New guidelines seek to improve palliative care at end of life

Last Updated: 2008-01-14 17:00:11 -0400 (Reuters Health)

NEW YORK (Reuters Health) – The American College of Physicians released guidelines on Monday that focus on improving the recognition and palliative care of pain, dyspnea, and depression — the most common symptoms seen with a serious illness at the end of life.

"Many Americans will face a serious illness at the end of life and their families will be involved in their care," Dr. Amir Qaseem, lead author of the guidelines, said in a statement. "We wanted to pull together best available evidence on improving care that relieves or soothes symptoms at the end of life."

The new guidelines were generated based on a systematic review of relevant studies identified through a search of MEDLINE and other sources. Dr. Karl A. Lorenz, from the VA Greater Los Angeles Healthcare System, and colleagues screened over 24,000 titles to identify 6381 relevant abstracts and examined 1274 articles to find 89 relevant intervention studies and 33 high-quality systematic reviews.

The guidelines and the systematic review appear in the January 15th issue of the Annals of Internal Medicine.

The guidelines make five strong recommendations for improving the palliative care of pain, dyspnea, and depression. With the exception of the last recommendation (advance planning), which is based on low quality of evidence, the recommendations are based on moderate quality of evidence:

–Patients with a serious illness at the end of life should be regularly assessed for pain, dyspnea, and depression.

–Pain should be managed with therapies of proven effectiveness. In the case of cancer, this includes NSAIDs, opioids, and bisphosphonates.

–Dyspnea should be managed with therapies of proven effectiveness. Opioids can be used for patients with unrelieved dyspnea and oxygen can be given for the short-term relief of hypoxemia.

–Depression should be managed with therapies of proven effectiveness. With cancer, this includes treatment with SSRIs or tricyclic antidepressants and psychosocial intervention.

–Clinicians should make sure that advance care planning takes place for all patients with serious illness.

In their summary, the authors add: "Symptom control, continuity in care, and reducing caregiver burdens are critical elements of care for managing patients nearing the end of life."

Ann Intern Med 2008;148:141-159.