Palliative Care Guidelines Emphasize Pain, Dyspnea, and Depression

By Crystal Phend

Palliation should be considered as early as possible for all patients with seriously disabling illnesses or symptomatic chronic conditions at the end of life, even if the prognoses are ambiguous, according to guidelines just issued here.
Such care should include treatment for the three most common symptoms -- pain, shortness of breath, and depression -- said Amir Qaseem, M.D., Ph.D., of the American College of Physicians here, and colleagues in the Jan. 15 issue of the Annals of Internal Medicine.
Their recommendations emerged from a systematic review by Karl A. Lorenz, M.D., of the Veterans Affairs Greater Los Angeles Healthcare System in Los Angeles, and colleagues that appeared in the same issue.
End-of-life care should not be limited to the short period when the person is moribund, the American College of Physicians guidelines said.
However, it's not always easy to determine which patients are entering the period when they need palliative care, Dr. Lorenz's group noted.
They examined 33 systematic reviews and 89 reports of interventions addressing pain, dyspnea, depression, advance care planning, continuity, and caregiving in "end-of-life" care, which included terminal illness as well as chronic, eventually fatal illness with ambiguous prognosis, such as advanced dementia.
However, the researchers found no evidence-based tools validated to predict the best time to start palliative care.
"Asking clinicians 'Would it be a surprise if this patient were to die within six months?' is being used widely but also has had no rigorous testing," Dr. Lorenz and colleagues said.
Acknowledging death risk is important for determining when to begin palliative care, but these decisions should be individualized to patient symptoms and preferences, Dr. Qaseem and colleagues said.
"Waiting for near-certainty would fail to identify most dying people," Dr. Lorenz's group cautioned, "so palliative approaches need to be regularly incorporated for people living with serious illnesses."
For those with serious illness at the end of life, the guidelines recommended that clinicians should::
Regularly assess patients for pain, dyspnea, and depression.
Use therapies proven effective to manage pain, which for cancer patients includes nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates.
Use therapies proven effective against dyspnea, which include opioids in patients with unrelieved dyspnea and oxygen for short-term relief of hypoxemia.
Treat depression with proven therapies, which for cancer patients includes tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial intervention.
Ensure advance care planning, including completion of advance directives, for all patients with serious illness.
All five were strong recommendations for which benefits clearly outweighed risks, the authors concluded. However, none had more than a moderate quality of evidence because most of the studies focused specifically on cancer patients rather than the broad range of patients requiring end of life care.
The guidelines also recommended that clinicians routinely and periodically screen caregivers of these patients for practical and emotional needs.
Planning a patient's end-of-life care should occur as early as possible in the course of serious illness and be reassessed when significant clinical changes occur, they added.
Care planning should include determination of surrogate decision makers and preferences for resuscitation and emergency treatment as well as issues specific to each patient's clinical course. For those in intractable congestive heart failure, this could include planning whether to deactivate implantable cardioverter-defibrillators.
However, the authors of both the guidelines and systematic review cautioned that high-quality evidence on end-of-life care was limited and mostly focused on cancer.
Many interventions were not addressed in the guideline, such as interpersonal or social interventions, they added, nor were nutritional support, complementary and alternative therapies, and spiritual care addressed.
Those therapies that were included, though, represent good clinical care and "can prevent or alleviate suffering for many patients at the end of life," Dr. Qaseem and colleagues said.
Development of the guideline was supported exclusively by the ACP operating budget. One of the guideline authors reported receiving grants from the Agency for Healthcare Research and Quality, CDC, Novo Nordisk, Pfizer, Merck & Co., Bristol-Myers Squibb, Atlantic Philanthropies, and Sanofi Pasteur.
The systematic review was funded by the National Institute of Nursing Research and the Agency for Healthcare Research and Quality. Dr. Lorenz reported support from a Veterans Affairs Health Services Research & Development Service Career Development Award, and receiving grants from Amgen. A co-author reported support from an award from the National Cancer Institute.
Additional source: Annals of Internal MedicineSource reference: Qaseem A, et al "Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians" Ann Intern Med 2008; 148: 141-146. Additional source: Annals of Internal MedicineSource reference: Lorenz KA, et al "Evidence for improving palliative care at the end of life: a systematic review" Ann Intern Med 2008; 148: 147-159.