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Palliative Care
Erika Oleson, DO, MS
image BASICS
Palliative care is a specialty that focuses on preventing and alleviating suffering of patients (and their families) living with life-limiting illness at any stage of that illness.
  • Palliative care's principal aim is to prevent and alleviate suffering—whether physical (pain, breath-lessness, nausea, etc.), emotional, social, or spiritual regardless of underlying diagnosis.
  • The goal of palliative care is to improve or maintain quality of life of both patient and family despite serious illness.
  • Palliative care is available for patients with serious, life-limiting illness, at any stage of their disease, with or without concurrent curative care.
  • Location of care: Patients and their families may access palliative care services in hospital, rehabilitative or skilled nursing facility, and ambulatory setting.
  • Hospice: In the United States, hospice is available for patients whose average life expectancy is 6 months or less and whose principal goal is to stay home (including long-term care or assisted living facility), avoid hospitalizations, and disease-directed care with a curative intent. Unlike regular nursing services in the home, hospice does not require a patient to be homebound and offers backup support for patients 24 hours a day and 7 days per week.
Symptoms/syndromes commonly treated in palliative care:
  • Pain
    • Chronic pain
    • Headache
    • Neuropathic pain
    • Pain from bone metastases
    • Pruritus
  • GI symptoms (˜60% incidence)
    • Ascites
    • Anorexia/cachexia
    • Nausea (and vomiting)
      • Think of the underlying etiology and treat accordingly.
        • GI causes: constipation, bowel (full or partial) obstruction, ileus, heart burn, reflux, inflammation
        • Intrathoracic causes: cardiac, effusions (cardiac, pulmonary), mediastinal causes, esophageal
        • Autonomic dysfunction
        • Centrally mediated: intracranial pressure change, inflammation, cerebellar, vestibular, medication or metabolic cause stimulating vomiting center and/or chemoreceptor trigger zone
    • Bowel obstruction
    • Constipation and impaction of stool
    • Diarrhea
    • Dysphagia
    • Mucositis/stomatitis
    • Sialorrhea
  • General medical
    • Delirium (40-85%)
  • Pulmonary symptoms
    • Cough, chronic
    • Breathlessness or dyspnea (60%): often due to heart failure, COPD, lung cancer, and so forth
  • Psychological symptoms
    • Anxiety
    • Depression
    • Insomnia
  • Skin
    • Decubitus ulcer
    • Pruritus
    • Complex wounds (fungating tumors, etc.)
The PEACE tool evaluates the following (1):
  • Physical symptoms
  • Emotive and cognitive symptoms
  • Autonomy and related issues
  • Communication: contribution to others and closure of life affairs-related issues
  • Economic burden and other practical issues, also transcendent and existential issues
Comprehensive physician examination is warranted, especially as directed by underlying diagnosis, symptoms, and functional decline.
Initial Tests (lab, imaging)
Per diagnosis and symptoms
  • Targeted interventions to maximize quality of life and minimize symptom burden while taking into consideration the patient's values, goals, fears, and social setting.
  • Treatment should involve an interdisciplinary team—addressing potential and realized suffering, whether physical, emotional, social, or spiritual.
  • Attempt to minimize polypharmacy
  • Consider trimming medications that offer little improvement in the quality of life.
  • Medication should focus on symptom management.
  • Continue to use appropriate disease-modifying medications especially if they lessen symptom burden and enhance immediate quality of life.
  • Improve compliance by addressing patient/caregiver understanding.
  • P.753

  • Pain (4)[A]
    • Use immediate-release opioids PO/IV/SC and titrate to control.
    • Once pain is controlled, convert to long-acting opioids with short-acting agents made available as tolerance develops and/or patient develops breakthrough pain.
  • Bone pain: NSAIDs added to narcotics are more effective than narcotics alone.
  • Vomiting associated with a particular opioid may be relieved by substitution with an equianalgesic dose of another opioid or a sustained-release formulation (5).
    • Dopamine receptor antagonists (metoclopramide, prochlorperazine, promethazine) are commonly used. Haloperidol may help with nausea.
