in the clinic palliative care in theclinic · in theclinic in the clinic palliative care palliative...

Inthe

ClinicIn the Clinic

Palliative CarePalliative Care vs. Hospice page ITC2-2

Management of Common Symptoms page ITC2-4

Communication, Psychosocial, and Ethical Issues page ITC2-11

Patient Education page ITC2-13

Practice Improvement page ITC2-14

Tool Kit page ITC2-14

Patient Information page ITC2-15

CME Questions page ITC2-16

Physician WritersKeith M. Swetz, MDArif H. Kamal, MD

Section EditorsDeborah Cotton, MD, MPHDarren Taichman, MD, PhDSankey Williams, MD

The content of In the Clinic is drawn from the clinical information and educationresources of the American College of Physicians (ACP), including PIER (Physicians’Information and Education Resource) and MKSAP (Medical Knowledge and Self-Assessment Program). Annals of Internal Medicine editors develop In the Clinicfrom these primary sources in collaboration with the ACP’s Medical Education and Publishing divisions and with the assistance of science writers and physicianwriters. Editorial consultants from PIER and MKSAP provide expert review of thecontent. Readers who are interested in these primary resources for more detail can consult http://pier.acponline.org, http://www.acponline.org/products_services/mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.

CME Objective: To review current evidence on palliative care.

The information contained herein should never be used as a substitute for clinicaljudgment.

© 2012 American College of Physicians

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How does palliative care differfrom hospice?Whereas hospice is only appropriatefor patients who agree to give up in-surance coverage for life-prolongingtreatment and meet a Medicare-determined prognosis of 6 monthsor less, consultative palliative carecan assess and treat patients any-where along the disease trajectory,regardless of prognosis (see theBox). Unlike hospice care, consulta-tive palliative care focuses on goal-setting and symptom needs alongside ongoing curative or disease-directed therapies. Whileworking alongside primary care andsubspecialty providers, consultativepalliative care can assist in managingcomplex symptoms, conductingfamily meetings, and assisting in dif-ficult conversations. This is especiallyvaluable when the multiple, lengthydiscussions required could strain aprimary care or hospital physician’sschedule and resources. Also, consul-tative palliative care works in an interdisciplinary fashion, thus pro-viding additional resources (e.g.,chaplains, social workers, physicaltherapists, pharmacists) to aid the

medical team in addressing a pa-tient’s needs. Whereas hospice careis delivered in patient homes orlong-term care facilities, the vast ma-jority of consultative palliative care is provided in hospitals or an out-patient clinic setting. Lastly, hospiceinherently recognizes a trajectory toward EOL; consultative palliativecare strives to address complexsymptom and quality-of-life needsto support the primary care physi-cian before patients become termi-nally ill.

Which patients should beconsidered for palliative care?The Center to Advance Palliative Carerecently put forth a consensus docu-ment to identify patients in need of apalliative care assessment (Table 1) (2).Clinicians should periodically review apatient’s unmet needs regarding symp-tom management, independence andfunctional abilities, advance care plan-ning, psychosocial distress, spiritualand existential issues, caregiver andfamily support, and prognostic under-standing. If these needs are not beingmet, consultative palliative care maybe appropriate.

© 2012 American College of Physicians ITC2-2 In the Clinic Annals of Internal Medicine 7 February 2012

Palliative medicine focuses on quality of life and the alleviation of symp-toms in patients with serious illness. It aims to consider the physical,mental, spiritual, and social well-being of patients and their families in

order to maintain hope while ensuring patient dignity and respecting autonomy.Palliative care medicine encompasses both consultative palliative care for patients with serious illnesses, and hospice care for patients at the end-of-life(EOL). Palliative care is appropriate at any stage of a serious illness whether thegoal is cure or maximizing quality of life. It is a fundamental component of thepractice of medicine in all disciplines and at all levels of health. When cure orlife prolongation is no longer possible, palliative care becomes the central com-ponent of treatment. Whereas hospice is only appropriate for patients whoseprognosis is 6 months or less, consultative palliative care can assess and treat patients anywhere along the chronic disease trajectory, regardless of prognosis.

The number of palliative care programs has grown significantly over thepast decade, largely to meet deficiencies noted in the 1990s that timely dis-cussions and decisions about goals of care among patients with serious ill-nesses were uncommon and that pain and other symptoms were routinelyundertreated (1). To meet these deficiencies, along with the increasing num-ber of Americans with chronic illness, the number of palliative care teamshas grown by over 400% from 2000 through 2011. Recent studies suggestthat palliative care and hospice are associated with improved survival.

Palliative Carevs. Hospice

Palliative Care vs. HospiceConsultative palliative care

• Addresses goals of care and focuseson quality of life, family support,and symptom management

• Can begin with onset of symptomsfrom a serious, life-limiting disease

Hospice• A specific type of palliative care

provided when a patient is terminally ill (i.e., life expectancy < 6 months if the disease runs itsexpected course)

• Provides team-based support services to patient, family, and care-givers in the home or an institution


© 2012 American College of PhysiciansITC2-3In the ClinicAnnals of Internal Medicine7 February 2012

What treatments are prohibitedor allowed when patients arereceiving palliative care?Unlike hospice, there are no treat-ment restrictions for patients whochoose palliative care, including cura-tive or life-prolonging treatments.Treatments that relieve symptomsmay also prolong life (e.g., supple-mental oxygen in hypoxic patients).At other times, disease-modifyingtreatments may cause symptoms orimpose a burden that negatively af-fects quality of life (e.g., cytotoxicchemotherapy or hemodialysis insome patients). Provided they help a patient achieve his or her goals,hemodialysis, chemotherapy, radia-tion therapy, blood transfusions,and surgical procedures may all bewithin the purview of palliativemedicine.

How is palliative care paid for bymost insurance and how does thisdiffer from hospice?Funding and reimbursement for pal-liative care differ from those of hos-pice. Palliative medicine is recognizedas a board-certified subspecialty bythe American Board of MedicalSpecialties. Accordingly, palliativecare consultations are usually reim-bursed similarly to other subspe-cialty consultations.

Whereas consultative palliative careis billed through a fee-for-servicemodel, hospice uses a geographi-cally prorated per diem paymentsystem. Regardless of the durationof patient enrollment in hospice,both nonprofit and for-profit hos-pices receive a set amount per day(often about $150 US) to provideall the medication, equipment, andspecialty services that the patientrequires for comfort and quality of life. Once admitted to a hospiceprogram, this per diem rate mustcover all disease-modifying treat-ments that assist in symptom control, such as antibiotics, bloodtransfusions, radiation therapy for local pain, and octreotide forbowel obstruction. In hospice,

cost is often a barrier to receivingthese expensive, but potentially palliative or life-prolonging, interventions.

What tools are available to assistin prognostication or estimatingsurvival in seriously ill patients?Prognostication is difficult in many disease states and relies onphysician experience with seriouslyill patients, comfort using validatedprognostic scales, understanding ofconcomitant or comorbid con -ditions that may augment progno-sis, correct identification of the imminent dying syndrome, and familiarity with death trajectories.

Basic assessment of functional sta-tus with a Karnofsky PerformanceScore (KPS) or the Eastern Coop-erative Oncology Group (ECOG)Performance Status (PS) may helpprognostication in advanced cancerand HIV/AIDS, but are not usefulin the chronic degenerative diseases(heart failure, chronic obstructivepulmonary disease, dementia, end-stage renal failure) that account formore than 75% of deaths in theUnited States (3).

