Palliative Care
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Contents |
More Specific Terms
Introduction
- Provision of supportive care for terminally ill patients rather than pursuing aggressive therapeutic treatment.
Clinical-trials
- cancer patients felt better, survived longer, made fewer emergency department visits, & were more likely to die at home when palliative cancer was intiated early after a diagnosis of metastatic non-small-cell lung cancer [7]
- early palliative care reduces chemotherapy use near the end of life, but does not decrease survival [8]
Management
- Dimensions of quality care at the end of life
- self determination
- symptom management
- pain
- depression
- anxiety [4]
- delirium
- multidimensional quality of life
- physical
- emotional
- social
- spiritual
- family well-being
- circumstances surrounding death - setting, treatment
- resource use/costs
- Goals of medicine
- curing disease/prolonging life
- restoration/preservation of function
- relieving suffering
- Compliance with issues of medical ethics.
-
- acting in the patient's best interest
- non-malificence, i.e. doing no harm
- justice: treat similar patients similarly
- veracity: always tell the truth, especially in prognosis
- Goals of medicine often conflict
- chance to live longer vs a less optimal dying process
- states worse than death where death would be welcome
- the meaning of a natural life span & allocation of resources
- 30 % of Medicare dollars spent in final year of life
- 30 % of Medicare dollars spent in final year of life
- Delivering end of life care requires a combination of 3 things
- a framework for ethical decision making
- technical competence
- systems of care that facilitate coordination of care across goals & venues
- Elements of a good death:
- pain/symptom management
- avoiding unnecessary prolongation of dying
- preparation for death
- clear decision making
- acheiving a sense of control
- a sense of completion in life
- affirmation of the whole person
- strengthening relationships with loved ones
- contributing to others
- relieving burden on loved ones
- self determination
- decision-making capacity
- standards for decision-making in patients lacking capacity
- ethical hierarchy
- advance directives
- substituted judgment
- best interest determined by proxy
- in most states, physicians turn to family members when no proxy has been appointed
- physicians should not turn to family members for decision making if patient has capacity, unless asked by the patient to do so
- concordance of patients preferences & family member's knowledge of those preferences is not high, but is higher than concordance between that of patients & their physicians
- unrelated friends
- may be ethically appropriate decision makers
- state law may require advance directives of court appointment as the patient's guardian
- court appointment of a guardian should be sought in any incompetent patient without an appropriate surrogate decision maker
- situations where the patient preferences should be made explicit
- treatment decision making
- when a reasonable person might prioritize goals other than maximizing survival duration as the primary goal of care
- advance care planning - when the probability of mental capacity in the near future reaches some threshold value
- Patient self determination Act of 1991 ( PSDA)
- Ethical considerations in treatment decisions
- no ethical difference between not starting treatment & stopping one that has been started
- all medical interventions are considered ethically (& legally) equivalent, including antibiotics, tube feeding, IV hydration, etc.
- Do not resuscitate ( DNR) orders
- Physician-assisted suicide
- Special considerations in end of life decisions
- emergency privilege
- unusual treatment choices - in situations where a patient chooses a care plan that defies the physician's recommendations, the patient's wishes should be respected provided:
- the patient has decision-making capacity & has had the proper informed consent
- the patient's requested plan fits within the goals of medicine
- Mismatch between preferences & prognosis: (See futility)
- patient preferences do not match reality 'futility'
- situations where the 'futility' is considered
- Futility situations are usually the result of suboptimal practice of clinical ethics
- Families in end of life care:
- families are important stakeholders in end of life care
- decision makers
- caregivers
- those who must live on after a patient dies
- SUPPORT study revealed financial hardships of family
- Care setting at the end of life
- great variability among patients in their desire to die at home vs in the hospital -> many patients don't care
- hospice care
- End of life issues in long-term care
- decisions about the aggressiveness of care are best made early in the nursing home stay to insure that care will be consistent with the overall goals
- upon admission to the nursing home
- designation of surrogate decision makers
- specification of care goals
- completion of advance directives, if needed
- specification of limitations on aggressiveness of care including hospitalization or life-sustaining treatments
- such decisions are often made without the input of the patient, even when the patient has decisional capacity
- documentation of patient participation & preferences, if obtainable
- see chronic pain
- may overlap with depression
- Low threshold for treatment of depression
- chronic pain may play a role
- low dose haloperidol may be useful
- workup of potentially reversible causes
More General Terms
Additional Terms
- core elements of palliative care program
- hospice
- management of bowel obstruction without a tube
- management of nausea/vomiting by etiology
- medical ethics
- palliative care consultation
- palliative prognostic measure
References
- Rosenfeld K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 12-15, 2001
- Frederich M., Multicampus Program in Geriatrics & Gerontology, Syllabus: The Cutting Edge in Palliative Medicine, 2001
- Rosenfeld K. In: Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 25-28, 2002
- Norton SA et al, Proactive palliative care in the medical intensive care unit: Effects of length of stay for selected high-risk patients. Crit Care Med 2007, 35:1530 PMID: [1]
- Luce JM and White DB The pressure to withhold or withdraw life-sustaining therapy from critically ill patients in the United States. Am J Respir Crit Care Med 2007, 175:1104 PMID: [2] - Medical Knowledge Self Assessment Program (MKSAP) 14, 15, American College of Physicians, Philadelphia 2006, 2009
- Breitbart W, Strout D. Delirium in the terminally ill. Clin Geriatr Med. 2000 May;16(2):357-72. PMID: [3]
- Temel JS et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010 Aug 19; 363:733 PMID: [4]
- Kelley AS and Meier DE. Palliative care - A shifting paradigm. N Engl J Med 2010 Aug 19; 363:781. PMID: [5] - Greer JA et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non–small-cell lung cancer. J Clin Oncol 2012 Feb 1; 30:394 PMID: [6]
- National Guideline Clearinghouse Palliative treatment of cancer. (Finnish Medical Society Duodecim) ngc-guideline: [7]
- Clinical practice guidelines for quality palliative care. National Consensus Project ngc-guideline: [8]
- Palliative care. Institute for Clinical Systems Improvement ngc-guideline: [9]
- Palliative care consultation, quality-of-life measurements, and bereavement for end-of-life care in patients with lung cancer: ACCP evidence-based clinical practice guidelines. (2nd Edition) ngc-guideline: [10]
- Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines. (2nd Edition) ngc-guideline: [11]
- 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. ngc-guideline: [12]
- Expert Commentary: Perspective, Karl Lorenz, MD, MSHS A Guideline for Palliative and End of Life Care [13]
