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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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You’re an anesthesiologist and you’re contacted by a patient who is dying of cancer. He wants an end of life anesthetic so that he will be unconscious and die without pain and suffering. What do you do? Will you enable dying under general anesthesia?

A recent article from the United Kingdom discussed this topic of end of life anesthesia, otherwise known as “terminal anesthesia.” Terminal anesthesia refers to a situation when a patient has a terminal illness such as end-stage cancer and is suffering through their last days. They request to have a general anesthetic so they are unconscious throughout the process of dying under general anesthesia.

Is anyone doing terminal anesthesia anywhere? The Journal of Medical Ethics reported that in 2016, “France passed a law granting terminally ill patients the right to continuous deep sedation until death. This right was proposed as an alternative to euthanasia and was presented as the ‘French response’ to problems at the end of life. The law draws a distinction between continuous deep sedation and euthanasia.”

Euthanasia, or the ending of life through pharmacologic intervention, is illegal in the United States, the United Kingdom, and most nations. In the 1980s and 1990s, Dr. Jack Kevorkian of the United States infamously created a euthanasia machine that injected lethal doses of sodium pentothal (a hypnotic sleep drug), potassium chloride (an overdose of potassium which caused cardiac arrest), and pancuronium (a paralyzing drug) into terminal patients who requested a pharmacologic suicide. Dr. Kevorkian was convicted of second degree murder, and served 8 years of a 10-to-25-year prison sentence.

Dr. Jack Kevorkian and his euthanasia machine

Dying patients may have an interest in terminal anesthesia. In a survey of 500 individuals in the United Kingdom regarding end-of-life options, 88% of the respondents said they would like the option of a general anesthetic if they were dying.

What would terminal anesthesia look like? Medication(s) would be administered through an intravenous line to bring on unconsciousness without hastening death. These last three words are key, because terminal anesthesia is specifically not to be euthanasia. Terminal patients are frail, and their cardiac and respiratory systems will be sensitive to oversedation. Terminal anesthesia is not to directly stop the patient from breathing, stop their hearts from beating, or put them at risk from aspirating food into their lungs. The duration of the IV sedation/anesthesia must be maintained until the patient’s heart eventually stops because of their underlying terminal medical illness. Because of the danger of food aspiration into the windpipe (trachea), tube feedings to the stomach during the time of this terminal anesthetic would not be allowed.

What drugs could be used for terminal anesthesia? Propofol (an IV hypnotic drug) and midazolam (an IV benzodiazepine also known as Versed) are the most likely agents. The initial infusion of these drugs must be gradual, because bolus doses of these powerful agents into the bloodstream of a frail, end of life patient, could easily halt their breathing and hasten death. No pulse oximetry or other monitors would be used, and the person administering the drug would not remain in constant attendance with the patient. These two facts—the lack of monitoring and the lack of being physically present to attend to the patient—are boldly in defiance of what anesthesiologists do when they administer general anesthesia to patients. The motto of the American Society of Anesthesiologists is “Vigilance.” Terminal anesthesia implies minimal vigilance, and for this reason I cannot imagine the practice being approved in the United States.

An April 2021 publication in the journal Anaesthesia disagrees. The authors describe end of life anesthesia as “an impending development for which the specialty should prepare.” Co-author Jaideep Pandit, MD, professor of anesthesia at Oxford University, said, “Ethically, it is the right thing to do to make this offer to dying patients where it is technically feasible and the literature says it is. The desire to be unconscious in times of great adversity is understandable—it isn’t surprising or wrong to want to be unconscious in adverse situations. We as physicians are here to help, and if we have the means to help and meet the patient’s desire and it is ethical to do so, then we should strive to make this option feasible.” This article described the first use of end of life anesthesia as occurring over 25 years ago: “The first description of using general anesthesia in end‐of‐life care was in 1995 by John Moyle, a consultant anesthetist and palliative care physician. Moyle recognized the limitations of conventional approaches . . . Moyle developed a protocol for infusing the then relatively new anesthetic agent propofol and described its use in two patients, who died peacefully after 4 and 9 days of continuous infusion. . . . Moyle and others recommended very slow intravenous infusion by a pump at a carefully titrated dose (e.g. just 5 mg.h^‐1 vs. the 100–200 mg typically used as a bolus) The depth of anesthesia achieved was inadequate for a surgical procedure, but was ideal for an undisturbed dying patient.”

A study from Sweden described their experience with propofol for end of life sedation. Two indications for using propofol were identified. The first was refractory nausea and vomiting, and the second was the need for palliative sedation due to refractory anxiety or agitation, with or without intractable pain. Monitoring of the patient was as follows: “During the first hour of treatment, the patients were checked repeatedly by both the nurse and the physician caring for the patient. Then, evaluation was performed after 2, 6, and 12 hours. These assessments were preferably made by the physician, but when symptom control had been established, the evaluation was made by the nurse. Patients on continuous treatment with propofol were thereafter evaluated at least twice daily by the nurse in addition to their daily routine care. The physician visited the patient at least once daily for evaluation.” The mean dose range of propofol during treatment was between 0.90 and 2.13 mg/kg/h, (or for an average 70-kilogram patient, between 70 and 150 mg of propofol per hour). The length of treatment with propofol varied between 2 hours and 44 days. The study reported “All but three patients died at the unit, and the median survival was 38 days, compared with the usual median survival of 14 days at the unit.”

Euthanasia is illegal, but general anesthesia is legal. Could general anesthesia really be approved so that individuals do not have to experience the suffering of dying? What if the United States passed a law, similar to the 2016 law in France, that granted terminally ill patients the right to continuous deep sedation until death? Will this type of terminal sedation/anesthesia ever happen in the United States? It’s currently common to utilize anesthesia/deep sedation for patients who are on ventilators in an intensive care unit (ICU). If such a patient has an untreatable illness, they may die while they are in the ICU under deep sedation, but the application of terminal anesthesia outside of an ICU is not seen in the United States today.

There are other ethical, medicolegal and practical implications to utilizing terminal anesthesia. Who would give the IV sedation/general anesthesia? The Hippocratic Oath states, “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan,” so it’s unlikely any American physician would administer the anesthetic. Would the medical malpractice court system litigate that cases of terminal anesthesia were indeed euthanasia, and therefore illegal? If the American Society of Anesthesiologists opposed the idea, could continuous deep sedation at end-of-life ever come to fruition? What if some medical professional with a license to administer anesthesia decided to open up a practice of administering terminal anesthetics? Could such an individual collect cash payments or insurance payments for administering general anesthesia to patients who were on hospice, and thereby earn a large quantum of money for each case?

Everyone fears dying, and no one wants to have a painful or torturous death. Expect to hear more discussion about this topic in years to come, but don’t expect physician anesthesiologists in the United States to prescribe or administer terminal anesthesia any time soon.