1. A controlled trial to im-prove care for seriouslyill hospitalized patients.The study to under-stand prognoses andpreferences for out-comes and risks oftreatments (SUPPORT).The SUPPORT PrincipalInvestigators. JAMA.1995;274:1591-8.[PMID: 7474243]

2. Weissman DE, MeierDE. Identifying pa-tients in need of apalliative care assess-ment in the hospitalsetting: a consensusreport from the Cen-ter to Advance Pallia-tive Care. J PalliatMed. 2011;14:17-23.[PMID: 21133809]

3. Fox E, Landrum-McNiff K, Zhong Z,Dawson NV, Wu AW,Lynn J. Evaluation ofprognostic criteria fordetermining hospiceeligibility in patientswith advanced lung,heart, or liver disease.SUPPORT Investiga-tors. Study to Under-stand Prognoses andPreferences for Out-comes and Risks ofTreatments. JAMA.1999;282:1638-45.[PMID: 10553790]

Table 1. Suggested Criteria for Consideration of a Palliative CareAssessment at Time of Hospital Admission*Criteria Definition

Surprise You would not be surprised if the patient died within 12 months

Frequent admissions Repeated admission for same condition within several months

Complex symptoms Admission for difficult symptoms or psychological need

Complex care Functional dependence or complex home requirement support needed

Failure to thrive Decline in functional status, weight, or ability to care for self

Advance care need No history of completing an advance care planning document or having a discussion

Limited social support Family stress, chronic mental illness, lack of caregivers

Limited prognosis Metastatic or locally advanced cancer, hip fracture with cognitive impairment, or out-of-hospital cardiac arrest; any one of these criteria may be sufficient to warrant consultation; multiple criteria need not be present

*Data from reference 2.


4. Abernethy AP, CurrowDC, Frith P, FazekasBS, McHugh A, Bui C.Randomised, doubleblind, placebo con-trolled crossover trialof sustained releasemorphine for themanagement of re-fractory dyspnoea.BMJ. 2003;327:523-8.[PMID: 12958109]

5. Currow DC, McDonaldC, Oaten S, Kenny B,Allcroft P, Frith P, et al.Once-daily opioids forchronic dyspnea: adose increment andpharmacovigilancestudy. J Pain Symp-tom Manage. 2011;42:388-99. [PMID: 21458217]

6. Mahler DA, SeleckyPA, Harrod CG. Man-agement of dyspneain patients with ad-vanced lung or heartdisease: practicalguidance from theAmerican college ofchest physicians con-sensus statement. PolArch Med Wewn.2010;120:160-6.[PMID: 20502400]


Other prognostic tools, such as the Palliative Performance Score, may behelpful in determining whether a pa-tient has days or weeks versus weeksto months to live. Disease-specificprognostic tools, such as the Mitch-ell Mortality Index for dementia orthe Seattle Heart Failure Score forheart failure, may be helpful but aremost often used in a subspecialtypalliative care setting in collabora-tion with the disease-specific sub-specialist treating the patient. A patient’s understanding of the limi-tations of available prognostic toolsis important.

Who should be part of thepalliative care team?Effective palliative care requires aninterdisciplinary team, which at aminimum usually involves physiciansand advance practice nurses but in-creasingly includes chaplains, socialworkers, psychiatrists and psycholo-gists, dietitians, pharmacists, andphysical and occupational therapists.Other services that the team maycall upon are music and pet thera-pists, mindfulness training practi-tioners, massage therapists, childlife experts, and bereavement/griefcounselors.

combination medications, with a rec-ommended limit of 2 g for patientswith liver disease. Severe pain (painscore 7–10) is primarily treated byopioids. Adjunct therapies, such asNSAIDs, corticosteroids, antiepilep-tics, and antidepressants with benefitin certain pain syndromes (e.g., neuro-pathic pain), can be used at any point.Commonly used noninjected opioidsare detailed in Table 2 (morphineequivalents are given in the Box).

Oral administration of opioids ispreferred because it is convenientand inexpensive and produces stableblood levels. Intramuscular injec-tions are not recommended becauseof the associated pain, unreliable ab-sorption, and relatively long intervalto peak drug concentrations. If aparenteral route is needed, intra-venous or subcutaneous adminis-tration is preferred. Intravenous

How should pain be evaluated andmanaged?Nonopioid treatments, including as-pirin, acetaminophen, or nonsteroidalanti-inflammatory drugs (NSAIDs),are used for mild pain (score of 1–3on the 0–10 pain intensity scale).Moderate pain (pain score of 4–6) istreated with a combination of opi-oids and nonnarcotic pain relievers. Ifthese agents are combined in a singlepill (such as oxycodone and aceta-minophen), care must be taken toavoid inadvertent overdosing of thenonopioid (acetaminophen) compo-nent when need for the opioid ingre-dient increases. Similarly, patientsmust be cautioned regarding simulta-neous use of nonprescription formu-lations of acetaminophen (or othernonopioid components) to avoid un-intentional overdose. The daily cu-mulative acetaminophen dose (< 4 g)limits the dosing of the opioid in

Palliative Care vs. Hospice... Palliative care and hospice are related but distinctforms of palliative medicine. They are not synonymous and should not be reservedonly for patients who are imminently dying. Palliative care focuses on symptommanagement, quality of life, and delineating the goals of care in patients with se-rious illness, whether the goal is cure, life prolongation, or maximizing quality oflife and function. Hospice is a special type of palliative care, reserved for patientsin the last 6 months of life. All patients with serious illnesses should have goals ofcare elucidated and symptoms assessed and managed. If goals remain unclear andsymptoms are difficult to manage, consultation with a palliative care specialistmay be warranted.

CLINICAL BOTTOM LINE

Managementof CommonSymptoms



opioid dose in a 24-hour period(based on morphine equivalents)and dose the long-acting drug at50%–75% of the 24-hour total (seethe Box). The long-acting opioidmay be increased every 3 to 4 days ifbreakthrough medication is fre-quently required. When calculating abreakthrough opioid dose, cliniciansshould consider the amount of opi-oids that a patient uses in a 24-hourperiod and should prescribe 10%–15% of that daily requirement as an immediate-release breakthroughmedication on an as needed basis. Aslong-acting opioids may take 1 to 3 days to take full effect, the pa-tient’s mental status should bemonitored closely. Ideally, to allowease in dose titration, the sameagents should be used for relief ofboth breakthrough and basal pain.

Several opioids should be avoidedwhen treating chronic pain. Meperi-dine is rarely appropriate for oral usebecause of variable oral bioavailabilityand accumulation of neurotoxicmetabolites with prolonged use at highdoses or in cases of renal failure. Thisaccumulation lowers the seizure

administration provides the mostrapid onset of analgesia but has theshortest duration of action. Trans-dermal opioid patches are useful forchronic pain management in opioid-tolerant patients. Codeine, tramadol,and morphine should be used withcaution in patients with renal insuf-ficiency. Short-acting opioids aloneare often insufficient to managechronic pain. Here, long-acting opi-oids, such as extended-release mor-phine, extended-release oxycodone,and transdermal fentanyl patches,can be used to ensure basal pain re-lief throughout the day. A shorter-acting opioid should be prescribedas needed to relieve breakthroughpain. Combination opioid and acet-aminophen preparations should be avoided to prevent unintendedacetaminophen overdose. Usingshort-acting opioids and acetamin-ophen in separate tablets may allowthe dose of opioid to be increasedappropriately while the amount ofacetaminophen is kept fixed. Toavoid overmedication, start thelong-acting basal pain medicationby calculating the total short-acting

Morphine EquivalentsThe “1:2:3” ruleThe following drugs are equivalent:

• 1 mg IV morphine• 2 mg PO oxycodone• 3 mg PO morphine

The “30:20:10:7.5:1.5” rule is acorollary of the “1:2:3 rule” butincludes hydromorphone• 30 mg PO morphine• 20 mg PO oxycodone• 10 mg IV morphine• 7.5 mg PO hydromorphone• 1.5 mg IV hydromorphone

Rather than memorizing individualdrug potencies, using these ratiosallows clinicians to calculateequivalent dose using stoichiometry:

Example: Patient is on oxycodone SR 20 mg every 12 h and morphine IR 10 mg every 4 hours, 4 times aday. How many “oral morphineequivalents” is this?• Oxycodone 20 mg x 2 doses = 40 mg

x (30 mg PO morphine/20 mg PO oxycodone) = 60 oral morphineequivalents

• Morphine 10 mg x 4 doses = 40 oral equivalents

Patient is receiving 100 oral morphineequivalents.

