Clinical review

Palliative care

J Andrew Billings, director. 

Palliative Care Service, Founders 600, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114-2698, USA

JBillings{at}partners.org

Palliative care is defined as comprehensive, interdisciplinary care of patients and families facing a terminal illness, focusing primarily on comfort and support.¹ Key aspects include meticulous symptom control; psychosocial and spiritual care; a personalised management plan that maximises patient-determined quality of life; family oriented care that extends through the time of bereavement; and delivery of coordinated services, especially in the home but also in hospital, extended care facilities, day care centres, and specialised units. In this article I introduce current concepts about palliative care and review advances in this subject over the past five years, highlighting developments of particular interest to generalists.

	Methods

Top Methods Advances in pain management Advances in alleviating other... Advance care planning Dementia care Hastening death References

My choice of topics derives from my familiarity with patterns of medical practice, particularly in the United States; presentations at meetings; review of current textbooks; and monitoring of general medical journals, selected specialty journals on pain and cancer, and nine palliative care journals (see extra box on the BMJ 's website).

Why the need for palliative care?
Numerous recent studies confirm earlier observations that dying people and their families experience a wide range of unmet needs, while receiving very costly care.² One large US study, SUPPORT, underscores many of these problems.³ This investigation enrolled patients who were admitted to an academic hospital with common, severe medical conditions and who had a median survival of six months. Considerable suffering and inappropriate use of resources were observed. Many patients died in pain or with high "symptom burdens."⁴ Doctors proved no better than chance in judging whether their patients wanted cardiopulmonary resuscitation. Family members often experienced social and financial devastationhaving to quit a job or suffering major losses of income or savingsbecause of the illness.

	Advances in pain management

Top Methods Advances in pain management Advances in alleviating other... Advance care planning Dementia care Hastening death References

Almost all pain faced by terminally ill people can be adequately relieved by simple, easily understood oral regimens that generally do not produce troublesome side effects.¹⁰ However, clinical practice continues to be characterised by unrelieved pain, illogical prescribing of analgesics, and widespread "opiophobia."

Analgesics for chronic pain should be administered at whatever dose is required to relieve distress. They should be prescribed "around the clock," based on their duration of action (usually every 4 hours for opioids), not when required, and must be supplemented by a "breakthrough" or "rescue" dose that is given as needed between the regular administrations. The analgesics may be supplemented with adjuvants, such as tricyclic antidepressants, anticonvulsants, psychostimulants, and glucocorticoids. All patients receiving opioids regularly require treatment to prevent constipation. An oral, poorly absorbed opioid antagonist, such as naloxone, can be helpful when usual laxatives are not working.¹¹

(Credit: SAM TANNER/PHOTOFUSION) View larger version (132K): [in this window] [in a new window]   Palliative care focuses primarily on alleviation of symptoms and support

Neuropathic pain is increasingly recognised for its importance in pain that is difficult to control.¹² The treatment drugs of choice are anticonvulsants and tricyclic antidepressants. Gabapentin is a first line anticonvulsant drug for neuropathic pain. ^{13 14} Tricyclic antidepressants are effective in alleviating neuropathic pain even in patients who are not depressed, while selective serotonin reuptake inhibitors have not shown consistent benefit.¹⁵ Other drugs for managing pain include

• Bisphosphonates to prevent and treat bony metastases and associated pain in a variety of cancers,¹⁶ as well as radioisotopes such as strontium-89
• New opioid preparations, particularly long acting oral formulations and transdermal delivery systems, that simplify drug administration and may have other advantages
• Systemically administered local anaesthetics, such as parenteral lignocaine (lidocaine) or oral mexiletine, and ketamine for neuropathic pain
• Psychostimulants to counteract sedative effect of opioids
• Topical local anaesthetics, such as Emla cream (lignocaine and prilocaine), to reduce skin pain from medical procedures
• Specialised pain relieving procedures, such as nerve blocks and spinal (epidural and intrathecal) analgesia.

	Advances in alleviating other symptoms

Top Methods Advances in pain management Advances in alleviating other... Advance care planning Dementia care Hastening death References

Gastrointestinal symptoms
The use of prokinetic drugs and new serotonin antagonist antiemetics has improved the management of cancer related gastroparesis, nausea, and vomiting. Octreotide relieves AIDS related diarrhoea and can help in the management of intestinal obstruction. Nutritional supplements, including total parenteral nutrition,¹⁷ have failed to show benefit in patients with advanced cancer who have an intact digestive tract. Progestational drugs, such as megestrol acetate, and glucocorticoids improve anorexia.¹⁸

Dyspnoea
Opioids and oxygen are the drugs of choice for managing dyspnoea, and benzodiazepines are added for the almost inevitably accompanying anxiety. Nebulised opioids have not proved superior to oral or parenteral drugs in managing breathlessness.¹⁹

Confusional states
Delirium in terminally ill people is underrecognised and undertreated, with considerable associated morbidity.²⁰ A study comparing haloperidol, chlorpromazine, and lorazepam in treating delirious AIDS patients confirms that the first two drugs, often in low doses, are superior in managing this condition. Importantly, the neuroleptics improved the organisation of thinking both for patients with agitation or other behavioural disturbances (so called "hyperactive delirium") and for more tranquil patients with confusion ("hypoactive delirium"), who may not have been routinely treated in the past.²¹

