The term “palliative care” was first introduced by a Dr. Balfour Mount, a Canadian physician who had introduced “hospice-like” services into a number of Canadian hospitals [8]. The definitions of palliative medicine have since evolved over the years – this is detailed in Table 31.2 [4, 7, 9–12]. At first palliative care was epitomized as the care associated with patients dying from cancer. As the field evolved and the benefits of palliative care emerged, it was clear that this type of care could be provided to a broader range of patients with a vast array of serious illnesses, and the field expanded its opportunities and options for many different patient populations with both acute and chronic health issues. Currently, the most contemporary definition of palliative care involves the following three components : (1) aggressive, expert-based symptom management, (2) psychosocial support of both the patient and the patient’s family, and (3) an expansive discussion of the patient’s goals of care for his/her medical care [4].

While working toward achieving all three of these goals , palliative care prioritizes providing both the patient and his/her family with relief from the symptoms, pain, and stress of serious illness—whatever the diagnosis, wherever the location, and whatever the outcome. The ultimate goal of palliative care is to improve the quality of life for both the patient and the family. Palliative care can be initiated early in the course of treatment of any illness (regardless of severity) and may be delivered across the continuum of healthcare settings (including the home, the nursing home, the long-term acute-care facility, the acute-care hospital, the intensive care unit (ICU), any perioperative setting, the emergency room, or outpatient clinic) [4, 13–15].

Palliative care can be available when life-prolonging therapy begins, after life-prolonging therapy is withheld or withdrawn, and even during any bereavement period for the patient’s family after the patient’s death (Fig. 31.1) [16]. Figure 31.1a depicts the traditional model of palliative care where a patient first receives life-prolonging/life-sustaining therapy until it fails, and only then is palliative care offered and provided [4, 10]. Many physicians feel the perioperative environment fits this paradigm as surgeons can sometimes be slow to consider palliative medicine until all efforts to restore the patients’ health have failed. Figure 31.1b depicts an overlapping model where palliative care is gradually increased while the patient receives a gradual decrease in life-prolonging therapy [4, 10]. Figure 31.1c depicts an integrated model where palliative medicine is delivered at the beginning of an illness and is provided concurrently with life-prolonging therapy [4, 10]. The amount of palliative care can increase and decrease depending on the preferences and needs of both the patient and the family [4, 10]. Figure 31.1d depicts an ICU individualized integrated model where the patient receives palliative care alongside ICU care [4, 10]. In the ICU , hospice care is not nor can it be integrated into critical care because, though palliative care can be provided concurrent to critical care, hospice care cannot. One should note that usual “life-prolonging” medical care in any care environment ends with the patient’s death, whereas palliative care engagement and application peak at death and continue after death to address the bereavement needs and issues of the patient’s family [4, 10].

Whether in the ICU, the emergency room, the perioperative care, or any patient care area, expert statements recommend coordinating palliative care with life-prolonging care. Life-sustaining medical/surgical care and palliative care can be complementary as long as the patient’s medical/surgical condition and the patient’s goals of care are in parallel and complementary. In 2013, the American Academy of Hospice and Palliative Medicine (AAHPM) “Choosing Wisely” initiative listed the top five initiatives that should be considered in any patient’s care [16]. One of those top five items encouraged the idea that palliative care should be provided to patients with a serious illness and should not be delayed while the patient is being actively treated [16]. Overall, palliative care is appropriate at any age (pediatric to geriatric) and at every stage of any serious illness and can be provided concurrently with curative or other life-prolonging therapies [17].

Although palliative care can be integrated into the continuance of geriatric care, it is still underused in the United States [4, 17]. Despite national efforts to improve end-of-life care , reports of pain and other alarming burden of symptoms in the last year of life have been increasing over the last 10 years [18]. Moreover, advances in healthcare have transformed many previously lethal diseases (human immunodeficiency virus and AIDS, heart failure, chronic obstructive pulmonary disease, some forms of cancer, end-stage renal disease, and dementia) into chronic conditions where significant physical and psychological burdens exist for both the patient and their family [4]. To meet the growing need for palliative care, hospital-based, home-based, hospice-based, emergency room-based, and community-based palliative care programs are increasingly being developed and utilized in greater numbers each year [19]. However, there are still not enough trained specialized palliative care providers to meet public demand; the Center to Advance Palliative Care focuses on the fact that there is approximately 1 cardiologist for every 71 patients experiencing a myocardial infarction, 1 oncologist for every 141 newly diagnosed patient with some form of cancer, and only 1 specialized palliative care physician for every 1200 patients living with a serious or life-threatening illness [4, 10].

Earlier in the evolution of hospice care in the United States, many healthcare providers and patients considered hospice and palliative medicine to be the same entity. Many healthcare providers are confused by the relationship or the distinctions between palliative care and hospice care. Simply stated, hospice care and the field of palliative care can be complimentary to one another, but differences do exist. End-of-life care has been used globally to refer to the process of addressing the medical, social, emotional, and spiritual needs of patients who are nearing the end of life. End-of-life care may include a broad range of medical, surgical, and social services, including disease-specific interventions and palliative/hospice care for those with advanced serious conditions who are near death [7]. More specific than palliative care, hospice is for the dying patient [4]. On the other hand, palliative care is based on the patient’s or family’s need, in contrast to hospice care that is based on the patient’s prognosis. Palliative care can be provided with every effort related to restoring the patient’s health regardless of any life-sustaining treatment (including ICU care). Hospice care, however, tends to focus on the patient’s goals of care at the end of life and cannot/usually is not typically provided concurrently with aggressive curative or life-prolonging treatment options [4]. Palliative care can be provided with no limitations to care – even with the use of cardiopulmonary resuscitation (CPR) , intubation, and all other life-sustaining therapies [7]. Hospice tends to discourage life-sustaining options that do not support the patient’s goals of care and highly encourages each patient or surrogate to consider having active Do Not Resuscitate/Do Not Intubate orders.

