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GA for Palliative Care. I spent a bit of time reading over this paper in @Anaes_Journal …https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/full/10.1111/anae.15459
Thanks to @Anaes_Journal for making it #FOAMed and thanks to @lotusgav for pointing it out to me
Thanks to @Anaes_Journal for making it #FOAMed and thanks to @lotusgav for pointing it out to me
I’m going to run a bit of a Twitter experiment in open peer review. I’m tagging @lotusgav @SteveBruce @gingersauruz @GongGasGirl @scruff888 @GasBagGreenie @DrGetafix @needsanap1 @ozmonique and @JenReilly78 but anyone can join, so spread the word #gapallcare
If you don’t want to listen in then mute the hashtag #gapallcare. Also big shout out to the #ASM21mel crew for @anzca ASM this week. Tune in, the ASM will be interesting. The paper isn’t at #ASM21mel, but people might want to say something, so I that hashtag in
Thanks to @TaklaAntony @juliansavulescu @NeonatalEthics and JJ Pandit for a beautifully written, lucid, philosophy paper.
Philosophy?!
Yes, that’s right, philosophy. I’m going to do some philosophy too (maybe not as well) #gapallcare
#Philosophy is the basic science of thinking. You think every day, so you are using philosophy every day. If you aren’t mindful of that, you will be dragging it around like an anchor. If you learn some philosophy, you will have a set of tools to supercharge your work. #gapallcare
You decide what is the right thing to do ( #ethics), how to put information together ( #logic), how to find stuff out ( #epistemology) and how to communicate ( #rhetoric). Philosophy everywhere #gapallcare
This paper is ethics – what is the right thing to do. #gapallcare
I’ll break the discussion up into sections with hashtags, so if you are just interested in one thing you can click a hashtag and go straight to it. #gapallcarewhy #gapallcarehow #gapallcarewho #gapallcarehmm (as in things that make you go hmm…) #gapallcare
Why might we want #gapallcare ? #gapallcarewhy
The authors say: Some symptoms are hard to treat at the end of life. Dying can be anxious and fearful. We think GAs are OK for fear and anxiety (eg dentistry). A UK survey said people like the idea. Respecting people’s autonomy is good. #gapallcare #gapallcarewhy
How should #gapallcare be done? #gapallcarehow
The authors say: This is not to replace all the other treatments for pain and anxiety and other symptoms. It is not for euthanasia. Use an intravenous infusion of general anaesthetic and build it up slowly. Going low and slow might help safety. #gapallcare #gapallcarehow
The authors also talk about sedation vs GA. #gapallcare #gapallcarehow
There are no bright lines between being a bit mellow… #gapallcare #gapallcarehow
Fairly stoned… #gapallcare #gapallcarehow
And completely out… #gapallcare #gapallcarehow
The idea in the paper is to be unconscious – not responding spontaneously or to most stimuli. For this you need a few things usually part of a GA, but at the same time you will leave some things out. #gapallcare #gapallcarehow
You need an expert to start the GA and make sure you have reached the desired degree of unconsciousness, but not so much that it is an immediate risk to life. You’ll need long term IV access, some smart IV pumps, and the usual monitors. #gapallcare #gapallcarehow
Once you have reached a steady state we need to think about what we need to keep going. Having a typical GA involves a lot of very close continuous monitoring and is hardly anyone’s idea of a peaceful end of life. So we need to not do some things. #gapallcare #gapallcarehow
We want to not do stuff that is going to disturb the patient and family. Once things are steady a lot of the monitoring is going to go. As a start I’m thinking of just leaving the monitors a person with sedation/pain infusions in a hospice gets. #gapallcare #gapallcarehow
The Anaesthetist isn’t going to stay for the whole of the time. We don’t have enough people and we want peace and space for the family and person. The Anaesthetist probably should come back once or twice a day to make sure things are OK. #gapallcare #gapallcarehow
That does involve some more risk, but I’m pretty happy with the doctrine of double effect here. The aim is not to impose more risk, but remove burdensome interventions. #gapallcare #gapallcarehow
The authors also mention feeding and giving water to the person under GA, given that the final dying process may take several days or more. I think this would be something to be discussed with the person. #gapallcare #gapallcarehow
You would need a tube into the stomach. People under GA aren’t hungry or thirsty, so there isn’t much to be had for symptom relief. We also have examples where these tubes are taken out because they are burdensome, even knowing that might hasten death. #gapallcare #gapallcarehow
It isn’t something that is likely to be able to be done at home. An unconscious person needs a *lot* of very good, close, nursing care. People need to be moved, kept clean and comfortable to stop a lot of problems. This needs a skilled nursing team. #gapallcare #gapallcarehow
The authors report #gapallcare is available if you are within 14 days of death in France. It might be better to have a set of some clinical and patient preference criteria. Proximity to death, optimised other palliative treatment, patient treatment goals etc #gapallcarehow
Concerns and need for more thoughts #gapallcare #gapallcarehmm
The consent process is critical. Stopping the GA returns the person to a state that they said they didn’t want. A clear set of goals needs to be written so that the treating team and the proxy decision makers can get subsequent decisions right. #gapallcare #gapallcarehmm
The authors point out that there is a risk of unwanted awareness, but this is rare. This may be a little higher for this group of people because they are so frail and don’t tolerate big doses of anaesthesia. #gapallcare #gapallcarehmm
Mostly we judge by the person moving or changes in BP etc. There are occasions when people will move and it is just an effect of the anaesthetic. The families and carers need to know that while it may look distressing, the person is not suffering. #gapallcare #gapallcarehmm
The subject of euthanasia is naturally going to be a big issue at end of life, and it will come to mind with this paper. I’m going to suggest we focus just on #gapallcare because there is some significant divergence and I want to focus on the issue of the paper #gapallcarehmm
Feel free to engage but please read the whole paper, and remember- this is philosophy, and the void isn’t going to shout into itself. #gapallcare
