Papadimos, Thomas J. MD, MPH*; Gafford, Ellin F. MD†; Stawicki, Stanislaw P. A. MD‡; Murray, Michael J. MD, PhD§
As anesthesiologists and intensivists, we have a responsibility to recognize the dying patient and to be more involved in end-of-life issues. This is essential because only about 45% of patients actually recognize that they are, indeed, dying,1 and more than half of patients then are not aware of the gravity of their situation. If they were, they might choose other options. For example, although a majority of the population does not wish to die in a hospital, more than half do so.2 Fifty-eight percent of patients in the United Kingdom die in a hospital,3 and over 20% of U.S. deaths occur in an intensive care unit (ICU).4
Not only are patients “unaware” (or in denial), either of which may be difficult to assess or address, but their primary physician may also be in denial. Physicians tend to overestimate patient survival, especially if they are familiar with the patient.5 If we recognize that a patient is dying, when does one transition from cure to palliative care, a transition that is truly an intellectual challenge?6 Physicians’ ability to predict outcome is not particularly good in the short term (days to weeks) but better in the long term (weeks to months) and the ability to prognosticate accurately has a profound influence on patients’ and families’ decisions regarding end-of-life care,7 which can be especially difficult when dealing with patients who do not have a malignancy.8
Recognition of the dying process allows for development of a plan to alleviate symptoms, facilitation of patient discussions with family regarding wishes and preferences, implementation of advanced directives, and transition to palliative and comfort care. We believe that anesthesiologists and intensivists need to become more involved in end-of-life issues, the use of advanced technology for patients at the end of their lives, goal assessment and planning for the critically ill, and decisions for those about to undergo high-risk surgical procedures.
AMERICAN SOCIETY OF ANESTHESIOLOGISTS STATEMENTS AND THE ANESTHESIOLOGY PERSPECTIVE
Our society has offered, through its statements, its vision as to where we are likely going and why it is appropriate to do so about supporting transitions from cure to palliation, thereby emphasizing the importance of the anesthesiology community’s role and/or input into the process and discourse. The American Society of Anesthesiologists statement on Critical Care and Trauma Services (Approved by the American Society of Anesthesiologists House of Delegates on October 17, 2001, and last amended October 19, 2011) points out that anesthesiologists’ management of surgical patients in the operating room is similar to those services provided by intensivists, and that anesthesiologists trained in critical care medicine are capable of providing additional “intensive and diagnostic therapeutic interventions within the ICU during resuscitation that directly affect patient outcomes.” These services, that are distinctly different from primary care providers and surgeons (nonintensivists), are clearly beneficial to patients. However, the American Society of Anesthesiologists statement on Critical Care and Trauma Services goes appropriately further and states that as intensivists, anesthesiologists must care for the “psychological needs of the patient and their family, ensure that ethical precepts are adhered to, provide holistic patient and family care along with expert opinion in ethics, end of life, and palliative care for the critically ill, and provide leadership in data management, research, and evaluation of clinical outcomes.”
This American Society of Anesthesiologists document astutely points out that anesthesiologists who train in critical care medicine enhance the reputation of all anesthesiologists in any organization or institution. This document also highlights the fact that anesthesiology intensivists are frequently the only anesthesiologists with whom hospital staff outside the operating room have regular contact.
How does this perspective apply to anesthesiologists regarding diagnosing dying? While many anesthesiologists do not recognize the value that intensivists bring to an anesthesiology department, many academic and community practices see their significant value in enhancing the reputation of an organization and ensuring its financial viability. Because of our aging population’s increasing numbers and longevity, the use of advanced technologies (especially devices), the high acuity of illness, and numbers of comorbidities, the anesthesiologist’s vantage point/perspective regarding the medical, social, economic, and political changes in society is highly valued. As anesthesiologists continue to push their practice boundaries beyond the operating room, it is only natural that their expertise in diagnosing dying is appreciated and sought after. We argue that the ability to “diagnose dying” makes anesthesiology intensivists, or a subset there of, effective palliatists. The natural progression, or evolution, of anesthesiology intensivist’s boundaries has increased to include palliative medicine. This is more than an invitation; it is a necessity of intervention by the anesthesiologists who practice critical care medicine.
