Palliative care

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Palliative care is defined in health care as "care alleviating symptoms without curing the underlying disease".^[1] Palliative care is practiced by hospice and palliative medicine.

Clinical practice guidelines^[2] and a systematic review^[3] by the American College of Physicians make five recommendations to health care providers for patients who are at the end of life. The first four recommendations are specifically for patients with serious illness who are at the end of life.

1. "Clinicians should regularly assess patients for pain, dyspnea, and depression."
2. "Clinicians should use therapies of proven effectiveness to manage pain. For patients with cancer, this includes nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates."
3. "Clinicians should use therapies of proven effectiveness to manage dyspnea, which include opioids in patients with unrelieved dyspnea and oxygen for short-term relief of hypoxemia."
4. "Clinicians should use therapies of proven effectiveness to manage depression. For patients with cancer, this includes tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial intervention."
5. "Clinicians should ensure that advance care planning, including completion of advance directives, occurs for all patients with serious illness."

Pain control[edit]

Dyspnea[edit]

Opioid analgesics[edit]

Opioid analgesics may relieve dyspnea according to a systematic review^[4] and more recent narrative review^[5]. Opioids are recommended in clinical practice guidelines by the American College of Physicians^[2], and the American College of Chest Physicians^[6].

Suggested doses are:^[5]

"Unless contraindicated, in the UK and Canada, patients are usually started on oral immediate release morphine sulfate. The approach is slow initiation over the first week, with dose titration taking place at weekly intervals over 4 weeks. One recommended dose schedule suggests a start up dose of morphine sulfate of 1 mg daily (can be 0.5 mg twice daily) and, if tolerated, then 1.0 mg twice daily in week 2 increasing by 1.0 mg per week until the lowest effective dose is found to treat dyspnoea. In Canada we might start at a similar dose but move up to 1.0–2.5 mg every 4 h by the end of week 1. Patients are most likely to be dyspnoeic during waking hours when they are most active, so a dosing interval of 4-hourly while awake should ensure adequate levels of opioid during that time period while optimising the likelihood of compliance. If troublesome dyspnoea remains, a dose increase of 25% each week seems reasonable over 3–4 weeks. Once a stable dose is achieved (ie, there is no need for change over 2 week), colleagues in Canada will often substitute a twice daily sustained release preparation at a comparable daily dose"

Alternatively, an initial dose is 10-mg tablets of sustained-release morphine sulfate; however, this has only been studied in patients with normal PCO₂.^[7]

Non-drug treatment[edit]

A systematic review by the Cochrane Collaboration suggests benefit from:^[8]

• Breathing training
• Walking aids
• Neuro-electrical muscle stimulation (NMES)
• Chest wall vibration (CWV)

Nutrition, hydration, gastrointestinal discomfort[edit]

Survival[edit]

Palliative care may surprisingly improve survival.^[9]

Veterinary palliative care[edit]

The principles of hospice care are entering the practice of veterinary medicine. ^[10] Many of the same principles apply, although cost, the greater acceptability of euthanasia, and a lesser range of treatments than available to humans can complicate the situation. One change is recognition that oral administration of drugs may be extremely distressing to companion animals, but that owners can often be trained to use injectable drugs.

References[edit]

See also[edit]

• Medical ethics