Sedation and general anaesthesia in end‐of‐life care: the boundary has to be defined

Abstract

We read with great interest the article by Takla et al. [1], which discussed extending general anaesthesia for the relief of suffering in palliative care. As anaesthetists and intensivists with experience in providing procedural sedation and end-of-life care, we would like to share our viewon this controversial topic. Sedation is a continuumwhich extends from normal alert consciousness to complete unresponsiveness [2]. The International Committee for the Advancement of Procedural Sedation has highlighted the difference between procedural sedation and general anaesthesia. It stated that general anaesthesia targets an unarousable state in which airway intervention is often required and spontaneous ventilation is frequently inadequate. Procedural sedation, on the other hand, targets a state during which airway patency, protective airway reflexes, spontaneous ventilation and haemodynamic stability are preserved [2]. Indeed, the American Society of Anaesthesiologists also shared similar definitions in regard of sedation vs. general anaesthesia [3]. Although procedural sedation may not be entirely the same as palliative sedation, webelieve theydosharemany similarities. After understanding the key differences between sedation and general anaesthesia, a number of potentially technical, legal and ethical difficulties would be expected. For instance, should airway and ventilation support be provided if significant airway obstruction, profound respiratory depression and imminent death occur during the slow induction of general anaesthesia? If life-saving support is provided, their disease suffering would be prolonged. It would be considered against the patient’s wish and deemed unethical. However, if life-saving support is not provided, the resulting immediate death may not be protected by the ‘rule of double effect’ as argued by Takla et al. [1]. Since the bad effect, immediate death, could be considered outweighing the intended good effect, complete unconsciousness, the proportionality between the good effect and the bad effect could not bemaintained [4]. The hypothetical challenges stated above question the feasibility of extending general anaesthesia, beyond the level of continuous deep sedation, to dying patients in the palliative ward setting. On the other hand, we think general anaesthesia could be a feasible option in managing end-of-life care in highly selected critically ill patients who were placed on mechanical ventilation. We acknowledge that extension of general anaesthesia to the relief of suffering in palliative care is full of controversy and subject to debate. We appreciate the efforts of Takla et al. in providing an insightful platform in the journal for discussion. However, we believe that the boundary between deep sedation and general anaesthesia has to be clearly defined beforehand, so that further discussions on this difficult topic can be maintainedandmeaningful conclusionsdrawn.