IR = immediate release; IV = intravenous; PO = oral; SR = sustained release.

Table 2. Commonly Used Noninjected Opioids in Palliative Care Agent Form Available Onset Duration Note

Morphine Immediate release (IR) 15–30 min, 4 h Can be given rectally; “sublingual” (tablet, liquid, or peak at 60 min liquid is absorbed in the gut, not in concentrated liquid) the buccal mucosa; avoid in renal

failureSustained release (SR) 2–4 h 8–12 h Tablets cannot be crushed; can be (tablet) given orally or rectally; avoid in

renal failureOxycodone IR (tablet, liquid, or 15–30 min, 3–6 h Safer in renal failure than morphine,

concentrated liquid) peak at 60 min but still may not be toleratedSR (tablet) 1 h 8–12 h SR morphine should be tried first due

due to cost considerationsFentanyl IR (buccal tablet, 5–15 min 4 h (max Not recommended for opioid-naive

“film” or “lozenge” 4 doses/d) patients; expert consultation or intranasal) recommended before useSR 12–18 h 72 h (less in Patients should be on at least 60 oral (transdermal patch) (for initial dose) some patients) morphine equivalents before starting;

need 3 days after placement to assess benefit before adjusting; temperature can alter absorption (i.e., fever increases absorption)

Hydromorphone IR 15–30 min, peak 4 h Safer in renal failure and hepatic (tablet or liquid) at 60 min failure; can be used orally or rectally SR 6–8 h 24 h Only available in 1 SR form in the U.S.;(tablet) expert consultation recommended

before use



threshold and causes neurotoxic ef-fects, including tremors, twitching, andnervousness. Partial opioid-receptoragonists and agonist–antagonistagents, such as buprenorphine, de-zocine, nalbuphine, pentazocine, andbutorphanol, may cause delirium andprovide less incremental analgesiawhen used alone. Methadone is diffi-cult to titrate, has an onset of action farshorter than its half-life, poses riskof inadvertent overdose and shouldonly be administered by providersexperienced in its use.

How should the side effects ofopioid analgesics be managed?Opioids have predictable side effects, including nausea, constipa-tion, pruritus, and sedation. Seda-tion usually dissipates over a 1- to2-day period as tolerance develops;significant sedation is often re-versible with dose reduction or rota-tion to another opioid. Stimulant orosmotic laxatives should be pre-scribed concurrently for patientswho use opioids daily to help pre-vent constipation, and laxative dosescan be adjusted to a patient’s bowelhabits. Stool softeners alone aregenerally ineffective. A combinationof docusate and either senna orbisacodyl is a popular initial pro-phylactic therapy. Osmotic laxatives,such as magnesium citrate, lactu-lose, and polyethylene glycol, areused if the prophylactic regimendoes not produce daily bowel movements at least every other day.Polyethylene glycol powder is inex-pensive, well-tolerated, and effec-tive. Lactulose and magnesium citrate are expensive and less well-tolerated. Opioid-related itchingand urticaria are rare and caused byhistamine release and may be re-lieved by switching to another opi-oid. A nonsedating antihistaminemay help with pruritus. Opioid-induced nausea is usually temporary, and tolerance typically develops in3–5 days. It is best treated with anti-dopaminergic antiemetics, such asmetoclopramide or prochlorperazine.Corticosteroids or ondanse-tron may

be useful in refractory cases. Somepatients will have less nausea if theopioid blood level remains constantrather than peaking periodicallythroughout the day. Changing thedosing interval of an immediate-release preparation from every 4 hours to a smaller dose every 3 hours may level out blood levelsand reduce nausea and vomiting.Changing to sustained-release orthe transdermal route also producesmore constant opioid blood levelsand may be helpful.

What additional measures shouldbe considered in pain due tospecific causes?Visceral pain is usually dull, colicky,and poorly localized. It is typicallycaused by distention, torsion, or in-flammation and most frequentlyoccurs in conjunction with pancre-atic, hepatic, renal, or intestinalcancer. The discomfort may be associated with autonomic symp-toms, such as nausea or diaphoresis.Referred pain may arise from liveror gallbladder pain and may radiateto the right shoulder. Visceral paincan also be caused by severe consti-pation due to underlying disease,medications, and immobility. Pal-liative surgery can be useful to re-lieve visceral pain caused by bowelobstruction. Blockade of the celiacplexus, sympathetic plexus, orsplanchnic nerves may also be use-ful in patients with pain refractoryto opioid analgesics.

Neuropathic pain is usually causedby direct pathologic changes to thecentral or peripheral nervous system.In terminally ill patients, this is usu-ally related to cancer causing nerveroot compression or encroachmenton a plexus of nerve fibers. Corti-costeroids are effective in reducingtumor swelling and edema and mayreduce the pain of obstruction whileimproving mood, appetite, and ener-gy levels. Corticosteroids can reduceedema and lyse certain tumors,thereby enhancing the analgesic ef-fect of nonopioid and opioid drugs.

Calculating Short- and Long-ActingOpioid Doses1. Convert the 24-hour dose of each

medication to “oral morphineequivalents” (OMEs).

2. If the short-acting agent is differentfrom the long-acting agent, thecalculated dose of the short-actingagent in OMEs should be reduced by50% because of incomplete cross-tolerance.

3. If the long- and short-acting agentsare the same drug, no adjustment forincomplete cross-tolerance isrequired.

4. Provide a breakthrough dose ofbetween 10%–15% of the combinedtotal daily OME dose; this may begiven as a short-acting opioid every1–2 hours. No reduction in thiscalculation is required for incompletecross-tolerance.

For example: A patient receivingoxycodone ER 30 mg every 12 hourscontinues to require hydromorphone 4 mg tablets every 4 hours forbreakthrough (she is using 6 doses aday). How should one increase thelong acting medication dose?

Step 1: Calculate oral morphineequivalents (OME) for each drug:

• Long-acting agent: (2 x 30 mgoxycodone/day) x (30 mg PO morphine/20 mg PO oxycodone) = 90 OME

• Short-acting agent: (6 x 4 mghydromorphone /day) x (30 mg POmorphine/7.5 mg PO hydromorphone)= 96 OME

Steps 2 and 3: Here, the short and long-acting agents are different drugs, sothe short-acting daily dose in OMEshould be reduced by 50% (96 x 0.5 =48 OME). Sum the short and long-acting OME daily doses (90 + 48 =138 OME). Calculate the new totaldaily dose of the long-acting to begiven: 118 OME x (20 mg oxycodone/30 mg PO morphine) = 92 mgoxycodone. This may be given as 40 to50 mg oxycodone ER every 12 hours.

Step 4: Calculate the new breakthroughdose: use total current OMEs fromstep 1 (no adjustment): 90 OME + 96 OME = 186 OME. Use 10 – 15%for breakthrough: (~ 18 to 28 OME) x(20 mg PO oxycodone / 30 mg POmorphine) = 12-19 mg PO oxycodoneimmediate release as needed every 1–2 hours for breakthrough pain.



They are effective in managing ma-lignant infiltration of the brachialand lumbar plexus and spinal cordcompression, as well as headachefrom brain tumors. As an adjunct, atrial of dexamethasone 2–4 mgtwice daily is a reasonable startingpoint.

