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Should patients receive general anesthesia prior to extubation at the end of life?*

Truog, Robert D. MD, MA; Brock, Dan W. PhD; White, Douglas B. MD, MAS

doi: 10.1097/CCM.0b013e3182413b8a
Alternate Point of View Article

Billings has proposed that any potentially conscious and imminently dying patient who is undergoing withdrawal of ventilator support should be offered general anesthesia to fully protect against suffering. Here we examine whether his proposal is compatible with the doctrine of double effect, a philosophical construct that is generally in accord with the legal requirements for palliative care in the United States. We review the essential elements of the doctrine of double effect, and emphasize the importance of pre-medicating patients before ventilator withdrawal (anticipatory dosing) and of titrating medications to the needs of the patient. The doctrine of double effect requires physicians to balance the risk of the patient suffering against the risk of hastening the patient's deathwhen titrating the medications used to provide comfort. We argue that the values and preferences of the patient should determine how these risks are balanced. We therefore agree with Billings that general anesthesia may be indicated for patients who prefer to minimize the risk of suffering while accepting a greater risk of having their death hastened. This approach would not be appropriate, however, for patients who place a higher value upon avoiding the risk of hastening death, even when this involves a greater risk of potential suffering.

From the Harvard Medical School (RTD, DWB), Children's Hospital Boston (RTD), Boston, MA; and the University of Pittsburgh Medical Center (DBW), Pittsburgh, PA.

* See also p. 700.

Dr. White has received funding from the National Institutes of Health.

The authors have not disclosed any potential conflicts of interest.

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© 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins