Palliative care

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Palliative care is defined in health care as "care alleviating symptoms without curing the underlying disease".[1]

Clinical practice guidelines[2] and a systematic review[3] by the American College of Physicians make five recommendations to health care providers. 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."

Dyspnea

Opioid analgesics

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"

Non-drug treatment

A systematic review by the Cochrane Collaboration suggests benefit from:[7]

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

Alternatively, an initial dose is 10-mg tablets of sustained-release morphine sulfate; however, this has only been studied in patients with normal PCO2.[8]

References

  1. ↑ Anonymous. Palliative care. National Library of Medicine. Retrieved on 2008-01-15.
  2. ↑ 2.0 2.1 Qaseem A, Snow V, Shekelle P, Casey DE, Cross JT, Owens DK et al. (2008). "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.". Ann Intern Med 148 (2): 141-6. PMID 18195338. Cite error: Invalid <ref> tag; name "pmid18195338" defined multiple times with different content
  3. ↑ Lorenz KA, Lynn J, Dy SM, Shugarman LR, Wilkinson A, Mularski RA et al. (2008). "Evidence for improving palliative care at the end of life: a systematic review.". Ann Intern Med 148 (2): 147-59. PMID 18195339.
  4. ↑ Jennings AL, Davies AN, Higgins JP, Gibbs JS, Broadley KE (2002). "A systematic review of the use of opioids in the management of dyspnoea.". Thorax 57 (11): 939-44. PMID 12403875. PMC PMC1746225. Review in: ACP J Club. 2003 May-Jun;138(3):72 Review in: Evid Based Nurs. 2003 Jul;6(3):84
  5. ↑ 5.0 5.1 Rocker G, Horton R, Currow D, Goodridge D, Young J, Booth S (2009). "Palliation of dyspnoea in advanced COPD: revisiting a role for opioids.". Thorax 64 (10): 910-5. DOI:10.1136/thx.2009.116699. PMID 19786716. Research Blogging. Cite error: Invalid <ref> tag; name "pmid19786716" defined multiple times with different content
  6. ↑ Mahler DA, Selecky PA, Harrod CG, Benditt JO, Carrieri-Kohlman V, Curtis JR et al. (2010). "American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease.". Chest 137 (3): 674-91. DOI:10.1378/chest.09-1543. PMID 20202949. Research Blogging.
  7. ↑ Bausewein C, Booth S, Gysels M, Higginson I (2008). "Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases.". Cochrane Database Syst Rev (2): CD005623. DOI:10.1002/14651858.CD005623.pub2. PMID 18425927. Research Blogging. Review in: Evid Based Nurs. 2008 Oct;11(4):118
  8. ↑ Poole PJ, Veale AG, Black PN (1998). "The effect of sustained-release morphine on breathlessness and quality of life in severe chronic obstructive pulmonary disease.". Am J Respir Crit Care Med 157 (6 Pt 1): 1877-80. PMID 9620921.

See also

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