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Anesthesiologists and the Quality of Death

Shander, Aryeh MD*†; Gandhi, Nisha MD*‡; Aslakson, Rebecca A. MD, PhD§

doi: 10.1213/ANE.0000000000000166
Editorials: Editorial

From the *Department of Anesthesiology and Critical Care Medicine, Englewood Hospital & Medical Center, Englewood, New Jersey; Departments of Anesthesiology, Medicine, and Surgery, Mount Sinai School of Medicine; Icahn School of Medicine, Mount Sinai Hospital, New York, New York; and §Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland.

Funding: Not Applicable.

Conflicts of Interest: See Disclosures at the end of the article.

Reprints will not be available from the authors.

Address correspondence to Aryeh Shander, MD, Department of Anesthesiology, Critical Care and Hyperbaric Medicine, Englewood Hospital and Medical Center, 350 Engle St., Englewood, NJ 07631. Address e-mail to

As clinicians, we see ourselves as guardians of health, a concept that pertains not only to absence of disease but also to a comprehensive state of physical, mental, social, and spiritual well-being for our patients.1,2 It is then only a matter of time when we find ourselves faced with the inevitable reality of end of life for a patient who has been under our care. Ensuring appropriate and compassionate end-of-life care for our patients is an integral part of subscribing to this holistic view of health. Indeed, the World Health Organization’s definition of palliative care “affirms life and regards dying as a normal process” and advocates for improving the quality of life of seriously ill patients and their families regardless of disease prognosis and through a team approach, addressing the needs of both.3

Death, suffering, and quality of life are central themes in these definitions, yet they are all too frequently in conflict in end-of-life situations. In her seminal ethnographic work exploring end-of-life care in surgical intensive care units (ICU), Joan Cassell4 described varying “moral economies” in the perioperative world:

“In the American surgeons’ moral economy, death is the supreme enemy to be battled at any cost….[For the intensivists,] not death but suffering [Cassell’s emphasis] is the supreme enemy; consequently, rather than attempting to sustain life to the bitter end, intensivists consider survivor’s quality of life.”

Both the surgeon and the intensivist are behaving morally, yet they are inevitably conflicted as a result of their divergent moral economies. Moreover, patients and their families may have similarly divergent moral economies that further complicate the situation. Thus, optimal end-of-life care for perioperative patients is understandably challenging and fraught with strong emotions and potential conflicts.

As both a philosophy and means for providing care, palliative care seeks to reduce patient and family suffering through aggressive symptom management, psychosocial support, and clarification of the patient’s goals of care.5 In 2006, palliative care was recognized as a formal subspecialty in the United States. Multiple studies since have shown how proactive palliative care can improve patient and family member symptom scores and decrease health care utilization and costs, without negatively impacting (and sometimes even increasing) survival time for patients with severe life-threatening illness.6–9 However, there are not enough palliative care clinicians in practice to be able to meet the needs of all seriously ill patients in the United States.10 The Committee to Advance Palliative Care notes that, compared with availability of 1 cardiologist for every 71 patients experiencing a myocardial infarction or 1 oncologist for every 141 newly diagnosed cancer patients, there is 1 palliative medicine physician for every 1200 patients living with serious or life-threatening illness.a Thus, this view is gaining momentum that while palliative care “specialists” should provide palliative care for patients and families with complex and challenging symptom management, psychosocial situations, and/or end-of-life care issues, nonspecialists should provide “generalist” palliative care for patients and families with less complicated and/or complex needs.11

It is self-evident that the first and foremost step in providing effective palliative care is to recognize the patients who are potential candidates. Whether dying or not, any patients with serious or life-threatening illness (quite likely, patients with ASA physical status classification of III or IV) can have palliative care needs. Yet many physicians only consider palliative care for end-of-life situations. Part of the reason could be that physicians can have understandable difficulty acknowledging that their patients may be dying. Hence, they may be late to involve palliative care, and it is the patients and families who potentially suffer as a result. Patients may end up receiving life-prolonging care that, given their situation, is inconsistent with their wishes, and families may sustain moral distress in believing that they are “prolonging” the death of their loved one. Evidently, to provide generalist palliative care, or seek specialist palliative care, physicians must first acknowledge that despite all its advances, modern medicine cannot “cure” everyone.12

In this issue of Anesthesia & Analgesia, Papadimos et al.13 discuss this important and timely topic. In their The Open Mind article, “Diagnosing Dying,” they briefly discuss the importance of end-of-life and palliative care, highlight the important role of anesthesiologists with emphasis on American Society of Anesthesiologists statements, review the available tools for prognostication, and call on anesthesiologists to assume a more active role in identifying patients who can benefit from proactive palliative care.13

Although it can be argued that death is not a diagnosis per se, but rather a part of the cycle of life, Papadimos et al.13 underscore a very important unmet need in the practice of anesthesiology: the active, objective, and timely identification of potentially dying patients, and better advocating for these patients to receive palliative care. We similarly advocate for better provision of palliative care for patients and believe appropriate identification, management, and referral of patients likely to benefit from palliative care services should be considered a quality measure in its own capacity. Such a measure requires defining a denominator, the number of patients likely to benefit from proactive palliative care. Since the early 2000s, large insurance companies and health maintenance organizations such as Aetna and Kaiser Permanente have pioneered programs that use self-referral, physician referral, and/or a proprietary algorithms composed of medical and pharmacy codes and claims to identify patients who would likely benefit from proactive palliative care.14,15 Similar algorithms using specific diagnostic codes and other parameters such as hospital or ICU length of stay and/or readmission can be established to identify the patients at risk. The quality metric could be the proportion of these patients who either receive proactive palliative care consultation (i.e., specialist palliative care) or have goals-of-care discussions and advance directive plans documented in their medical records (i.e., generalist palliative care). Such a measure could facilitate alignment of clinical interventions with patient and family preferences and ensure that a patient’s prognosis is discussed before the patient becoming acutely ill.