Depression and use of psychostimulants
Depression is common in terminal illness but is underrecognised and undertreated. Many clinicians incorrectly presume that depression is normal or expected in advanced illness, rather than viewing it as a biologically based and treatable form of suffering distinct from sadness.²² The biological signs that usually form the basis of a diagnosis of major depression are often present in a terminal condition but are attributable to the medical illness rather than the psychological state. Clinicians must assess patients for classic depressive signs that cannot be ascribed to the underlying illness (for example, early morning waking that is not due to pain) and rely more on such psychological findings as excessive hopelessness, helplessness, worthlessness, and guilt and suicidal ideation. One study has suggested that simply asking "Are you depressed?" will identify practically all dying people with substantial mood disorders.²³

	Advance care planning

Top Methods Advances in pain management Advances in alleviating other... Advance care planning Dementia care Hastening death References

With our expanding ability to prolong life, death increasingly occurs after decisions have been made to forego life sustaining measures. Such decisions are familiar in an intensive care unit, but they may also be appropriate at home, where hydration or antibiotic treatment may be foregone. Approaches to preserving patient autonomy and choice around the time of death, when the capacity to make informed decisions may be impaired, have been the subject of great interest in the United States. Since so many dying people are no longer able to make decisions, designation of a healthcare proxy is indicated for all adults. Advance care directives are not legally binding in many jurisdictions and are generally not available, retrieved, or honoured during acute hospital care. They also do not influence the use of resources and costs, ^{24 25} except perhaps in rare communities or specific institutions that have made systematic efforts to educate the public and make the directives readily available. ^{26 27}

(Credit: RICHARD SHEINWALD/AP PHOTO) Dr Jack Kevorkian, controversial champion of physician assisted suicide

	Dementia care

Top Methods Advances in pain management Advances in alleviating other... Advance care planning Dementia care Hastening death References

Two important observations help to clarify the role of artificial feeding and hydration for dying people, especially those with neurological impairments. Firstly, McCann and colleagues observed symptoms in chronic care patients who stopped drinking. The only evidence of physical suffering was a dry mouth, which was readily treatable with simple mouth care.²⁸ Dehydration in advanced illness therefore does not seem to cause physical discomfort and need not be treated or prevented with artificial hydration. Secondly, patients who are aspirating continue to do so even after placement of nasogastric or percutaneous gastric tubes. Feeding tubes should definitely not be inserted in order to prevent aspiration.²⁹ Among patients aged 65 or over who have gastrostomies placed in hospital, 24% die within 30 days and 63% within a year, suggesting a limited role for this intervention in sustaining life or improving wellbeing.³⁰

Volicer and colleagues have outlined a remarkable "hospice approach" to the care of patients with advanced dementia.³¹ In a special dementia care unit, the staff provide regular conferences to share information with patients' families and make recommendations about five levels of supportive care"Full care," "Do not resuscitate" (DNR), DNR plus "Do not transfer to a hospital" (DNT), DNR plus DNT plus "Do not work up fevers" (DNWU), and all of the above plus "Do not tube feed" (DNTF). In a comparable dementia unit where the only alternate to full care was DNR, a third of patients died receiving full care. In the specialised dementia unit, 62% of patients die with orders for the lowest level of support and only 2% are receiving full care.

	Hastening death

Top Methods Advances in pain management Advances in alleviating other... Advance care planning Dementia care Hastening death References

No aspect of palliative care has received as much attention recently as the ethics and possible legalisation of physician assisted suicide for terminally ill people. Practical experience in the state of Oregon³² sheds light on the subject. In the first 14 months in which physician assisted suicide was legalised in the state of Oregon, which has a population about 3.5 million and a monthly death rate of about 2400, fewer than two people a month requested and received a prescription for a lethal drug dose, and about half used the prescription.³³ Physicians granted one in six requests for a lethal medication, and only one in 10 requests resulted in a suicide.³²

Attention should shift away from the very small number of patients who persistently want to hasten their death to the growing information about the nature of suffering at the end of life, the motivation for seeking hastened death, guidelines on evaluating such requests, and general acceptance by ethicists, clinicians, and the US courts of appropriate management strategies based on widely recognised ethical distinctions.³⁴ No patient should turn to suicide because of treatable, reversible conditions such as pain or other physical suffering, loneliness, depression, anxiety, or concerns about being a burden on the family.³⁵ As many as 60% of dying people who express a wish to hasten their death are depressed and hence have treatable and potentially reversible suffering.²²

Even under the best of care, however, a small fraction of patients, probably less than 1%, will persistently wish to have death hastened.³⁴ These patients seem to be motivated more by concerns about not being able to function at a reasonable physical and mental level or about being a burden, rather than because of physical discomfort. Withholding or withdrawing life sustaining measures according to the wishes of the patient is now commonly endorsed in the United States and some other societies.

