> Table of Contents > Palliative Care
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.
DESCRIPTION
  • 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.
COMMONLY ASSOCIATED CONDITIONS
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.)
image DIAGNOSIS
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
PHYSICAL EXAM
Comprehensive physician examination is warranted, especially as directed by underlying diagnosis, symptoms, and functional decline.
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
Per diagnosis and symptoms
image TREATMENT
GENERAL MEASURES
  • 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.
MEDICATION
  • 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].
ISSUES FOR REFERRAL
  • 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.
REFERENCES
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.
Codes
&NA;
ICD10
Z51.5 Encounter for palliative care
Clinical Pearls
&NA;
  • 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.