The authors should be commended for bringing this important issue to the surface. We agree completely that anesthesiologists should take an active role in this process. As part of the multidisciplinary perioperative team, anesthesiologists are offered many opportunities to either provide generalist palliative care or to advocate for specialist palliative care consultation. As experts in pain management, many anesthesiologists are already valued members of palliative care teams. When the anesthesiologist discusses a perioperative plan with a patient, he or she can clarify who would make decisions on the patient’s behalf should the patient become too incapacitated in the perioperative period to make his or her own decisions. When interacting with critically ill patients in the ICU, anesthesiologists can introduce the potential benefit of palliative care with the ICU and/or surgical teams. In every interaction, anesthesiologists can also reassure patients and their families that clinicians will honor the “personhood” of the patient and care for their physical, mental, social, and spiritual needs regardless of disease progression or outcome. It should be emphasized here that the concept of personhood, despite being often taken for granted, can be a multifaceted and even a controversial topic as it involves fundamental questions on what criteria defines a “person” (an issue that is for example being hotly debated among the opponents and proponents of abortion rights).

Lessons can be learned from models attempting to extend and transfer palliative care into mainstream health care. With the use of a proprietary system of advance care planning tools since 1993, along with standardized Physician Orders for Life-Sustaining Treatments (POLST) advance directives since 1997, the community of La Crosse County, Wisconsin has integrated palliative care into the delivery of medical care such that 90% of decedents have an advance directive at the time of death, and these directives were consistent with the delivered end-of-life treatments in 99.5% of cases.16 With the use of proprietary advanced care tools and standardized Physician Orders for Life-Sustaining Treatment, the community of La Crosse County, Wisconsin, has integrated palliative care into its countywide health care system since 1993. As a result, 90% of decedents have an advance directive at the time of death. These directives were consistent with the delivered end-of-life treatments in 99.5% of cases.

With increasing patient age and perioperative illness complexity, the opportunity for anesthesiologists to be leaders of end-of-life management for hospitalized patients is unprecedented. Management of pain, nausea, and other symptoms is part of anesthesiology general practice and training. Anesthesiologists are one of the few specialists who regularly prescribe and manage the medications most frequently needed by palliative care patients. Moreover, if hospitals lack specialist palliative care services or if patient needs outstrip the available specialist resources, anesthesiologists can be the logical choice for physicians able to provide generalist palliative care. This shifting landscape makes palliative care more relevant to the practice of anesthesiology and provides a new way for anesthesiologists to extend their practice out of the operating room and to the bedside of patients and families who could benefit from their skill-set. Recognizing this need, the American Society of Anesthesiologists created a palliative medicine subcommittee in the summer of 2013.

We welcome the article by Papadimos et al.13 as a call for action to anesthesiologists to address an unmet and growing need for our professional skills. We invite our fellow anesthesiologists and other clinicians involved in the care of severely ill patients to take a proactive role in determining the possibility of impending death. Through proactive palliative care, accompanied by open, honest, and patient-centered dialogues, we can improve the quality of life, and the quality of the death, for our sickest patients and their families. We can address the basic needs of patients who arguably need us the most. Moreover, applying these skills to patients, particularly those who are dying, demonstrate our fundamental respect and regard for sanctity of life and human dignity. This is our duty as guardians of the life and well-being of our patients.

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Name: Aryeh Shander, MD.

Contribution: This author helped write the manuscript.

Attestation: Aryeh Shander approved the final manuscript.

Conflicts of Interest: Aryeh Shander has been a consultant or speaker with honorarium for or received research support from Bayer, Luitpold, Masimo, Novartis, Novo Nordisk, OrthoBiotech, Pfizer, Masimo & Zymogenetics. He is a founding member of SABM.

Name: Nisha Gandhi, MD.

Contribution: This author helped write the manuscript.

Attestation: Nisha Gandhi approved the final manuscript.

Conflicts of Interest: The author has no conflicts of interest to declare.

Name: Rebecca A. Aslakson, MD, PhD.

Contribution: This author helped write the manuscript.

Attestation: Rebecca A. Aslakson approved the final manuscript.

Conflicts of Interest: Rebecca A. Aslakson is a grantee of the National Palliative Care Research Center as well as PCORI, the Gordon and Betty Moore Foundation, and the Johns Hopkins School of Medicine. She is a past grantee/contractee of FAER and AHRQ.

This manuscript was handled by: Steven L. Shafer, MD.

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The authors are grateful to Mazyar Javidroozi, MD, PhD, for editorial assistance.

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a Center to Advance Palliative Care. A State-by-State Report Card on Access to Palliative Care in Our Nation's Hospitals. Recommendations for Action. Available at:
Cited Here...

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