The American Society of Anesthesiologists House of Delegates “Statement on Quality of End-of-Life Care” (approved October 15, 2003, and last affirmed on October 22, 2008) states that palliation is part of our specialty’s mission in conjunction with the quality of end-of-life experience for our patients. The fact that the American Society of Anesthesiologists makes the statement that “improvements in palliative care should be based on values-based advanced care planning” highlights the importance of the participation of anesthesiologists in general and anesthesiology intensivists, in particular, in palliative medicine. In addition, the American Society of Anesthesiologists’s guidelines regarding do-not-resuscitate orders and directives that limit treatment (approved by the American Society of Anesthesiologists House of Delegates on October 17, 2001, and last affirmed on October 22, 2008) in conjunction with the society’s guidelines for the Ethical Practice of Anesthesiology (Approved by the American Society of Anesthesiologists House of Delegates on October 15, 2003, and last amended on last amended October 19, 2011) makes anesthesiologists’ participation in the practice of, and education in, palliative care an imperative. Anesthesiologists should push their scope of practice into the field of palliative care. Ronald Cranford, MD, one of the physicians who played a pivotal role in introducing the do-not-resuscitate order into clinical practice, as passionate as he was about end-of-life issues, also recognized that the time had to be right before certain concepts would be accepted by society or by physicians (personal communication with M. J. Murray September 1999).9 Perhaps, now is that time, because over the last 10 years the number of medicare patients dying in the ICU or in hospital has decreased,10 and even our surgical colleagues have recognized the importance of patient-centered care at the end of life.11 One might ask how an anesthesiologist practicing exclusively in the operating room might play more of a role in diagnosing dying. We do not think that time is right for the Residency Review Committee to change core competencies to address end-of-life issues, nor should the American Board of Anesthesiology develop tools to assess one’s skills in assessing prognosis and in developing an end-of-life plan. However, we do believe that if anesthesiologists, who in their preoperative interview, in a short period of time, are able to gain patients’ trust, recognize that their patient has a poor prognosis might simply ask the patient whether she or he has shared with the surgeon her or his long-term wishes and preferences. We do something similar already by counseling patients to stop smoking in the preoperative visit; by planting the seed for patient-centered care, we think that anesthesiologists could perform as valuable a function. Hopefully, some anesthesiologists, especially intensivists, will seek advanced training (fellowships or otherwise) in palliative care. A visit to the American Board of Anesthesiology Website confirms that this is already happening; the times indeed are changing.
PROGNOSTICATION, TRANSITIONS, TRAJECTORIES, AND THE ANESTHESIOLOGIST
If one were to decide to become more involved in palliative care, how do they improve their ability to prognosticate and diagnose dying? Clinicians have traditionally based their prognostication on personal impressions, or by using various prognostic tools, which include (a) disease-specific and (b) performance status measures.
The first of the objective measures involves disease-specific prognostic tools. These tools are usually used in clinical trials, transplantation, and heart failure12 but are not usually used at the end of life. Examples of the disease-specific prognostic tools include The Seattle Heart Failure Model13 and the Body-Mass Index, Airflow Obstruction, Dyspnea, and Exercise (BODE) index for chronic obstructive pulmonary disease,14 the Mayo End-Stage Liver Disease (MELD) Score,15 and the Child-Turcotte-Pugh Score for liver failure.16,17
A second set of tools that may help in establishing prognosis of critically ill patients independent of illness type are the performance status measures.18 Performance status can assist providers in establishing the need for palliative and hospice care.19 Stone’s Palliative Prognostic Index in cancer patients uses breathlessness, delirium, and anorexia to quantify the need for palliative care.20 Providers may alternatively use criteria-based models based on the clinical features of advanced diseases to establish prognosis (see below).12,18 These tools are better than personal impression because they use evidence-based markers to develop a score that has been validated experimentally or clinically.21
As important as the assessment of prognosis is, the recognition and management of key transitions at the end of life is of equal importance.18 Boyd and Murray18 claim that, “Instead of seeking to refine prognostic accuracy, we propose that clinical judgment informed by evidence can improve care.” These authors would have physicians ask themselves whether they would be surprised if their patient died within the next 6 to 12 months. If not, then look for more general clinical indicators that suggest the patient is at increased risk for dying. They further suggest that a short list of disease-related clinical indicators derived from prognostic models and existing palliative prognostic guides be used to formulate clinical plans. Consequently, 4r questions that need to be asked are: (1) could this patient be in the last days of life? (2) was this patient’s condition expected to deteriorate in this way? (3) is further life-prolonging treatment inappropriate? and (4) have reversible causes of deterioration been excluded? “The ability to make an accurate and timely diagnosis of dying is a core clinical skill based on careful assessment that could be done better in all care settings.”18
“Death trajectories,” an increasingly discussed topic, can be better understood in the context of the prognostic tools discussed above.21 There are 4 global death trajectories that describe a progressive inability to perform the activities of daily living: terminal illness (prolonged illness with a sharp decline of function), organ failure (sharp decline of function with intermittent severe symptomatic crises), frailty (slow decline of function with death due to a complication of progressive disabililty), and sudden death (a trajectory reserved for patients without chronic illness). Now that death trajectories have entered the end-of-life discussion in the literature, they are, of course, accompanied by public and governmental discourses regarding their economic sequelae and how these trajectories affect society in a time of scarce resources. In the end, we know that many of the prognostic tools do not apply very well, or in some circumstances not at all, for example, in the ICU at the end of life.
