Propofol to induce sleep?

Written by:  Neurology and Neurophysiology Expert Witness No. 3614

One day a fellow physician came to my practice to be evaluated for a neurological condition.  The staff wanted to know what "special measures" we should take for a VIP.  Of course the answer to that is simple.  If one is already providing the best care possible, the answer is "the same measures we take for everyone".  If the answer were anything else, it would imply that every other patient received something less than optimal care.

It seems that at times certain patients receive care that is outside the established standards based on the patient's position, wealth, or notoriety.  If excellent medical care is the standard, this deviation from standard practices will by definition provide something other than optimal care.

One of the most recent examples of practicing outside the standard of care is the case involving Michael Jackson and Dr. Conrad Murray.  While the details of the case are still being discussed in court, it is clear that Michael Jackson was given the powerful anesthetic Propofol to induce "sleep".

Propofol (Diprivan) is a short-acting, intravenously administered hypnotic agent. Its uses include the induction and maintenance of general anesthesia, sedation for mechanically ventilated adults, and sedation for procedures typically performed in an operative setting with constant monitoring.  Propofol acts on the GABAA receptor to slow the closing time of the channel.  Activation of this receptor in the brain produces sedating effects.  While there is some variability in how patients respond to Propofol, it is always highly sedating and commonly associated with decreased respirations.

The American Academy of Sleep Medicine has a number of suggestions for managing various forms of insomnia.  While the use of some sedatives is considered useful, there has never been a recommendation for the use of general anesthetics.  Such an idea is so far outside the standard of care that most physicians consider it comical at best.

For any physician dealing with a patient the most important aspect of the interaction is to practice within the standard of care.  There is no level of notoriety or financial incentive on behalf of the patient that should warrant clear violations of that standard.  Incidents of this nature are shameful and an embarrassment to the profession. 

However, we can only speculate as to how many other physicians refused Michael Jackson's request for such medications and instead provided sound advice such as entering a coordinated drug rehabilitation program.  Of course, any such physicians are not sitting in the courtroom today.

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