Peripheral neuropathy or nerve rootimpingement is a common sourceof discomfort in patients with orwithout cancer. Neuropathic painmay be constant or episodic and isusually characterized as burning,tingling, stabbing, or shooting. Sev-eral therapies are effective for neu-ropathic pain, including opiods. Tricyclic antidepressants, venlafax-ine, and duloxetine may be espe-cially useful in patients with bothneuropathic pain and depression.Gabapentin and pregabalin are alsoeffective for neuropathic pain. Areasonable initial trial might beginwith nortriptyline 10 mg nightlyincreasing by 10 mg every 3–5 daysup to 50 mg nightly. If tolerated,this can be increased to 100 mgnightly, or if side effects develop(e.g., anticholinergic), a secondagent, such as gabapentin or prega-balin, may be tried. Slow titration ofmedications is encouraged in elderlypatients or in patients who previ-ously experienced side effects dueto rapid titration.

Lastly, bone metastases represent aspecial situation in which other ad-junct measures, such as radiationtherapy, corticosteroids, bisphos-phonates, or interventional procedures (e.g., cryoablation or radiofrequency ablation) may pro-vide additional pain relief.

What treatments are mosteffective for relieving dyspnea?Dyspnea is common in palliativecare and is often caused directly bycardiac or pulmonary processes.However, it may also be associatedwith debilitation; wasting syn-dromes; neurodegenerative disor-ders; or progressive, chronic disease.

Potential, reversible causes, includ-ing symptomatic pleural effusions,pneumonia, severe anemia, and as-cites, should be treated. The pa-tient’s subjective report of dyspnea,not only the oxyhemoglobin satura-tion, should prompt treatment. Dys-pnea severity often correlates poorlywith respiratory rate, arterial bloodgas, oxyhemoglobin saturation, oruse of accessory musculature.

The gold standard pharmacologictreatment for dyspnea is low-doseoral morphine, given as a cumula-tive dose of 10–20 mg per day (4,5) and has the best proven efficacyin patients with chronic respiratorydisease. Although opioids maycause respiratory depression if thedosage is increased too quickly inan opioid-naive patient, several studies have shown such treatmentfor dyspnea does not lead to a de-creased respiratory rate, increasedcarbon dioxide retention, or earlierdeath. Indeed, the American Col-lege of Chest Physicians has advo-cated for aggressive treatment ofdyspnea, including with opioids,and their consensus statement dis-cusses how this can be done safely(6). When opioids are selected anddosed according to the patient’s re-nal and hepatic function as well asopioid tolerance, the discomfort ofdyspnea is palliated without result-ant respiratory depression. Otheropioids aside from morphine (e.g.,fentanyl, hydromorphone) have notbeen as well-studied but may beconsidered when morphine is con-traindicated.

In an observational study of 83 opioid-naïve patients receiving palliative care(54% with chronic obstructive pulmonarydisease [COPD]), sustained-release oralmorphine was started at 10 mg/24 hourand up-titrated as needed to a maximumdosage of 30 mg/24 hours. Sixty-two percent of patients had at least a 10% re-duction in reported dyspnea with daily mor-phine, 70% of whom required only 10 mg of sustained-release morphine daily (num-ber needed to treat, 1.6; number needed toharm, 4.6). Although arterial blood gas


7. Abernethy AP, McDonald CF, FrithPA, Clark K, HerndonJE 2nd, Marcello J, etal. Effect of palliativeoxygen versus roomair in relief of breath-lessness in patientswith refractory dysp-noea: a double-blind,randomised con-trolled trial. Lancet.2010;376:784-93.[PMID: 20816546]

8. Bausewein C, Booth S,Gysels M, Higginson I.Nonpharmacologicalinterventions forbreathlessness in advanced stages of malignant andnonmalignant dis-eases. CochraneDatabase Syst Rev.2008:CD005623.[PMID: 18425927]

9. Wood GJ, Shega JW,Lynch B, Von RoennJH. Management ofintractable nauseaand vomiting in pa-tients at the end oflife: “I was feelingnauseous all of thetime . . . nothing wasworking”. JAMA.2007;298:1196-207.[PMID: 17848654]

10. Witlox J, EurelingsLS, de Jonghe JF,Kalisvaart KJ, Eikelen-boom P, van GoolWA. Delirium in eld-erly patients and therisk of postdischargemortality, institution-alization, and demen-tia: a meta-analysis.JAMA. 2010;304:443-51. [PMID: 20664045]

11. Lawlor PG, Gagnon B,Mancini IL, Pereira JL,Hanson J, Suarez-Almazor ME, et al.Occurrence, causes,and outcome ofdelirium in patientswith advanced can-cer: a prospectivestudy. Arch InternMed. 2000;160:786-94. [PMID: 10737278]


testing was not believed to be appropriatein this sample, no episodes of respiratorydepression were observed and no patientrequired hospitalization associated withmorphine. One in three patients continuedto derive benefit at 3 months (5).

In contrast to opioids, benzodi-azepines are not consistently usefulfor treating dyspnea, but may bebeneficial in patients whose dysp-nea is worsened by anxiety. Supple-mental oxygen may be useful in relieving dyspnea in terminally illpatients with hypoxemia, but is nobetter than medical room air in pa-tients without hypoxemia (7).

A double-blind, randomized, placebo-controlled study of 239 patients with refractory dyspnea and baseline arterialoxygen partial pressure > 55 mm Hg com-pared 7 days of oxygen or room air at 2 liters per minute via nasal cannula. Nodifference between the 2 groups was ob-served in the relief of dyspnea (7).

Nonpharmacologic interventions,such as fans, have been suggested to help with breathlessness.

A systematic review of 47 studies evaluat-ing nonpharmacologic interventions forbreathlessness concluded that breathingtraining, gait aids, neuroelectrical musclestimulation, and chest wall vibration wereeffective for relieving breathlessness, where-as data were insufficient to support musictherapy, relaxation, fan use, counseling, orpsychotherapy (8)

How should clinicians selectantiemetics in patients with nausea?Nausea may be caused by severalprocesses, and understanding itsorigin helps to guide effective ther-apy. Most recommendations comefrom small studies or expert opinionbased on putative neurotransmitters(9). Opioid-induced nausea may respond best to alterations ofdopaminergic signaling with eithermetoclopramide or prochlorper-azine. Chemotherapy-induced nau-sea is more often responsive to serotonin antagonists (e.g., on-dansetron, granisetron). Corticos-teroids may be helpful adjuvants toother antiemetics in chemotherapy

regimens and are the primary treat-ment for nausea due to increasedintracranial pressure. For incom-plete mechanical bowel obstruction,the standard of care is dexametha-sone, octreotide, and metoclo-pramide; for higher grade obstructions, venting gastrostomytubes in addition to octreotide maybe required. Reduced motility may be best relieved by metoclo-pramide, whereas radiation-inducednausea responds best to serotoninantagonists. Anticholinergic anti-histamines (e.g., scopolamine,meclizine, and diphenhydramine)are most helpful in the setting ofmotion-associated nausea and vom-iting, or when lesions are present inthe posterior fossa (e.g., cerebellarstroke or metastases) (9). If nauseaor vomiting is persistent, an agentfrom a different class that may worksynergistically should be added,rather than another one with a sim-ilar mechanism of action that mayincrease side effects.

