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Five Things Physicians and Patients Should Question in Hospice and Palliative Medicine

Authors: Daniel Fischberg, Janet Bull, David Casarett, Laura C. Hanson, Scott M. Klein, Joseph Rotella, Thomas Smith, C. Porter Storey Jr., Joan M. Teno, Eric Widera, AAHPM Choosing Wisely Task Force

Journal of Pain and Symptom Management February 2013

Hospice and Palliative Medicine: Physicians and Patients Take Note

Advances in medical science over the last 50 years have been unprecedented, yet the quality of care, efficiency, access and health outcomes in the United States are inferior compared to other developed nations. At a time of dramatically increased spending, an aging population and an increasing illness burden, it is necessary for physicians and patients to choose treatment wisely. In 2008, the Congressional Budget Office estimated that $700 billion annually goes to health care spending that has not been shown to improve health outcomes. The overuse and misuse of tests and treatments exposes patients to potential harm. The American Board of Internal Medicine Foundation’s Choosing Wisely campaign is an effort to encourage the physician leadership to reduce harmful or inappropriate use of resources. Medical societies are asked to identify five tests or procedures commonly used in their field which are of questionable value or harm. The American Academy of Hospice and Palliative Medicine proposed five practices that patients and physicians should question in the care of patients in palliative and hospice care.

A task force identified the five practices that are overused or misused in palliative and hospice care. Members solicited opinions from all members of the Academy and interest groups, and they considered the potential impact and evidence to support the proposed recommendations. The recommendations are:

  1. Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral –assisted feeding.Feeding tubes do not result in improved survival, prevention of aspiration pneumonia or improved healing of pressure ulcers. A small study of bereaved family member interviews reported that 25.9% of decedents with feeding tubes were physically restrained and 29.2% were pharmacologically restrained. Nearly 40% of patients dying with dementia were bothered by the feeding tube.
  2. Don’t delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment.The delivery of palliative care concurrent with the disease-directed treatment can improve the quality of life, symptom control and family satisfaction with care. When patients experience burdensome symptoms, difficult treatment choices or emotional distress related to serious illness, palliative care should be offered in combination with disease-modifying therapy.
  3. Don’t leave an implantable cardioverter-defibrillator (ICD) activated when it is inconsistent with the patient/family goals.About 25% of patients with ICDs experience a shock from their device within weeks of death. For patients with advanced irreversible disease, defibrillator shocks rarely prevent death, may be painful and are typically distressing to caregivers and family members. The outcome of deactivation allows for a patients natural death from disease progression without the discomfort of futile shocks.
  4. Don’t recommend more than a single fraction (SF) of palliative radiation for an uncomplicated painful bone metastasis.Bone is the most common site of cancer metastases and the most common cause of cancer related pain. The American Society for Therapeutic Radiation Oncology reports that single fraction vs. multiple fraction regimens of external beam radiation for painful bone metastases are equally effective. The single fraction regimen is associated with less side effects and less inconvenience for the patient, but a higher incidence of recurrence (20% compared to 8 % for multiple fraction). Painful bone metastases can usually be retreated at the time of recurrence if they were previously treated with a single fraction of radiation.
  5. Don’t use topical lorazepam, diphenhydramine, and haloperidol gel for nausea.Topical medications can be safe and effective, and the preferred route of delivery for patients unable to swallow pills. A study of healthy volunteers administered these anti-nausea drugs in gel form applied to the skin. No to minimal levels of drug were detected in the blood, demonstrating that they are not absorbed in adequate concentration to provide symptom relief.

Palliative medicine needs to aspire to an evidence base to demonstrate effectiveness. The challenges in caring for the terminally ill and the poorly defined outcomes that identify “effectiveness” are challenges which are not insurmountable. Research is needed to identify novel treatments and advance the science of comfort, and to evaluate the risks and potential benefits of the existing practices.

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