Craig D. Blinderman

Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer

BACKGROUND Patients with metastatic non-small-cell lung cancer have a substantial symptom burden and may receive aggressive care at the end of life. We examined the effect of introducing palliative care early after diagnosis on patient-reported outcomes and end-of-life care among ambulatory patients with newly diagnosed disease. METHODS We randomly assigned patients with newly diagnosed metastatic non-small-cell lung cancer to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Quality of life and mood were assessed at baseline and at 12 weeks with the use of the Functional Assessment of Cancer Therapy-Lung (FACT-L) scale and the Hospital Anxiety and Depression Scale, respectively. The primary outcome was the change in the quality of life at 12 weeks. Data on end-of-life care were collected from electronic medical records. RESULTS Of the 151 patients who underwent randomization, 27 died by 12 weeks and 107 (86% of the remaining patients) completed assessments. Patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (mean score on the FACT-L scale [in which scores range from 0 to 136, with higher scores indicating better quality of life], 98.0 vs. 91.5; P=0.03). In addition, fewer patients in the palliative care group than in the standard care group had depressive symptoms (16% vs. 38%, P=0.01). Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, P=0.05), median survival was longer among patients receiving early palliative care (11.6 months vs. 8.9 months, P=0.02). CONCLUSIONS Among patients with metastatic non-small-cell lung cancer, early palliative care led to significant improvements in both quality of life and mood. As compared with patients receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival. (Funded by an American Society of Clinical Oncology Career Development Award and philanthropic gifts; ClinicalTrials.gov number, NCT01038271.)

Comfort Care for Patients Dying in the Hospital.

For hospitalized patients whose death is imminent, palliative care can alleviate distressing symptoms that are common during the last few days or weeks of life. The essentials of such care that are presented in this review are intended to provide both generalists and specialists in fields other than palliative care with a practical, evidence-based approach to alleviating these symptoms in patients who are dying in a hospital. Communication skills that are essential to personalized care and goal setting are described briefly; the alleviation of the psychosocial and spiritual suffering that is often faced by terminally ill patients and their families is addressed only incidentally. The term “comfort care” is used here to describe a set of the most basic pallia tive care interventions that provide immediate relief of symptoms in a patient who is very close to death. Typically, these measures are used to achieve comfort for the patient rapidly; diagnostic or therapeutic maneuvers that might be appropriate for palliation in earlier stages of the illness are usually not considered in this context. Many elements of this approach can be used to ease patients’ distress in other phases of a life-threatening illness and in nonhospital settings, and they can also be applied to relieve symptoms in patients with less grave conditions. The Need for Comfort-Care Skills in Hospital Pr actice Although a growing proportion of deaths in the United States now occur at home or in nursing homes, hospitals remain a major site for end-of-life care; in 2010, 29% of deaths occurred in the hospital, and the average terminal admission lasted 7.9 days. 1 Multiple distressing symptoms affect hospitalized patients who have advanced, life-threatening illnesses, 2,3 and some of these symptoms worsen as the patient approaches death. 4 Poorly controlled symptoms have been documented in patients with advanced cancer, congestive heart failure, chronic obstructive pulmonary disease (COPD), and many other life-threatening conditions. 5,6 The meticulous management of distressing symptoms is important in any phase of illness, but it becomes a primary focus near the end of life. 7 Palliative care services can reduce the distress caused by symptoms and improve the quality of life of patients near the end of life. 8 However, the current scarcity of board-certified palliative care specialists — a workforce shortage that is projected to continue far into the future — means that the responsibility for ensuring excellent end-of-life care for dying patients will continue to fall primarily on generalists and on specialists in areas other than palliative care. 9,10 Thus, familiarity with basic comfort measures is an essential skill for all clinicians who are caring for patients whose death is imminent. 7,11

Estimates of the Need for Palliative Care Consultation across United States Intensive Care Units Using a Trigger-based Model