Anesthesiologists need to incorporate the expertise of palliative care specialists and of ethicists into their practice, when practical and when they are available. While most anesthesiologists do not consider themselves diagnosticians or gate keepers and may think this discourse is beyond their purview, the fact is that the specialty of anesthesiology, with its expanding scope, is at the crossroads of many discourses. Death of the patient is not the only outcome that we must attend to in the hospital setting. Anesthesiologists must understand that their involvement will not only help alleviate the pain (emotional and physical) of patients and their families but also will help decrease the emotional and social burdens of the staff caring for the patients.
Palliative care teams assist in the formulation of the patient’s care plans and goals. They are a great resource for assessment of the patient and for developing rational plans with the patient and families. In all clinical situations, patients’ values and wishes must be respected when making decisions about any care plan, with many considerations taking place when critical care and life support decisions are involved. To forcibly place a patient in a path of existence, they find intolerable may truly be a fate worse than death. While it can be argued that not all dying patients are the same and that circumstances vary, there should always be time at some point during the perioperative period to discuss the diagnosis of dying.
Special consideration must be given to the use of invasive devices and methods at an advanced age or using them to delay the end of life. Beyond conventional/high-frequency oscillatory ventilators and intra-aortic balloon pumps is the use of ventricular assist devices (right heart, left heart), extracorporeal membrane oxygenation, and extracorporeal cardiopulmonary resuscitation. Implantable cardiodefibrillators are another topic altogether at the end of life. It is in these contexts that the concept of “stability” in the setting of life support may be inherently misleading. While stability is certainly better than clinical decline, a prolonged “stable but critical” condition can be an indication that no recovery is occurring, and therefore, the patient is “stable” but is not going to recover. Consequently, static existence on life support is more likely to become the only “sign/symptom” of the dying process.
Metrics have become standards in the delivery of all types of medical care, but these usually clear guidelines become increasingly blurred as dying becomes the patient’s diagnosis. We have a responsibility to be as consistent and accurate with our dying patients as we do our living ones. Ultimately, it is incumbent on the physician to be able to recognize the dying patient, irrespective of whether he or she uses the tools, methods, or teams mentioned above, and regardless of the specialty he or she practices.
A Time for Introspection and Discourse
The discussion raised here is meant to bring to our attention as a profession the need to better understand not only the problems inherent in prognostication, and to advocate that we become individually more adept at identifying the patient who will die, but also to urge the anesthesiology community to push, once again, the boundaries of their scope of practice and collaboration. As a subset of anesthesiologists begins to formally train in palliative medicine, serious consideration and groundwork should be laid for a Society of Anesthesiology Palliatists (a subset of the American Society of Anesthesiologists) that will interact across the swath of clinical care. When it is time to provide comfort, we should avoid any unintended harm to the dying patient. Anesthesiologists are well positioned to be part of the discourse, and the anesthesiology community should, in fact, make it their duty and obligation to be involved.
At the time this manuscript was submitted to the journal, Michael J. Murray was the Section Editor for Critical Care, Trauma, and Resuscitation for Anesthesia & Analgesia. This manuscript was handled by Steve Shafer, Editor-in-Chief, and Dr. Murray was not involved in any way with the editorial process or decision.