Cardiopulmonary Resuscitation (CPR) /Do Not Resuscitate (DNR) Orders/Do Not Intubate (DNI) Orders/Anesthesiology

CPR is provided approximately 800,000 times each year within the United States [4, 20]. It is the only medical intervention where no consent is required and where an explicit physician order is absolutely necessary for it to be withheld from a patient [4, 20]. In 1983, the President’s Commission for the Study of Ethical Problems in Medicine clarified that patients had a right to expect CPR as the standard of care in all situations of cardiac arrest [4, 21]. The only time that CPR should be withheld in only is if a note exists where a patient’s wish was clearly documented to have CPR withheld [22]. During the 1980s, a patient’s DNR orders were routinely rescinded when entering the perioperative area as perioperative personnel believed that routine anesthesia and surgical care in the operating room (e.g., volume resuscitation/administration and use of vasoactive medications) would be considered or confused with “resuscitation” [4, 21, 22]. During the last two decades, opinions have been evolving to consider that DNR orders should only apply to the actual delivery of CPR in the event of an actual cardiac arrest and all the medical treatments before the actual event of a cardiac arrest are actually not CPR (and so should not be affected by an active DNR order) [23]. Moreover, studies still support variation in practice concerning how to manage active DNR orders for perioperative patients who present for procedures whether in or out of the operating room. In one study, anesthesiologists were twice as likely as either other healthcare providers to assume that DNR patients would readily suspend their DNR order in the operating room [4, 24]. Furthermore, when comparing these providers with others, they were much less likely to discuss the implication of an active DNR order with their patients, more likely to refuse to provide care for a DNR patient, and more likely to ignore a patient’s active DNR request even if the patient made his/her wishes explicit after an informed discussion [4, 24].

The Patient Self Determination Act of 1990 established as law in the United States that a patient’s right to self-determination was the supreme standard in medical ethics, taking precedence over beneficence [4, 9, 25]. Because of this act, routine suspension of an active DNR orders in the perioperative period is considered a violation of a patient’s right of self-determination [4, 26–28]. As a result, the American Society of Anesthesiologists’ (ASA) practice guidelines refute the required rescission of an active DNR order within the perioperative period and instead support the act of “required reconsideration” of a patient’s active DNR status before proceeding with any surgical procedure and exposure to anesthesia [4, 29]. In this discussion with a patient, the anesthesiologist or surgeon should address the patient’s goals of care and core values in the context of risks and benefits of either the anesthesia or the surgical procedure [21]. In this author’s estimation, four possible outcomes of this DNR discussion exist. These outcomes are the following: (1) keep the DNR orders active throughout the perioperative periods, (2) fully rescind the DNR order completely with the idea of reactivating the DNR orders at some point after surgery, (3) agree to provide some aspects of resuscitation but deny other aspects of the DNR orders, or (4) allow for either the surgeon or the anesthesiologist to use substituted judgment for the patient based on the wishes of the patient [4, 30]. Many anesthesiologists are uncomfortable with providing anesthesia to a patient with active DNR or DNI orders . As anesthesiologists titrate anesthesia to achieve the desired effect for patient comfort in order to tolerate a surgical procedure, patient safety concerns with possible needs to secure an airway or manage hemodynamic changes could be at odds with an active DNR/DNI order . As such, some anesthesiologists may be unwilling to proceed to the operating room with an active DNR/DNI order. On the other hand, having a truthful discussion with the patient can allow for the anesthesiologists to understand the true nature of the patient’s active DNR/DNI orders. Many patients have the DNR order for times when patient would consider the situation to be futile or completely nonbeneficial. When the patient is informed of the nature of how anesthesia is delivered, this author has found that patients are quite reasonable and most of the time are completely willing to rescind the DNR/DNI orders for the duration of the anesthesia procedure and for a period of time after the surgical procedure. Clinical anesthesia and surgical care should be discussed with the patient while keeping the patient’s overall goals of care as the centerpiece of the discussion. The healthcare team is not ensuring a particular outcome but rather ensuring that care is designed around the patient’s individual goals of care and values and continues to be medically consistent with standards of care [4, 21].

But, what if the patient wants the DNR and the DNI orders maintained throughout any care provided within the operating room or procedural area? Based on the previous discussion, patients with active DNR/DNI orders can have none of, a portion of, or all of their DNR/DNI wishes maintained in the operating room and throughout the perioperative period. Managing these patients with care limitations and/or end-of-life issues can be psychologically and ethically challenging for some healthcare providers especially the anesthesiologists [4]. What is an anesthesiologist to do when presented with a clinical situation where he/she feels ethically uncomfortable to provide intraoperative care for a geriatric hospice or palliative care patient at the end of life ? In those circumstances, the American Medical Association Code of Ethics does offer some assistance and states that a clinician should not be compelled to perform procedures or provide care that they view as inconsistent with their own personal values [4, 31]. Rather, the practitioner should involve a second clinician who is willing to comanage the patient by performing the desired procedure or provide the care desired by the patient [4, 31]. Consistent with this guidance, an anesthesiologist can refuse to provide care for a patient when he or she has fundamental ethical concerns of providing anesthesia care for this patient, but the anesthesiologist cannot abandon the patient and is required to promptly find another anesthesiologist who would be willing to provide the care to the patient. Similar to management of other patients with care limitations (i.e., the Jehovah’s witness patients who refuse blood transfusions), anesthesia care practices should consider developing individual practice guidelines to support and facilitate the care of any patients who wishes to maintain active DNR orders throughout the perioperative period [4].