How should agitation and distressbe evaluated and treated?When they are seriously ill, patientsmay be agitated for various reasons,including delirium, pain, anxiety, ordyspnea. Assessing patients for reversible causes of agitation, suchas pain, urine retention, or fecalimpaction, is important to ensuresymptom palliation and comfortfirst, before assuming delirium isthe underlying cause. Patients dis-tress may result in hyperactivity orapathy and withdrawal; moaning orgrunting; use of accessory musclefor breathing; or tachypnea, tachy-cardia, or diaphoresis. Unfortu-nately, these signs and symptomsare nonspecific, do not always cor-relate with distress, and warrantfurther evaluation and appropriateintervention. Irregular breathingpatterns (e.g., Cheyne-Stokes res-pirations, tachypnea after a strokeor in the setting of acidosis) andtracheal secretions (“death rattle”)may be interpreted by loved ones asdistress or struggling. The clinician


12. Breitbart W, Marotta R,Platt MM, Weisman H,Derevenco M, Grau C,et al. A double-blindtrial of haloperidol,chlorpromazine, andlorazepam in thetreatment of deliri-um in hospitalizedAIDS patients. Am JPsychiatry. 1996;153:231-7. [PMID: 8561204]

13. Block SD. Assessingand managing de-pression in the ter-minally ill patient.ACP-ASIM End-of-Life Care ConsensusPanel. American Col-lege of Physicians -American Society ofInternal Medicine.Ann Intern Med.2000;132:209-18.[PMID: 10651602]

14. Yavuzsen T, Davis MP,Walsh D, LeGrand S,Lagman R. System-atic review of thetreatment of cancer-associated anorexiaand weight loss. J Clin Oncol. 2005;23:8500-11. [PMID: 16293879]

15. Loprinzi CL, KuglerJW, Sloan JA, Mail-liard JA, Krook JE,Wilwerding MB, et al.Randomized com-parison of megestrolacetate versus dex-amethasone versusfluoxymesterone forthe treatment ofcancer anorexia/cachexia. J Clin Oncol. 1999;17:3299-306. [PMID: 10506633]


plays a key role in educating thesepersons regarding normal and ex-pected signs of death and dying ver-sus the atypical signs noted abovethat may require intervention. Whenpatients are actively dying (last24–48 hours of life), prophylacticanticholinergics (e.g., scopolamine)can be given to reduce or preventdistressing tracheal secretions. Al-though standard of care, the evi-dence on this practice is equivocal.

How should delirium be managedin seriously ill patients?Delirium is common in terminallyill patients and is associated withworse outcomes (survival and mor-bidity) in elderly patients (10) aswell as in those with advanced can-cer (11), although the mechanismis not well-understood. Delirium,an acute change in mental status,may present with agitation or hypoactivity and must be distin-guished from dementia, a chronicchange in cognitive function. Delir-ium, whether agitated or hypoac-tive, must be treated to ensure patient comfort and safety, andmanagement may be essential inrelieving the distress of loved ones.It is important for clinicians to rec-ognize delirium and identify poten-tially reversible causes (e.g., side effects of psychoactive drugs suchas benzodiazepines, untreated pain,urinary obstruction or bowel im-paction, sensory deprivation frommissing eye glasses or ear wax).

A meta-analysis of 42 “high-quality” ob-servational studies of elderly patients eval-uated “poor outcomes” as defined as mortality, institutionalization, or demen-tia. The authors concluded that deliriumwas associated with poor outcome inde-pendent of other factors, such as age, sex,or comorbid conditions (10).

Delirium in terminally ill patientscan generally be treated with smalldoses of haloperidol. Agitation andrestlessness that does not respondto haloperidol will typically re-spond to the more sedating chlor-promazine 10–25 mg PO or SQ.

Benzodiazepines are less effectivethan neuroleptic agents in thetreatment of delirium and are asso-ciated with a greater incidence ofparadoxical reactions, including worsened delirium (12). Non -pharmacologic methods, such as reorientation, are also useful.

Is depression a normal part ofserious illness and when should itbe treated?Depression may be present in termi-nally ill patients, and physiciansshould have a low threshold to as-sess and consider therapy. A demor-alized or transiently depressed moodlasting a few days to a few weeksmay be normal in patients facing se-rious, life-threatening illness. Symp-toms persisting for several weeksand meeting diagnostic criteria fordepression, however, are neithernormal nor expected (see the Box).Treatment of depression with selec-tive serotonin reuptake inhibitors isusually safe, but drug–drug interac-tions should be considered. Psychos-timulants, such as methylphenidate,are safe, fast-acting, and effective inmedically ill populations withoutmajor contraindications (e.g., unsta-ble angina, malignant hypertension,tachyarrythmia). Prognosis shouldalso be considered, because treat-ment may require several weeks toachieve effect (13). Mirtazapine atlow and high doses may help treatdepression in patients with con-comitant insomnia or anorexia, re-spectively. Tricyclic antidepressants,duloxetine, or venlafaxine may begood choices for depression withconcomitant neuropathic pain.

Seriously ill patients with activesuicidal ideation, such as through arequest for aid in hastening death,often have fears of unmanageablesymptoms, loss of control, or otherstressors. Suicidal ideation and itssymptoms or underlying concernsshould be assessed immediately,and referral to an appropriate men-tal health or palliative care profes-sional should be considered (13).


16. McMahon MM, Hur-ley DL, Kamath PS,Mueller PS. Medicaland ethical aspectsof long-term enteraltube feeding. MayoClin Proc. 2005;80:1461-76. [PMID: 16295026]

17. Hanson LC, Ersek M,Gilliam R, Carey TS.Oral feeding optionsfor people with de-mentia: a systematicreview. J Am GeriatrSoc. 2011;59:463-72.[PMID: 21391936]

18. Candy B, SampsonEL, Jones L. Enteraltube feeding in older people withadvanced dementia:findings from aCochrane systematicreview. Int J PalliatNurs. 2009;15:396-404. [PMID: 19773704]

19. Smith TJ, Dow LA, Vi-rago E, Khatcheress-ian J, Lyckholm LJ,Matsuyama R. Givinghonest informationto patients with advanced cancermaintains hope. On-cology (WillistonPark). 2010;24:521-5.[PMID: 20568593]


When and how should providersapproach treatment of anorexia in patients with serious illness?Reduced appetite and weight lossare common in patients dying ofcancer or chronic disease. As eatingand enjoying food are essentialcomponents of social interaction, alack of interest in food and poornutrition are distressing to manyfamilies. Pressure may be placed onthe patient to eat larger portionseven if it is uncomfortable. Care-givers may accuse patients of “giv-ing up” by not forcing themselvesto eat. Further, patients may feelguilty by their lack of desire orability to eat and at causing familymembers to worry. Educating pa-tients and caregivers on how dis-ease processes cause anorexia andcachexia is helpful in relieving guiltand promoting acceptance of a dy-ing patient’s altered eating habits.A realistic discussion regarding nutrition and hydration in advancedirectives is also useful. Caregiversshould make every effort to allowthe patient to participate in the so-cial aspects of meals, realizing thatthe patient may just enjoy a bite ortwo of a favorite food.

If prognosis is uncertain and deathis not imminent, appetite stimulantsmay be considered. In cancer-related anorexia, the most com-monly studied medications areprogestins, such as megestrol (indoses of 400–800 mg/d PO) ormedroxy progesterone (typically 500 mg twice daily by mouth). In asystematic review, some of thesemedications improved anorexia andpromoted weight gain but had noimpact on mortality and an uncer-tain effect on quality of life (14).Side effects include an increased in-cidence of thromboembolic disease,hyperglycemia, adrenal suppression,and vaginal bleeding. Prokineticagents, such as metoclopramide (10 mg 4 times daily by mouth atmeals and at bedtime), can reducenausea but do not facilitate weight

gain or relieve anorexia. Short-termcorticosteroids (e.g., dexamethasone 2–4 mg PO before breakfast and atmidday) have improved nausea andanorexia in patients with advancedcancer in several trials, but few datahave been published on their use inpalliative care populations. Data onwhether dronabinol, fish oil supple-ments, ghrelin, melatonin, nan-drolone, oxandrolone, and NSAIDsare bene ficial are limited.

A randomized study of 475 patients withcancer anorexia/cachexia showed thatmegestrol acetate and dexamethasonewere associated with similar appetite en-hancement and nonfluid weight gain,both more than fluoxymesterone. Dexam-ethasone was stopped more commonlybecause of steroid toxicity; megestrol acetate had a higher rate of venous throm-boembolism (5% vs. 1% for dexametha-sone) (15).

