General Anaesthesia in End of Life Care – GAEL.

Recent advances in anaesthetic techniques – using ultra slow infusions of medicines – mean that it is possible to give them to patients close to death without affecting their breathing. The medicine is given slowly, and the patient made unconscious gradually over a period of 15-20 minutes. The medicine can be slowed or stopped at any point.
But the second is when a patient who is dying and has only a short time to live, expresses a clear wish to be unconscious. Some dying patients just want to sleep

What does the paper say?

That means that GAEL, which as we have said is feasible and ethical, could be available now for dying patients in the UK without any change in the law.
Our paper, published today in the journal “Anaesthesia”, describes a practice that we call GAEL – General Anaesthesia in End of Life Care.
But the most powerful potential way to relieve these sensations would be with a general anaesthetic.

We already have palliative care. Why do we need GAEL?

But in some cases they are not enough. In about one in five dying patients, the patient may be given a sedative medicine like diazepam or midazolam – something that makes them more relaxed and sleepy. Third, you could have a general anaesthetic and be “knocked out”. You would have no memory at all of the procedure.
There are two separate and important situations when GAEL might be used in a dying patient.
In our paper, we note that there is a need for clear guidance for professionals who would provide GAEL. The Royal College of Anaesthetists should in conjunction with palliative care societies take the lead in drafting guidance
The paper: We think that there is a strong ethical case for making this option more widely available. These researchers showed that this anaesthetic medicine could be used in patients who were dying. It made the patients comfortable, but importantly they were still able to breathe. The medicine was continued and they remained asleep until they died naturally some hours or days later.
That is different from sedation – which aims to make someone sleepy and more calm, but doesn’t always mean that they are unconscious.
GAEL is compatible with palliative care

Why anaesthesia and not sedation?

  GAEL has been practised internationally for at least 25 years.
Co-author Jaideep Pandit, Professor of Anaesthesia worked in the mid 1990s with the doctor who first described general anaesthesia at end of life and helped rediscover this, so it has long ago been published and is not new.
The studies that have used GAEL, have continued the medicines for a period of between 1 and 14 days until the patient died naturally. It is clear that in those cases the medicine did not hasten death.
If you need a surgical procedure, you do not want to be in pain.
Medicines like propofol are very commonly used when a patient is having surgery. But they can also be used for dying patients.
General anaesthesia is the specialised medical technique of making sure that someone is completely unconscious and unaware of something
These same three options could be applied to the dying process. There are more complicated ethical issues in making this sort of option available for patients with a terminal illness who might live for a longer time.
In the mid 1990s, anaesthetists in the UK and in Italy separately described the use of low doses of the anaesthetic propofol in palliative care – for patients close to death who were agitated or delirious or in pain despite all other medical techniques.
There are three ways of achieving this.
We think that there is a strong case that patients who are predicted to have less than 2 weeks to live, should have the option of GAEL. Takla A, Savulescu J, Kappes A, Wilkinson DJC (2021) British laypeople’s attitudes towards gradual sedation, sedation to unconsciousness and euthanasia at the end of life. PLOS ONE 16(3): e0247193. https://doi.org/10.1371/journal.pone.0247193 Anaesthesia and sedation are at different ends of a spectrum – reflecting the degree of certainty about complete unconsciousness.
Some might want to be sedated if necessary.

Is GAEL compatible with palliative care?

Any of these might be appropriate, depending on the procedure and depending on the person –
A general anaesthetic is the most powerful medical technique we have for making sure that someone is comfortable and not experiencing pain or discomfort.
Second, you could be partly sedated – you would be much less stressed or worried about it. You might remember some of the procedure afterwards.
Takla, A, Savulescu, J, Wilkinson, DJC. A conscious choice: Is it ethical to aim for unconsciousness at the end of life?. Bioethics. 2021; 35: 284– 291. https://doi.org/10.1111/bioe.12838
Our other work on GAEL:

Would people want this?

First, you could be completely awake – but have medicines to block the pain of the procedure. You would remember everything.
General anaesthesia in end of life care GAEL has been described in a small number of papers since then – by doctors in Sweden, Australia, the US. It has been available – usually as an option of last resort. Our paper General anaesthesia in end-of-life care: extending the indications for anaesthesia beyond surgery has been published today in Anaesthesia. It is part of a series of work led by researcher Antony Takla, together with Julian Savulescu and Dominic Wilkinson. The recent paper is a collaboration with Professor Jaideep Pandit, Professor of Anaesthesia at Oxford. The first is when other techniques have not worked. Other medicines are not enough and the patient is still distressed or in pain.
There are a range of unpleasant sensations that someone might experience when they are dying. That includes feelings of pain, suffocation and other suffering, but also delirium, fear, anxiety, sadness, loneliness, vulnerability, embarrassment and loss of dignity.
But it is not commonly discussed or provided. Few people know about it.