    • Droperidol: insufficient evidence to advise on the use for the management of nausea and vomiting
  • Constipation: Consider prophylactic stool softeners (docusate) and stimulants (bisacodyl or senna) or osmotic laxatives (6)[A].
  • Dyspnea: Consider oxygen, if congestive heart failure (CHF); diuretics and/or long-acting nitrates, benzodiazepines
    • In addition to treating the underlying cause of breathlessness, as the disease advances, low-dose opioids may be beneficial to patients (4,8)[C]. Immediate-release opioids PO/IV treat dyspnea effectively and typically at doses lower than necessary for the relief of moderate pain.
  • Delirium: lowest doses necessary of benzodiazepines or antipsychotics (haloperidol, etc.)
    • Monitor patient safety and use nonpharmacologic strategies to assist orientation (clocks, calendars, environment, and redirection).
    • Droperidol: When cause of delirium cannot be identified/corrected rapidly, consider neuroleptics (haloperidol or risperidone).
  • Pruritus: no optimal therapy (9)[A]
  • Anxiety: insufficient data for recommendations of specific medication, but anxiolytics and/or other agents may be tried (10)[A].
  • Megestrol acetate improves appetite and slight weight gain in patients with anorexia-cachexia syndrome (11)[A].
  • Referral to palliative care
    • Any patient with a serious, life-limiting illness who could benefit from help with burdensome symptoms or suffering and/or complex goals of care discussion (12)[A].
    • Early referral to palliative care may improve quality of life and longevity for patients with advanced cancer (13)[A].
  • Referral to hospice care
    • Any patient with an average life expectancy of 6 months or less. Consider the question, “Would you be surprised if the patient died within the next 6 months?” If the answer is no, they likely meet prognostic criteria for hospice.
      • Consider patients who have multiple hospitalizations and/or emergency department visits in the prior 6 months.
      • Refer to local hospice guidelines for additional disease-specific criteria.
1. Okon TR, Evans JM, Gomez CF, et al. Palliative educational outcome with implementation of PEACE tool integrated clinical pathway. J Palliat Med. 2004;7(2):279-295.
2. Puchalski C, Romer AL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med. 2000;3(1):129-137.
3. Anandarajah G, Hight E. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician. 2001;63(1):81-89.
4. Lorenz KA, Lynn J, Dy SM, et al. Evidence for improving palliative care at the end of life: a systematic review. Ann Intern Med. 2008;148(2): 147-159.
5. Smith HS, Smith JM, Smith AR. An overview of nausea/vomiting in palliative medicine. Ann Palliat Med. 2012;1(2):103-114.
6. Candy B, Jones L, Larkin PJ, et al. Laxative for the management of constipation in people receiving palliative care. Cochrane Database Syst Rev. 2015;(5):CD003448.
7. Candy B, Jones L, Goodman ML, et al. Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011;(1):CD003448.
8. Ben-Aharon I, Gafter-Gvili A, Paul M, et al. Interventions for alleviating cancer-related dyspnea: a systematic review. J Clin Oncol. 2008;26(14):2396-2404.
9. Xander C, Meerpohl JJ, Galandi D, et al. Pharmacological intervention for pruritus in adult palliative care patients. Cochrane Database Syst Rev. 2013;(6):CD008320.
10. Candy B, Jackson KC, Jones L, et al. Drug therapy for symptoms associated with anxiety in adult palliative care patients. Cochrane Database Syst Rev. 2012;(10):CD004596.
11. Ruiz Garcia V, López-Briz E, Carbonell Sanchis R, et al. Megestrol acetate for treatment of anorexiacachexia syndrome. Cochrane Database Syst Rev. 2013;(3):CD004310.
12. Weissman DE, Meier DE. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17-23.
13. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
Z51.5 Encounter for palliative care
Clinical Pearls
  • Early referral to palliative care may help enhance the quality of life and potential longevity of patients living with serious illness.
  • Bone pain: NSAIDs added to narcotics are more effective than narcotics alone.
  • Laxatives should be started when opioid treatment has begun to avoid constipation.