Does artificial nutrition andhydration help patients to feelbetter or live longer?Use of enteral and parenteral feedingin terminally ill patients is controver-sial. Nutritional benefits, such as in-creasing weight or strength, are mostpronounced in patients with goodfunctional status (ECOG PS 0–1) orwhen nutritional intake is limited inaerodigestive malignancies (e.g.,esophageal cancer for which thepatient is undergoing concurrentradiation and chemotherapy).

Evidence suggests that enteral feed-ing has no benefit in patients withadvanced dementia in terms of sur-vival, quality of life or decreased riskfor aspiration pneumonia. Parenter-al nutrition carries such risks asline-associated infection, hyper-glycemia, electrolyte imbalances,and fluid overload. There is no evidence that either enteral or par-enteral nutrition prolongs or im-proves the quality of life for patientsin the last weeks of life and someevidence suggests harm. Discussinga patient’s nutritional preferencesbefore extreme weight loss andanorexia occur is important and

Indicators of Depression in SeriouslyIll Patients*Psychological symptoms

• Dysphoria• Depressed mood• Sadness• Tearfulness• Anhedonia• Hopelessness• Helplessness• Social withdrawal• Guilt• Suicidal ideation

Other indications• Intractable pain or other symptoms• Somatic preoccupation• Poor compliance or refusal of

treatment• Treatment with corticosteroids,

interferon or other agentsHistorical indicators

• Personal or family history of psychiatric illness

• Pancreatic cancer*Data from reference 13.



may help to prevent emotional stressfor the patient and family later(16). Oral nutritional supplements

may be considered if consistentwith the patient’s goals of care (17, 18).

relative to one’s current situationand can be preserved by settingachievable goals (e.g., to controlpain, to allow walks in one’s neigh-borhood or other activities thatprovide enjoyment) often alleviatesanxiety and fosters further discus-sion. Studies suggest that hope ismaintained when patients are given truthful prognostic informa-tion and treatment options, evenwhen the news is bad (19). Inap-propriately avoiding such discus-sions may limit a patient’s ability to fully benefit from treatments of burdensome symptoms or evaluation of emotional concerns.Such avoidance may further rob a patient of the opportunity tocomplete important tasks of lifeclosure.

A multisite, prospective, longitudinal co-hort study of 332 patients and associatedcaregivers demonstrated that only 37% ofpatients reported having EOL discussionsbefore baseline assessment, and that EOLdiscussions were associated with fewer aggressive interventions near death. A keyconclusion was that aggressive care wasassociated with worse patient quality oflife and bereavement adjustment for fam-ily members (20).

How should clinicians approachEOL discussions?Seriously ill patients are commonlyreluctant to initiate discussions aboutgoals of care, prognosis, and what toexpect with their families and med-ical providers. They may fear physi-cian abandonment, withdrawal ofsupportive measures and treatments,and the emotional reactions fromloved ones if such concerns are ad-dressed. Physicians should facilitateconversations among patients, fam-ilies, and other providers to addressthe patient’s wishes and concerns.Such conversations may be emotion-ally charged and protracted, and mayrequire a series of visits to appro-priately address all issues, includingpreferences for life-sustaining treat-ments, supportive technologies, and desire for care at home vs. thehospital (see the Box).

Many physicians and families in-correctly believe that initiating con-versations on goals of care “takesaway hope.” Patients need to be as-sured that these discussions do notimply “giving up,” “losing hope,” orthat there is “nothing left to do.”Reminding patients that “hope” is

Management of Common Symptoms... Moderate to severe pain, particularly inthe setting of cancer, is best managed with opioids. Dyspnea is also effectivelytreated with opioids. In both settings, opioids that are monitored, selected, anddosed appropriately can be used without significant risk for respiratory depres-sion. Treatment of nausea is most effective when tailored to the putative associ-ated neurotransmitters. Anxiety can be problematic for patients, but somatic andnonsomatic contributors to distress should be investigated before pharmacother-apy is instituted. Delirium in EOL scenarios is common and distressing and shouldbe recognized early and treated with neuroleptics over benzodiazepines. Depres-sion is not a normal part of serious illness, and persistent symptoms of depressionwarrant treatment with psychostimulatns or selective serotonin reuptake in-hibitors, even in a terminal situation. Anorexia/cachexia is a multifactorial neuro-hormonal process, and efforts at encouraging oral intake for promoting patientcomfort and enjoyment should take preference over parenteral or enteral nutri-tion, particularly in late-state disease.


Communication,Psychosocial,and EthicalIssues

Comprehensive discussions on goalsof care should include:

• Assessing patient and caregiver understanding of illness and disease-directed treatment options

• Evaluating patient and caregiverappreciation of prognosis, eitherbroadly or detailed, as appropriate

• Developing strategies to treat andaddress both current and antici-pated physical changes, including declining in functional status andnew or worsening symptoms

• Chronicling patient and caregivergoals, fears, anxieties, and hope

• Assuring that patient and caregiverknow what to expect in the normalcourse of disease



How can physicians assist withadvance care planning, includingadvance directives?In addition to assessing goals ofcare and ensuring proper symptommanagement, a patient’s preferencesregarding care measures and surro-gate decision-making should be ad-dressed. State laws vary regardingdefault surrogate decision-makers ifone was not previously specified bythe patient—an advance directivethat appoints a durable health carepower of attorney or health careproxy may prevent later conflict orconfusion. Surrogates should be in-formed of and agree to support apatient’s wishes regarding symptommanagement and important carepreferences as the disease progresses.Surrogates should also know whatto do if the patient’s condition sud-denly deteriorates. Lastly, surrogatesshould be assured that their role isnot to choose or determine the pa-tient’s outcome but rather to repre-sent the patient’s expressed wisheswhen he or she can no longer do so. The surrogate exeperience can bepositive, therapeutic, and less stress-ful when they are empowered to exe-cute a patient’s wishes (21). Patientswith medical devices (e.g., pace-makers, cardioverter-defibrillators)or who receive chronic life-sustaining treatments (e.g., hemodialysis) re-quire special consideration and

careful advanced care planning toprevent undue medical burdenwhen the harms of these interven-tions outweigh the benefits.

Ideally, discussions on treatmentsthat no longer achieve the goalsshould take place when the pa-tient’s functional status and qualityof life are intact but declining, butbefore the patient loses the abilityto express preferences. Somephysicians may feel uncomfortablehonoring a patient’s request to discontinue treatment (e.g., hemodialysis) for a disorder notrelated to the underlying cause ofdeath (e.g., cancer). A clinicalethics committee may be helpfulin such situations.

What are the legal and ethicaldifferences between withholdingor withdrawing life-sustainingtreatments and euthanasia orassisted suicide?Goal-directed, voluntary withdrawalof medical technology is ethicallyand legally supported, and is not thesame as physician-assisted suicideor euthanasia (Table 3). The U.S.Supreme Court and lower courtshave consistently articulated thatthere is no moral, legal, or ethicaldifference between withdrawinglife-sustaining treatments and hav-ing never started such treatments.As patients ultimately die of theirunderlying illness, withholding orwithdrawing interventions, such asmechanical ventilation, feedingtubes, and hemodialysis, are consid-ered legally allowable and ethicallyneutral.

Physician-assisted suicide (alsocalled physician aid in dying) ismorally different. Physician-assisted suicide or euthanasia involves theintroduction of an external factorthat has a primary goal of hasteningdeath independent of the underly-ing disease process. Euthanasia, orthe administration of a lethal drugdirectly by a clinician, is not legal in the United States. Currently,

Table 3. Legal and Ethical Differences Among Withholding and Withdrawing Life-Sustaining Treatment, Palliative Sedation, Physician-Assisted Suicide, and Euthanasia*Variable Withhold Life- Withdraw Life- Palliative Physician- Euthanasia

Sustaining Sustaining Sedation and Assisted Treatment Treatment Analgesia Suicide

Cause of Underlying Underlying Underlying Intervention IIntervention death disease disease disease† prescribed by used by

physician and physicianused by patient

Intent/goal of Avoid Remove Relieve Termination Terminationintervention burdensome burdensome symptoms of life of life

intervention interventionLegal? Yes‡ Yes‡ Yes In Oregon and No

Washington; pending in Montana

*Data from reference 22.