Is GAEL new?

General anaesthesia is obviously legal. Whereas in many countries, including the UK, euthanasia is illegal.
Last year, in a separate study, published in the journal PLOS One we surveyed more than 500 members of the UK general public about the types of medical treatment options that they thought were ethical, and what they themselves would wish for if they were dying.
Almost 90% of those surveyed said they would like the option of a general anaesthetic if they were dying. About two thirds (64%) said they would personally choose to have an anaesthetic at the end of life.
There are, of course, risks and side effects with all medicines and medical techniques.
Dying patients who are in pain receive medicines like morphine. Four out of five dying patients receiving these medicines. They may be enough for the patient to be comfortable
Some people might want to be as awake as possible.
There are several strong ethical arguments in favour of GAEL

Isn’t this just euthanasia?

Savulescu, J. and Radcliffe‐Richards, J. (2019), A right to be unconscious. Anaesthesia, 74: 557-559. https://doi.org/10.1111/anae.14635
When you talk to people about how they would ideally like to die many say that they would like to die “in their sleep”. There is something enormously reassuring about the idea of going gently to sleep, and not waking up.
Existing approaches to palliative care involve the use of painkillers (analgesics) and sometimes sedatives.
GAEL is about promoting both of these ethical values.

But wouldn’t it be too risky?

Giving someone medicines to ensure that they are unconscious is very different from giving someone medicine to end their life. The paper outlines the medical and ethical aspects of GAEL. We argue that with advances in anaesthesia GAEL is a potentially feasible, safe and ethical approach. It is an option that a number of dying patients value. It should be more widely available.
There are different ways of treating and responding to these symptoms. Many symptoms might be relieved by good quality palliative care.
Takla, A., Savulescu, J., Wilkinson, D.J.C. and Pandit, J.J. (2021), General anaesthesia in end‐of‐life care: extending the indications for anaesthesia beyond surgery. Anaesthesia. https://doi.org/10.1111/anae.15459

When should GAEL be available?

Different people will want different things.
There are some potential concerns
GAEL is not a replacement for existing palliative care.  It is an extension of what is already commonly done, and an option within palliative care.
There are two key ethical values in palliative care – relief of suffering in patients who cannot be cured and respecting patient choices.

Is GAEL ethical?

This is primarily an option for patients with a short time to live. Guidance in France which is very similar suggests it should be only available to patients expected to die within 2 weeks

1. It is clear that some patients wish for unconsciousness as death approaches. They wish to be asleep at the end. There is an ethical imperative to respect patient’s dying wishes
2. Some patients experience unpleasant and distressing symptoms despite palliative care. Beyond a shadow of a doubt, the single most powerful and effective way of ensuring that a patient is not aware and symptom free – is to give them a general anaesthetic.
3. GAEL can be continued until a patient dies naturally. It is not a form of euthanasia. In our survey it was supported by both those who were religious and who had no religion, those who supported assisted dying and those who did not.

The rate of side effects with propofol when used in anaesthesia is extremely low.
No, GAEL is not euthanasia. It is not a form of assisted dying. It is a completely separate end of life option.

1. Some people would not wish for GAEL. Sigmund Freud famously declined pain relief when he was dying from cancer – wanting to have a clear head. But of course, the fact that some people would not want this option does not mean that other people, who do, should be denied access to it.
2. Some doctors may be concerned about the side effects of these medicines in dying patients. There is a need for clear guidelines about when GAEL should be available and how it should be administered. There may be a need for training and education of healthcare professionals about this end of life care option.
3. Because GAEL would potentially require specialist input from anaesthetists it may not be an option in some circumstances (for example it may only be feasible in a hospital or hospice environment). It may require resources that are not currently available.
4. GAEL might speed up the dying process in some patients (even if it does not usually do this). That is not different from other medicines commonly used in dying patients. It would remain ethical (and lawful) to use GAEL, but this should be discussed as part of informed consent for this treatment.

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And some patients wish to have the option of being completely asleep at the end of life
Others might want to be completely asleep. In our paper we describe a third possible approach. GAEL is the use of specialist anaesthetic medicines to ensure that the dying patient is completely unconscious.
But the option with the highest chance that you won’t feel anything – is of course general anaesthesia.
It is about a potentially important treatment option for patients with a short time to live – to be given a general anaesthetic in the hours or days before they die so that they are completely unconscious in the dying phase.
by Dominic Wilkinson @Neonatalethics