Palliative care at the end of life should focus on the assessment and alleviation of symptoms of pain, shortness of breath, and depression, according to new guidelines released by the American College of Physicians.
“The ACP's drawing a line in the sand and saying this is mandatory [and] is a very important symbolic and substantive step” in improving palliative care, said Dr. Diane Meier, professor of geriatrics and adult development at Mount Sinai School of Medicine, New York.
“As minimal as these expectations and requirements are, the fact that there are any is a huge step forward,” Dr. Meier said.
The guidelines (“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”) include five recommendations aimed at improving the care of patients with serious terminal illnesses (Ann. Intern. Med. 2008;148:141-6):
▸ Recommendation 1. Clinicians should regularly assess patients for pain, dyspnea, and depression.
“Evidence review showed that the three most common symptoms were pain, difficult breathing, and depression, so our guidelines address these,” Dr. Amir Qaseem said in a press statement. Dr. Qaseem, lead author of the guidelines, is senior medical associate in the ACP's clinical programs and quality of care department.
▸ Recommendation 2. Clinicians should use therapies of proven effectiveness to manage pain.
Strong evidence from cancer trials supports the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain. There was insufficient evidence to assess the usefulness of exercise or acupuncture in pain management.
▸ Recommendation 3. Clinicians should use therapies of proven effectiveness to manage dyspnea.
Evidence from several studies confirms that morphine can be valuable for treating dyspnea in patients with advanced lung disease or terminal cancer. Good quality evidence also supports the benefit of long-acting β-agonists in the treatment of dyspnea in chronic obstructive pulmonary disease. Evidence was mixed when comparing oxygen therapy with room air.
▸ Recommendation 4. Clinicians should use therapies of proven effectiveness to manage depression.
Good evidence supports the effectiveness of long-term use of tricyclic antidepressants or SSRIs. Good evidence also supports the use of psychosocial interventions for treating patients with cancer who have depression. These interventions include education, cognitive and noncognitive behavioral therapy, informational interventions, and individual and group support.
▸ Recommendation 5. Clinicians should ensure that advance care planning, including the completion of advance directives, occurs for all patients with serious illness.
“Research shows that individuals are more likely to use advance directives in the presence of extensive multicomponent interventions than with limited interventions,” the authors wrote. “Various processes, such as consulting caregivers, enhancing clear communication, eliciting values, and addressing the emotional context, are important elements for comprehensive advance care planning. Clinicians should help patients and families plan in advance for likely or important clinical decisions.”
The new recommendations provide much-needed guidance for physicians. “Physicians have been notoriously poorly trained and poorly prepared to address those aspects of human suffering,” Dr. Meier said. Every general physician has a small subset of patients with a serious, terminal illness.
“Internists need support in identifying, treating, and managing [these patients] over time,” she added.
The guidelines are based on a literature search that included studies from MEDLINE and reviews of cancer, heart failure, and dementia from the Cochrane Library's Database of Abstract of Reviews of Effects from January 1990 to November 2005. In addition, citations from nonsystematic literature were taken from the review by the National Consensus Project for Quality Palliative Care.
All of the recommendations are graded as strong, with moderate quality of evidence, with the exception of the recommendation on advance care planning, which was considered to have low quality of evidence.