Name: Thomas J. Papadimos, MD, MPH.
Contribution: This author conceived of the idea, wrote, researched, edited, and prepared this manuscript.
Attestation: Dr. Thomas J. Papadimos approved the final manuscript and attests to its integrity. Dr. Thomas J. Papadimos is the archival author.
Name: Ellin F. Gafford, MD.
Contribution: This author cowrote, edited, and prepared this manuscript.
Attestation: Dr. Ellin F. Gafford approved the final manuscript and attests to its integrity.
Name: Stanislaw P. A. Stawicki, MD.
Contribution: This author cowrote, researched, edited, and prepared this manuscript.
Attestation: Dr. Stanislaw P. A. Stawicki approved the final manuscript and attests to its integrity.
Name: Michael J. Murray, MD, PhD.
Contribution: This author cowrote, edited, and prepared this manuscript.
Attestation: Dr. Michael J Murray approved the final manuscript and attests to its integrity.
2. Hinton J. Which patients with terminal cancer are admitted from home care? Palliat Med. 1994;8:197–210
3. Sykes N. End of life issues. Eur J Cancer. 2008;44:1157–62
4. Truog RD, Campbell ML, Curtis JR, Haas CE, Luce JM, Rubenfeld GD, Rushton CH, Kaufman DCAmerican Academy of Critical Care Medicine. . Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med. 2008;36:953–63
5. Glare P, Virik K, Jones M, Hudson M, Eychmuller S, Simes J, Christakis N. A systematic review of physicians’ survival predictions in terminally ill cancer patients. BMJ. 2003;327:195–8
6. Munday D, Petrova M, Dale J. Exploring preferences for place of death with terminally ill patients: qualitative study of experiences of general practitioners and community nurses in England. BMJ. 2009;339:b2391
7. Luce JM. End-of-life decision making in the intensive care unit. Am J Respir Crit Care Med. 2010;182:6–11
8. Shipman C, Gysels M, White P, Worth A, Murray SA, Barclay S, Forrest S, Shepherd J, Dale J, Dewar S, Peters M, White S, Richardson A, Lorenz K, Koffman J, Higginson IJ. Improving generalist end of life care: national consultation with practitioners, commissioners, academics, and service user groups. BMJ. 2008;337:a1720
9. Oransky I. Ronald E Cranford. Lancet. 2006;368:112
10. Teno JM, Gozalo PL, Bynum JP, Leland NE, Miller SC, Morden NE, Scupp T, Goodman DC, Mor V. 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
11. Bergman J, Brook RH, Litwin MS. A call to action: improving value by emphasizing patient-centered care at the end of life. JAMA Surg. 2013;148:215–6
12. Lynn J. Perspectives on care at the close of life. Serving patients who may die soon and their families: the role of hospice and other services. JAMA. 2001;285:925–32
13. Levy WC, Mozaffarian D, Linker DT, Sutradhar SC, Anker SD, Cropp AB, Anand I, Maggioni A, Burton P, Sullivan MD, Pitt B, Poole-Wilson PA, Mann DL, Packer M. The Seattle Heart Failure Model: prediction of survival in heart failure. Circulation. 2006;113:1424–33
14. Celli BR, Cote CG, Marin JM, Casanova C, Montes de Oca M, Mendez RA, Pinto Plata V, Cabral HJ. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. 2004;350:1005–12
15. Forman LM, Lucey MR. Predicting the prognosis of chronic liver disease: an evolution from child to MELD. Mayo End-stage Liver Disease. Hepatology. 2001;33:473–5
16. Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60:646–9
17. Child GC, Turcotte JC. Surgery and portal hypertension. Major Probl Clin Surg. 1964;1:1–85
18. Boyd K, Murray SA. Recognising and managing key transitions in end of life care. BMJ. 2010;341:c4863
19. Lau F, Downing M, Lesperance M, Karlson N, Kuziemsky C, Yang J. Using the Palliative Performance Scale to provide meaningful survival estimates. J Pain Symptom Manage. 2009;38:134–44
20. Stone CA, Tiernan E, Dooley BA. Prospective validation of the palliative prognostic index in patients with cancer. J Pain Symptom Manage. 2008;35:617–22
21. Gisondi MA. A case for education in palliative and end-of-life care in emergency medicine. Acad Emerg Med. 2009;16:181–3