†Note “double-effect” (see text).

‡Several states limit the power of surrogate decision-makers regarding life-sustaining treatments.


20. Wright AA, Zhang B,Ray A, Mack JW, Trice E, Balboni T, etal. Associations be-tween end-of-lifediscussions, patientmental health, med-ical care near death,and caregiver be-reavement adjust-ment. JAMA. 2008;300:1665-73.[PMID: 18840840]

21. Wendler D, Rid A.Systematic review:the effect on surro-gates of makingtreatment decisionsfor others. Ann In-tern Med. 2011;154:336-46. [PMID:21357911]

22. Olsen ML, Swetz KM,Mueller PS. Ethicaldecision makingwith end-of-life care:palliative sedationand withholding orwithdrawing life-sustaining treat-ments. Mayo ClinProc. 2010;85:949-54.[PMID: 20805544]

23. Schenck AP, RokoskeFS, Durham DD, Cagle JG, Hanson LC.The PEACE Project:identification ofquality measures forhospice and pallia-tive care. J PalliatMed. 2010;13: 1451-9. [PMID: 21155640]

24. Dy SM, Asch SM,Lorenz KA, Weeks K,Sharma RK, Wolff AC,et al. Quality of end-of-life care for pa-tients with advancedcancer in an aca-demic medical cen-ter. J Palliat Med.2011;14:451-7.[PMID: 21391819]

25. Reuben DB. Qualityindicators for thecare of undernutri-tion in vulnerableelders. J Am GeriatrSoc. 2007;55 Suppl2:S438-42. [PMID: 17910568]

26. Qaseem A, Snow V,Shekelle P, Casey DEJr, Cross JT Jr, OwensDK, et al; Clinical Effi-cacy AssessmentSubcommittee ofthe American Col-lege of Physicians.Evidence-based in-terventions to im-prove the palliativecare of pain, dysp-nea, and depressionat the end of life: aclinical practiceguideline from theAmerican College ofPhysicians. Ann In-tern Med. 2008;148:141-6. [PMID: 18195338]


only 3 states (Oregon, Washington,and Montana) have provisions allowing physician aid in dying. Requests from patients regardingassisted dying should prompt a pal-liative care evaluation in an attemptto better understand the reasons forthe request.

Is palliative sedation everacceptable?Palliative sedation is acceptable andjustified when the intent of a treat-ment plan is to alleviate symptomsthat cannot be managed in anyother way, even though the treat-ment may unintentionally hastendeath due to possible side effects(22). This is often referred to as“double-effect” (Table 3). The in-tent of palliative treatments should

be congruent with patient wishes torelieve symptoms, must followstandards of care, and must be doc-umented alongside the patient’s orsurrogate’s understanding of thepotential risks.

Benzodiazepines or anestheticagents are often used when seda-tion is required in patients withsymptoms or distress refractory tousual measures. This type of seda-tion is neither experimental noroutside the bounds of the physi-cian’s responsibility to heal. Suchuse is ethically and legally accept-able, because its primary intent isto relieve suffering. Such care, how-ever, requires the consultation of apalliative care team and often ananesthesia pain service.

PatientEducationWhat should patients and their

families know about palliative care?Patients and families commonly,and incorrectly, think that hospiceand palliative care are the same andthat both focus exclusively on theneeds of imminently dying patients.They may also incorrectly thinkthat hospice care itself hastens oraims to hasten death. A clinician’sexplanation of the rationale for pal-liative care consultation and explicitstatements of the goals of palliativecare may allay spoken or unspokenfears, thus allowing for interven-tions aimed to relieve suffering.

When is the best time to discusspalliative care?Patient education is a fundamentalcomponent of a palliative care

plan. Clinicians should introducepalliative care options long beforethe patient becomes terminally ill. Such planning helps introduceuncomfortable topics, such asdeath and dying, and teaches the patients the importance ofsuch planning. There may be opportunities to routinely addressadvance directives and a durablehealth care power of attorney document with adults. When clinical situations change, it is key to fully inform patients andtheir surrogates on the altered condition, prognosis, and treat-ment options, including comfortmeasures and the surrogate’s rolein supporting the patient’s ex-pressed wishes regarding care decisions.

Communication, Psychosocial, and Ethical Issues... Early, regular discussionsamong physicians, patients, and families regarding goals of care and what to ex-pect as the disease progresses are important, help set goals, and help maintain“hope.” It is important to discuss advanced care planning and potential roles forsurrogate decision-makers. In cases of intractable suffering, palliative sedation isethically acceptable. If a patient perceives that the burden of a treatment out-weighs its benefits, withdrawing that treatment is the moral equivalent of neverhaving started the treatment.



Inthe

C linicTool Kit

In the Clinic

Palliative Care

PIER Moduleshttp://pier.acponline.org/physicians/ethical_legal/el755/el755.htmlPIER module on palliative care from the American College of Physicians.

PIER modules provide evidence-based, updated information on currentdiagnosis and treatment in an electronic format designed for rapid access atthe point of care.

Patient Informationwww.annals.org/intheclinic/toolkit-palliative-care-2012.htmlPatient information that appears on the next page for duplication and

distribution to patients.

General Informationwww.eperc.mcw.edu/EPERC/FastFactsandConceptsFast facts and concepts.www.capc.org/reportcardState-by-state report card on access to palliative care in hospitals.http://endoflife.stanford.eduStanford University’s End-of-Life Curriculum for learners and providers.www.globalrph.com/narcoticonv.htmOpioid conversion calculator.www.seattleheartfailuremodel.orgSeattle Heart Failure Model (prognostication calculator for advanced heart failure).www.aahpm.orgAmerican Academy of Hospice and Palliative Medicine.

7 February 2012Annals of Internal MedicineIn the ClinicITC2-14© 2012 American College of Physicians

PracticeImprovement assessment of patient and family

satisfaction using suggested tools.

The Carolinas Center for MedicalExcellence, with support from theCenters for Medicare & MedicaidServices, recently reported one ofthe first sets of quality measures forpalliative care. Covering eight do-mains of palliative care, the PEACEmeasures outline both characteristicsof distress assessment and manage-ment with a particular focus onsymptoms. Additionally, palliativecare team structure issues are ad-dressed, with provisions for stan-dardization of assessments amongall team members.

The American College of Physi-cians proposes evidence-basedsymptom intervention guidelinesfor EOL care that are valuable forthe primary care physician (26).This report provides guidance andevidence review for assessment andtreatment of pain, dyspnea, and de-pression alongside the critical com-ponents of advance care planningand utility of collaboration withmultidisciplinary palliative careteams.

What measures do U.S.stakeholders use to evaluate thequality of palliative care?The most widely used set of qualitymetrics are the Hospice PEACE set,developed by Hanson and colleagues(23). Covering all 8 domains of pal-liative care quality established by theNational Quality Forum (NQF), thisset has served as the model for othersupportive oncology (24) and geri-atrics metrics (25). Development ofNQF-endorsed measures for pallia-tive care are now under way; meas-ures for the Physician Quality Reporting System for the Centersfor Medicare & Medicaid Servicesare expected soon thereafter.

What do professional organizationsrecommend regarding the provisionof palliative care?In addition to the suggested criteria forpalliative care assessment (Table 1),the Center to Advance PalliativeCare has reported palliative careservice metrics. These include pro-visions for standardized and regularmultisymptom assessments, identi-fying caregivers, and documentingissues regarding transition manage-ment. They also advocate regular


In the ClinicAnnals of Internal Medicine

Pati

ent

Info

rmat

ion

THINGS YOU SHOULD KNOWABOUT PALLIATIVE CARE

What does “palliative” mean? What is palliative care?Palliative means “cloaking or protecting.” Often, whenyou or a loved one is experiencing serious illness, focusing on relief from uncontrolled symptoms (likepain, shortness of breath, or tiredness) is a major goal.Feeling supported, having more control over your care,and understanding what to expect in the future aremain concerns. Palliative care is a medical specialtythat works with your current doctors (such as internists, cardiologists, or oncologists) to assist inthese areas, while always respecting what is most important to you.

