Definition of Palliative Care

Short Answer

A. Incorrect. Mr. L. does not qualify for hospice because his creatinine has been stable for over a year (and therefore he probably has greater than 6 months life expectancy), and he wants to receive hospitalizations and intravenous antibiotics. Palliative care would be a better approach.

B. Incorrect. Mr. L. has been judged competent to make his own decisions and seems competent today. Patients and families often disagree, but the patient's wishes should be honored.

C. Correct. Mr. L is competent and has made an informed decision. The approach at this time should be on the quality of his end of life.

D. Incorrect. Mr. L. appears to be competent. His MMSE is good, and he is not depressed. Refusing dialysis is a reasonable decision given Mr. L's coexistent disease.


Long Answer

The correct answer is C: Adopt a palliative care approach, and consider starting opioids for his pain.

Palliative care is the treatment of symptoms or suffering caused by a serious illness that cannot be cured. It encompasses the entire range of such an illness. Even when life-prolonging therapies are being tried, symptom control should be emphasized and advance planning should be started in case the patient's status worsens. Although advance directives are an important part of this process, learning about the patient's quality of life, goals, and values are important as well, as preferences for care may often change as the disease worsens.

In patients where significant life-prolonging therapy is no longer an option, or where the risks and suffering may outweigh the benefits, it is often appropriate to discuss providing more palliative and comfort care and less aggressive care. Again, although issues pertaining to resuscitation and artificial ventilation may be an important part of this discussion, it should not be the sole issue. Chemotherapy, invasive tests or surgeries, and dialysis may all be less valuable to a patient at this point than making sure that pain and symptoms are well controlled, even if their prognosis is greater than six months and/or they still want to receive some therapy. Merely opening the discussion of changing the focus of care to keeping the patient comfortable and discussing preparation for the end of life can be therapeutic.

An excellent review, Discussing Palliative Care with Patients, by B. Lo et al, is in Ann Intern Med. 1999; 130(9):744-9. This article describes techniques for conversations about palliative care in both patients who are terminal and those with chronic, serious illness who are continuing treatment. First, its is important to start with open-ended questions, such as "What have you been told about your illness?" and "How is treatment going for you?" to ensure patients' understanding and allow them to express concerns. When patients share emotions, it is important to respond with validating statements, rather than to change the topic or retreat into technical discussions. The next step is to elicit patients' goals, hopes, and values. Conversations about specific clinical decisions will be easier when this information is known.

Palliative care can be provided to patients at all stages. Hospice care, however, is currently only available for patients with a prognosis of less than six months. In general, patients with metastatic solid tumors (except breast and prostate) who are not receiving chemotherapy have a prognosis of less than six months. Other helpful factors in determining a six-month prognosis are functional status (in bed more than 50% of the time or dependent in 3 activities of daily living, and progressing) and unintentional, progressive weight loss due to the terminal illness of greater than 10% over the last 6 months. More specific guidelines for determining hospice eligibility in patients with noncancer diagnoses are available elsewhere.

Most inpatient hospices will only accept patients with a prognosis of 3 months or less. Patients also need to be receiving comfort care only; hospitalizations, chemotherapy, radiation therapy, intravenous nutrition or antibiotics, many expensive medications such as enoxaparin, and regular transfusions cannot be provided through hospice programs. Excellent pain and symptom control and family and spiritual support through the dying process are the emphasis of the hospice philosophy.

The patient in this case has progressive renal failure, which will likely be the disease that takes his life. He has demonstrated competence throughout the decision-making process. The specifics of issues related to withdrawing dialysis are beyond the scope of this module, but can be reviewed elsewhere.

The goals and approach to palliative care vary depending on a patient's prognosis and wishes. The following cases discuss symptom management in patients that you might see in clinic who have decided to pursue a more palliative/comfort care approach, but are not in the last days to weeks of life and are not enrolled in hospice. Hospice patients generally do not receive the diagnostic tests such as x-rays and laboratory evaluation that are discussed here.

When managing the common symptoms seen in patients with terminal illness, familiarity with the differential diagnosis of the symptom must be balanced with the risk/benefit ratio and the patient's willingness to undergo further evaluation. Invasive testing can be offered as an option; the other choice is to diagnose as much as possible noninvasively, and focus on comfort.

Last update: 7/13/02; 2:51:29 PM.