RATIONALE Use of triggers for palliative care consultation has been advocated in intensive care units (ICUs) to ensure appropriate specialist involvement for patients at high risk of unmet palliative care needs. The volume of patients meeting these triggers, and thus the potential workload for providers, is unknown. OBJECTIVES To estimate the prevalence of ICU admissions who met criteria for palliative care consultation using different sets of triggers. METHODS Retrospective cohort study of ICU admissions from Project IMPACT for 2001-2008. We assessed the prevalence of ICU admissions meeting one or more primary palliative care triggers, and prevalence meeting any of multiple sets of triggers. MEASUREMENTS AND MAIN RESULTS Overall, 53,124 (13.8%) ICU admissions met one or more primary triggers for palliative care consultation. Variation in prevalence was minimal across different types of units (mean 13.3% in medical ICUs to 15.8% in trauma/burn ICUs; P = 0.41) and individual units (mean 13.8%, median 13.0%, interquartile range, 10.2-16.5%). A comprehensive model combining multiple sets of triggers identified a total of 75,923 (19.7%) ICU admissions requiring palliative care consultation; of them, 85.4% were captured by five triggers: (1) ICU admission after hospital stay greater than or equal to 10 days, (2) multisystem organ failure greater than or equal to three systems, (3) stage IV malignancy, (4) status post cardiac arrest, and (5) intracerebral hemorrhage requiring mechanical ventilation. CONCLUSIONS Approximately one in seven ICU admissions met triggers for palliative care consultation using a single set of triggers, with an upper estimate of one in five patients using multiple sets of triggers; these estimates were consistent across different types of ICUs and individual units. These results may inform staffing requirements for providers to ensure delivery of specialized palliative care to ICU patients nationally.

Time to Revise the Approach to Determining Cardiopulmonary Resuscitation Status

IN US HOSPITALS, CARDIOPULMONARY RESUSCITATION (CPR) is the de facto default option—patients must “opt out” by requesting or consenting to a do-not-attemptresuscitation order. Despite its worthy intent, requiring all patients or their surrogates to consent to a do-notattempt-resuscitation order to avoid CPR has resulted in an ethically unjustifiable practice that exposes many patients to substantial harms. Whenever there is a plausible risk of cardiac arrest, the standard approach is to ask patients or their surrogates about their preferences regarding CPR. However, the very act of asking can suggest to the patient and family that CPR may be beneficial, even when the clinician believes otherwise. Additionally, research in cognitive psychology has revealed that default options are often interpreted as recommendations or guidelines, or as the path of least resistance, and that such default options significantly affect decision making. For these reasons, patients or their surrogates may be biased toward choosing full resuscitation status, even when CPR likely would bring little or no benefit and would risk considerable harm. Therefore, the standard approach of neutrally seeking consent to withhold CPR may inadvertently diminish patients’ and families’ comprehension of the clinical situation and lead to decisions that are grounded neither in patients’ values nor in their best interest. Instead of assuming that CPR must always be offered, we suggest 3 distinct approaches based on the likelihood and degree of potential benefits and harms of resuscitation. In all 3 approaches, physicians must take the time to fully explain the patient’s prognosis and likely disease trajectory, clarify any misconceptions, and elicit the patient’s values and goals, which should form the basis for all CPR discussions. However, the options offered by the physician should change as the likely proportion of burdens to benefits increases.

Subcutaneous lymphatic drainage (lymphcentesis) for palliation of severe refractory lymphedema in cancer patients.

Subcutaneous lymphatic drainage has been reported to be an effective treatment for severe refractory lymphedema in patients with lymphatic accumulation because of obstructive cancer. We review published techniques for lymphatic drainage and describe two cases where these techniques were modified with good results.

Do surrogates have a right to refuse pain medications for incompetent patients

The relief of pain is widely considered to be a basic human right. Physicians are expected to make every attempt to relieve pain and suffering, especially in patients who do not have capacity. This article presents a case in which the family of a woman with severe somatic pain from metastatic breast cancer requests that pain medications be reduced and, at times, held. The ethical issues associated with surrogate decision making and the refusal of medical treatments are reviewed. The obligation to treat pain remains paramount despite family objections.

