care unit: report from a stakeholders’ conference. Crit Care Med 2012;40(2):502–9​. 43. ​Stevens RD, Hart
N, Heridge MS, editors. A textbook of post ICU medicine: the legacy of critical care. Oxford (United Kingdom): Oxford University
Press; 2014​. 44. ​Pochard F, Darmon M, Fassier T, et al. Symptoms of anxiety and depression in family members of intensive care
unit patients before discharge or death. A pro- spective multicenter study. J Crit Care 2005;20(1):90–6​. 45. ​Anderson WG, Arnold
RM, Angus DC, et al. Posttraumatic stress and compli- cated grief in family members of patients in the intensive care unit. J Gen
Intern Med 2008;23(11):1871–6​. 46. ​Cox CE, Docherty SL, Brandon DH, et al. Surviving critical illness: acute respira- tory distress
syndrome as experienced by patients and their caregivers. Crit Care Med 2009;37(10):2701–8​. 47. H ​ erridge MS, Tansey CM,
Matte A, et al. Functional disability 5 years after acute
respiratory distress syndrome. N Engl J Med 2011;364(14):1293–304​. 48. ​Adhikari NK, Tansey CM, McAndrews MP,
et al. Self-reported depressive symp- toms and memory complaints in survivors five years after ARDS. Chest 2011;
140(6):1484–93​.
Gustin Jr & Aslakson ​604

49. ​Iwashyna TJ, Ely EW, Smith DM, et al. Long-term cognitive impairment and func-
tional disability among survivors of sever sepsis. JAMA 2010;304(16):1787–94​. 50. ​Nelson JE, Meier DE, Litke A, et al.
The symptom burden of chronic critical illness.
Crit Care Med 2004;32(7):1527–34​. 51. ​Apatira L, Boyd EA, Malvar G, et al. Hope, truth, and preparing for death: Per-
spectives of surrogate decision makers. Ann Intern Med 2008;149:861–8​. 52. ​Schenker Y, White DB, Crowley Matoka M,
et al. “It hurts to know​. ​and it helps”: exploring how surrogates in the ICU cope with prognostic information. J Palliat Med
2013;16(3):243–9​. 53. ​Buchman TG, Cassell J, Ray SE, et al. Who should manage the dying patient?: rescue, shame, and the
surgical ICU dilemma. 2002. J Am Coll Surg 2002; 194(5):665–73​. 54. ​Buchman TG. Surgeons and their patients near the end of
life. Crit Care Med
2010;38:995–6​. 55. ​Shander A, Gandhi N, Aslakson RA. Anesthesiologists and the quality of death.
Anesth Analg 2014;118(4):695–7​. 56. ​Nelson JE, Mulkerin CM, Adams LL, et al. Improving comfort and communication in
the ICU: a practical new tool for palliative care performance measurement and feedback. Qual Saf Health Care
2006;15(4):264–71​. 57. ​Feldman D, Pamboukian SV, Teuteberg JJ, et al. The 2013 international guide- lines for heart and lung
transplantation guidelines for mechanical circulatory sup- port: executive summary. J Heart Lung Transplant 2013;32(2):157–87​.
58. ​Swetz KM, Kamal AH, Matlock DD, et al. Preparedness planning before mechan- ical circulatory support: a “how to” guide for
palliative medicine clinicians. J Pain Symptom Manage 2014;47(5):926–35​. 59. ​Long JW, Healy AH, Rasmusson BY, et al.
Improving outcomes with long-term “destination therapy” using left ventricular assist devices. J Thorac Cardiovasc Surg
2008;135(6):1353–60​. 60. ​Park SJ, Tector A, Piccinoi W, et al. Left ventricular assist devices as destination
therapy: a new look at survival. J Thorac Cardiovasc Surg 2005;129(1):9–17​. 61. ​Lietz K, Long JW, Kfoury AG, et al.
Outcomes of left ventricular assist device im- plantation as destination therapy in the post-REMATCH era: implications for pa- tient
selection. Circulation 2007;116(5):497–505​. 62. ​Dudzinski DM. Ethics guidelines for destination therapy. Ann Thorac Surg 2006;
81(4):1185–8​. 63. ​Swetz KM, Mueller PS, Ottenberg AL, et al. The use of advance directives among
patients with left ventricular assist devices. Hosp Pract 2011;39(1):78–84​. 64. ​Bramstedt KA. Destination nowhere: a potential
dilemma with ventricular assist
devices. ASAIO J 2008;54(1):1–2​. 65. ​Slaughter MS, Roberts JG, Milano CA, et al. Advanced heart failure treated with
continuous-flow left ventricular assist device. N Engl J Med 2009;361(23): 2241–51​. 66. ​Rizzieri AG, Verheijde JL, Rady MY, et al.
Ethical challenges with the left ven- tricular assist device as a destination therapy. Philos Ethics Humanit Med 2008;3(1):20​. 67.
Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term use of left ventricular assist
devices for end-stage heart failure. N Engl J Med 2001;345(20):1435–43​. 68. ​Swetz KM, Freeman MR, AbouEzzeddine
OF, et al. Palliative medicine consulta- tion for preparedness planning in patients receiving left ventricular assist devices as
destination therapy. Mayo Clin Proc 2011;86(6):493–500​.
Palliative Care for the Geriatric Anesthesiologist ​605

69. ​McCusker M, Ceronsky L, Crone C, et al. Institute for Clinical Systems Improve-
ment. Palliative Care for Adults. 2013​. 70. ​Quill TE, Abernethy AP. Generalist plus specialist palliative care–creating a
more
sustainable model. N Engl J Med 2013;368(13):1173–5​. 71. ​Dunn GP. Surgical palliative care: recent trends and
developments. Anesthesiol
Clin 2012;30(1):13–28​.

You might also like