The Institute of Medicine has identified end-of-life care as a top area needing quality improvement. End-of-life palliative care involves addressing the physical, psychological, social, and practical needs of patients and caregivers. By assessing symptoms and providing support, physicians can prevent or alleviate suffering at the end of life.

The Clinical Efficiency Assessment Subcommittee of the American College of Physicians (ACP) has released guidelines to improve palliative care for patients with seriously disabling or symptomatic chronic conditions at the end of life. High-quality evidence on end-of-life care is limited, and most is from studies of patients with cancer; therefore, some potentially beneficial interventions are not addressed. Nutritional support, complementary and alternative therapies, and spiritual care were not included in the review. The guidelines focus on the treatment of pain, dyspnea, and depression as well as advance care planning.

Treatment Strategies

Symptom control and following appropriate treatment strategies for pain, dyspnea, and depression significantly affect patients' experiences at the end of life. Further research is needed for potentially beneficial, but understudied, interventions and for conditions other than cancer.

PAIN

Strong evidence supports the use of non-steroidal anti-inflammatory drugs (NSAIDs), opioids, bisphosphonates (specifically for bone pain), and radiotherapy or radio-pharmaceuticals to control pain in patients with cancer. Head-to-head comparisons of treatments or delivery methods are difficult to obtain. Evidence is lacking on the use of exercise or acupuncture.

DYSPNEA

Studies show that morphine (Duramorph) is beneficial for treating dyspnea in patients with advanced lung disease or terminal cancer, although nebulized opioids did not provide additional benefit compared with oral opioids. Good-quality evidence shows that beta agonists are beneficial for patients with chronic obstructive pulmonary disease (COPD). Results were mixed in studies that compared oxygen with room air to reduce dyspnea in patients with COPD, heart failure, cancer, or all conditions.

DEPRESSION

Good evidence supports the long-term use of tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs), as well as psychosocial interventions (e.g., education, behavioral therapy, informational interventions, individual and group support) for patients with cancer and depression. Results were mixed, however, on the use of imagery and exercise.

Recommendations

Recommendation 1. Patients should be assessed regularly for pain, dyspnea, and depression (strong recommendation, moderate-quality evidence). Although each patient needs an individualized assessment, general issues occurring with most patients include symptom management, psychological well-being, care coordination and advance care planning, and caregiver burden.

Recommendation 2. Therapies of proven effectiveness should be used to manage pain (strong recommendation, moderate-quality evidence). Strong evidence supports the use of NSAIDs, opioids, and bisphosphonates in patients with cancer. Bisphosphonates are effective for bone pain in patients with breast cancer and myeloma.

Recommendation 3. Therapies of proven effectiveness should be used to manage dyspnea (strong recommendation, moderate-quality evidence). Opioids should be considered in patients with severe, unrelieved dyspnea (e.g., from cancer or COPD). In patients with advanced COPD, oxygen should be considered to treat hypoxemia. Although evidence also supports the use of beta agonists in patients with COPD, it has not been studied in end-of-life care.

Recommendation 4. Therapies of proven effectiveness should be used to manage depression (strong recommendation, moderate-quality evidence). Patients should be assessed and treated for depression. Strong evidence supports generally effective therapies (e.g., tricyclic antidepressants, SSRIs, psychosocial interventions) for patients with cancer.

Recommendation 5. Advance care planning, including advance directives, should be completed for all patients (strong recommendation, low-quality evidence). Advance care planning should occur as early as possible and be reassessed when significant clinical changes occur. All care plans should include designation of surrogate decision makers and resuscitation and emergency treatment preferences. Other issues include management of dementia, tube feeding, and when to discontinue therapy (e.g., chemotherapy, defibrillators). The use of skilled facilitators working with a team of decision makers that includes the patient, caregiver, and health care professionals and ensuring a shared understanding of the patient's values are critical in planning end-of-life care.