The appropriate use of increasingly sophisticated life-sustaining technology.

The medical community should formulate guidelines for appropriate use of organ-replacement therapies, taking into consideration the resources involved and the clinical expectation that the therapy can serve as a bridge to recovery or transplantation or can be a destination therapy.

Ethical Issues in Palliative Care

Ethical problems in medicine are common, especially when caring for patients at the end of life. However, many of these issues are not adequately identified in the outpatient setting. Primary care providers are in a unique and privileged position to identify ethical issues, prevent future conflicts, and help patients make medical decisions that are consistent with their individual values and preferences. This article describes some of the more common ethical issues faced by primary care physicians caring for patients with life-limiting illness.

Practice Patterns, Attitudes, and Barriers to Palliative Care Consultation by Gynecologic Oncologists

PURPOSE We sought to describe practice patterns, attitudes, and barriers to the integration of palliative care services by gynecologic oncologists. METHODS Members of the Society of Gynecologic Oncology were electronically surveyed regarding their practice of incorporating palliative care services and to identify barriers for consultation. Descriptive statistics were used, and two-sample z-tests of proportions were performed to compare responses to related questions. RESULTS Of the 145 respondents, 71% were attending physicians and 58% worked at an academic medical center. The vast majority (92%) had palliative care services available for consultation at their hospital; 48% thought that palliative care services were appropriately used, 51% thought they were underused, and 1% thought they were overused. Thirty percent of respondents thought that palliative care services should be incorporated at first recurrence, whereas 42% thought palliative care should be incorporated when prognosis for life expectancy is ≤ 6 months. Most participants (75%) responded that palliative care consultation is reasonable for symptom control at any stage of disease. Respondents were most likely to consult palliative care services for pain control (53%) and other symptoms (63%). Eighty-three percent of respondents thought that communicating prognosis is the primary teams responsibility, whereas the responsibilities for pain and symptom control, resuscitation status, and goals of care discussions were split between the primary team only and both teams. The main barrier for consulting palliative care services was the concern that patients and families would feel abandoned by the primary oncologist (73%). Ninety-seven percent of respondents answered that palliative care services are useful to improve patient care. CONCLUSION The majority of gynecologic oncologists perceived palliative care as a useful collaboration that is underused. Fear of perceived abandonment by the patient and family members was identified as a significant barrier to palliative care consult.

Reply: Palliative Care: A Core Competency for Intensive Care Unit Doctors

From the Authors: We thank Dr. Lamas and colleagues for their comments related to our article on estimating palliative care needs in critically ill patients (1). We agree that integrative models of palliative care in intensive care units (ICUs) certainly deserve further study and attention. This method of delivering palliative care is essential not only because there is a shortage of fellowship-trained palliative care specialists to meet these needs but also as a matter of professional integrity for critical care providers to be able to have the competencies to treat pain and symptoms common in this population, facilitate goals-of-care conversations, and provide high-quality end-of-life care for patients who die in the ICU. An ongoing challenge is how to best allocate specialized palliative care. The role of specialized palliative care is likely to change depending on the practice setting. For example, in ICUs with an open staffing model, patients may not have a primary critical care provider who is concerned with the provision of adequate palliative care, and palliative care consultants may be needed to perform a needs assessment; in closed units with adequate training, palliative care consultation may be reserved for only the most challenging cases: difficult-to-manage symptoms, complex decision making, or conflict resolution. As with any other consultation service, the amount of specialist involvement that is required inherently depends on the services that can be provided by the primary team. Adequate delivery of palliative care to critically ill patients should be a high priority, and figuring out how to best meet these needs will require buy-in and cooperation from ICU clinicians, palliative care specialists, patients’ primary physicians, and hospital administrators. It is imperative that we collaborate together, and, as Dr. Lamas and colleagues point out, study interventions, to create best practices and models that allow us to reach this common goal.