What do palliative care specialists do?Palliative care experts—including physicians, nursepractitioners, and physician assistants—work with alarger team of nurses, pharmacists, social workers,chaplains, discharge planners, physical therapists, andothers to put together a plan that helps you to feelbetter, to improve your quality of life, and support yourfamily as they support you. They work closely with youand your caregivers to help treat your symptoms, makesure you have the information you want, anticipateand plan for future needs, and ensure that your otherproviders are aware of your goals, wishes, and needs.

Is palliative care the same as hospice?No. Hospice requires that a patient has a disease thatwould be expected to take his or her life in 6 months or less if it progresses in the usual way. Palliative caredoes not have this type of limitation. All patients witha serious illness who have symptoms and questionsabout care planning, the future, effects of illness onloved ones, and communication or just want to feelbetter are eligible for palliative care. Your doctor maybelieve that seeing a palliative care professional,alongside your other doctors, may be helpful.

Situations When Palliative Care May Help• Repeated emergency department visits or

hospitalizations for a chronic disease.

• Feeling like you don’t have all the information youneed.

• Worrying about the future.

• Being concerned about the effects of your illness onyour loved ones.

• When your medications aren’t helping your pain,tiredness, shortness of breath, or other symptoms.

• When you are worried about getting the right treatment if your disease suddenly gets worse.

For More Information

www.getpalliativecare.orgA comprehensive resource for determining whether you or a loved oneneeds palliative care; includes a list of Web sites of organizations thatoffer support for people with serious illness.


CME Questions

7 February 2012Annals of Internal MedicineIn the ClinicITC2-16© 2012 American College of Physicians

Questions are largely from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP, accessed at http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/

to complete the quiz and earn up to 1.5 CME credits, or to purchase the complete MKSAP program.

1. An 81-year-old woman with metastatic breastcancer is admitted to the hospital forpleurodesis by tube thoracostomy. Her diseasewas in remission until 2 months ago, whenshe presented with several bone metastases;dyspnea; and recurrent malignant pleuraleffusion, which was treated withthoracentesis. She is considering severalpalliative therapy options.

The patient lives with her daughter. Prior to the recurrence of her disease, sheenjoyed playing with her grandchildren. She used to go to book club meetings butstopped about 2 months ago. The patientappears withdrawn and complains of loss of energy. She has become tearful at times,stating she is a burden on her daughter andthat she does not want to go home as shewill “just end up in the hospital again.”Current medication is oxycodone, whichadequately controls her low back pain.

Neurologic and mental status examinationsare normal. There is dullness to percussionin the left lower thorax.

In addition to the tube thoracostomy andpleurodesis, which of the following is themost appropriate management option forthis patient?

A. Initiate citalopramB. Initiate lorazepamC. Order brain MRI with gadoliniumD. Reassess patient after treatment for

bone metastases

2. An 86-year-old man with congestive heartfailure is evaluated at a follow-upappointment; he is accompanied by hisdaughter, who reports that he has been insteady decline over the past month. He hasanorexia and a 4.5-kg (10-lb) weight lossand has become reliant on her for manyroutine tasks, including dressing, bathing,and eating. He is unable to ambulate due todyspnea and fatigue and requires assistanceto get out of bed to a chair and to a bedsidecommode. He has been hospitalized 2 timesin the past 3 months for volume overload.The patient has chronic kidney disease andhas been on hemodialysis for the past 8 years. The patient wants to discontinuedialysis because the treatments areincreasingly unpleasant owing to fatigue, buthe denies dialysis-related pain or dyspnea.He says that he is aware that stoppingdialysis will result in near-term death. Hehas an advanced directive that states that he

does not want cardiopulmonaryresuscitation, artificial nutrition, orhydration. A depression screen is negative,and a mental status examination is normal.The patient’s wife is deceased, and hisdaughter is the surrogate decision maker.

Which of the following is the mostappropriate option regarding continuationof this patient’s dialysis?

A. Consult with psychiatryB. Consult with the patient’s daughterC. Coordinate discontinuation of dialysisD. Obtain approval of the patient’s

nephrologist

3. A 79-year-old woman is evaluated at homeby a visiting hospice nurse for dyspnea thatbegan 4 days ago and has worsened in thepast 24 hours. The patient has an 80-pack-year history of cigarette use and severeemphysema (FEV

10.6 L). She has executed a

do-not-resuscitate order and desires noother interventions. Over the past 6 weeks,her oral intake has decreased and shecannot walk without assistance because ofdiffuse weakness. She takes extended-release (ER) morphine (15 mg twice daily)for musculoskeletal pain and immediate-release (IR) morphine (20 mg) as needed forbreakthrough pain.

The hospice nurse reports that the patient isalert and oriented to person, place, time, anddate. Her temperature is normal, pulse is94/min, respiration rate is 24/min, and bloodpressure is 145/88 mm Hg. Oxygen saturationis 97% on ambient air. She has traceexpiratory wheezing over both lung fields anda reduced cough effort. She has hyperinflationof the chest and reduced breath sounds in alllung fields. There is no S

3, jugular venous

distention, or peripheral edema. Her last doseof ER morphine was 6 hours ago, and her lastdose of IR morphine was yesterday.

How should this patient’s dyspnea bemanaged?

A. A supplemental dose of IR morphineB. Emergency department evaluationC. Initiate furosemideD. Initiate home oxygen therapy

4. A 74-year-old man with metastatic lungcancer to the liver and pelvis is evaluatedfor low back pain. The pain is localized tothe right ischial region and has progressivelyworsened over the past month, despite theuse of IR morphine (15 mg) every 6 hours.

He states that the pain returns about 4 hours after taking his medication. Thepatient has no fever, no bowel or bladderdysfunction, no radiation of pain, and nomotor weakness. He previously had palliativechemotherapy and radiation therapy butstopped because of a steady increase intumor size. He has declined radiationtherapy for his bone lesions.

On physical examination, temperature is 36.6°C (97.8°F), blood pressure is 100/58 mm Hg, pulse rate is 90/min, andrespiration rate is 18/min. BMI is 18.Neurologic and mental status examinationsare normal.

Which of the following is the mostappropriate strategy for managing thispatient’s pain?

A. Add gabapentin 3 times dailyB. Increase frequency of IR morphine to

every 4 hoursC. Switch to IR oxycodone every 4 hoursD. Add ER morphine twice daily

5. A 69-year-old man is evaluated for low backdiscomfort. He has a history of primaryhypogonadism of the spine without evidenceof spinal cord compression. He is ambulatoryand functional in all activities of daily living.He recently received his annual infusion ofzoledronic acid and has been evaluated forvertebroplasty, which has not been done dueto warfarin use for a prosthetic mitral valve.The treatment improved but did not eliminatehis discomfort. He rates his discomfort as 5 on a scale of 1 to 10. He denies anyradiation of the pain, fever, motor weakness,or difficulties with bowel or bladder control.The patient takes at least 2 naproxen 250-mgtablets daily. The pain medication reduces butdoes not eliminate his back discomfort. Onphysical examination, temperature is normal,blood pressure is 150/88 mm Hg, pulse rate is88/min, and respiration rate is 16/min. BMI is 28. Neurologic and mental statusexaminations are normal. There is no pointtenderness over the lumbar vertebrae.

Which of the following is the mostappropriate strategy for managing thispatient’s pain?

A. Add an extended-release opioidB. Add a fentanyl patchC. Add a short-acting opioidD. Discontinue naproxen and substitute

ibuprofen


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