Likewise, decisions about foregoing life prolonging measures for incompetent patients can often be made by a proxy, particularly a formally assigned proxy or a close relative. The "rule of double effect"providing a medical treatment for the purpose of relieving suffering even though a foreseeable, unintended consequence of the treatment is to hasten deathhas been broadly accepted, though also criticised. ^{36 37} This rule should justify the liberal use of opioids and sedatives to control pain or dyspnoea or even emotional distress in terminal illness, a practice that can assure relief of suffering yet is considered distinct from euthanasia. An additional approach, voluntarily stopping eating and drinking, has been recommended so that patients may hasten their death without requiring a physician's direct assistance.³⁸ Finally, some commentators have endorsed "terminal" sedation, more accurately termed "sedation for intractable suffering in the dying patient,"³⁹ whereby a terminally ill person with irremediable suffering is sedated to unconsciousness. If fluids are not provided to such an unconscious patient, death soon ensues. With awareness of these options, physicians are better able to respond to a "bad death" as a medical emergency.⁴⁰

	Acknowledgments

I thank Drs Robert Arnold, Diane Meier, and Thomas J Smith and Martha Henderson for their helpful initial advice on topics to address. Drs Susan D Block and William Zinn helped greatly in editing of the manuscript. Derek Doyle generously made many suggestions on the paper in its final revision. Nan Lawless provided cheerful secretarial support.

	Footnotes

Funding: This work was supported in part by National Cancer Institute grant No R25 CA 66818-04 and the Robert Wood Johnson Foundation.

Competing interests: None declared.

A list of journals, books, and websites about palliative care appears on the BMJ's website

	References

Top Methods Advances in pain management Advances in alleviating other... Advance care planning Dementia care Hastening death References

1.	Billings JA. What is palliative care? J Palliat Med 1998; 1: 73-81[CrossRef][Medline].
2.	Field MJ, Cassel CK, eds. Committee on Care at the End of Life. Institute of Medicine. Approaching death: improving care at the end of life. Washington DC: National Academy Press, 1997. (www2.nas.edu/hcs/21da.htm)
3.	The SUPPORT Principal Investigators. A controlled trial to improve care of seriously ill hospitalized patients: the study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA 1995; 274: 1591-1598[Abstract].
4.	Desbiens NA, Mueller-Rizner N, Connors Jr AF, Wenger NS, Lynn J, for the SUPPORT Investigators. The symptom burden of seriously ill hospitalized patients. J Pain Symptom Manage 1999; 17: 248-255[CrossRef][Medline].
5.	Christakis NA, Lamont EB. Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study. BMJ 2000; 320: 469-473[Abstract/Free Full Text].
6.	Hearn J, Higginson IJ. Do specialist palliative care teams improve outcomes for cancer patients? A systematic literature review. Palliat Med 1998; 12: 317-322[Abstract/Free Full Text].
7.	Billings JA, Block SD. Palliative care in undergraduate medical education: status report and future directions. JAMA 1997; 278: 733-738[Abstract].
8.	Rabow MW, Hardie GE, Fair JM, McPhee SJ. End-of-life care content in 50 textbooks from multiple specialties. JAMA 2000; 283: 771-778[Abstract/Free Full Text].
9.	Baile WF, Kudelka AP, Beale EA, Glober GA, Myers EG, Greisinger AJ, et al. Communication skills training in oncology. Description and preliminary outcomes of workshops on breaking bad news and managing patient reactions to illness. Cancer 1999; 86: 887-897[CrossRef][Medline].
10.	Abrahm JL, for the ACP-ASIM End-of-life Care Consensus Panel. Management of pain and spinal cord compression in patients with advanced cancer. Ann Intern Med 1999; 13: 37-46.
11.	Meissner W, Schmidt U, Hartmann M, Kath R, Reinhart K. Oral naloxone reverses opioid-associated constipation. Pain 2000; 8: 105-109[CrossRef].
12.	Foley KM. Advances in cancer pain. Arch Neurology 1999; 56: 413-417[Free Full Text].
13.	Backonja M, Beydoun A, Edwards KR, Schwartz SL, Fonseca V, Hes M, et al. Gabapentin for the symptomatic treatment of painful neuropathy in patients with diabetes mellitus: a randomized controlled trial. JAMA 1988; 280: 1831-1836.
14.	Rowbotham M, Harden N, Stacey B, Bernstein P, Magnus-Miller L. Gabapentin for the treatment of postherpetic neuralgia: a randomized controlled trial [see comments]. JAMA 1998; 280: 1837-1842[Abstract/Free Full Text].
15.	Max MB, Lynch SA, Muir J, Shoaf SE, Smoller B, Dubner R. Effects of desipramine, amitriptyline, and fluoxetine on pain in diabetic neuropathy. N Engl J Med 1992; 326: 1250-1256[Abstract].
16.	Body JJ, Bartl R, Burckhardt P, Delmas PD, Diel IJN, Fleisch H, et al, for the International Bone and Cancer Study Group. Current use of bisphosphonates in oncology. J Clin Oncol 1998; 16: 3890-3899[Abstract/Free Full Text].
17.	Souba WW. Nutritional support. N Engl J Med 1997; 336: 41-48[Free Full Text].
18.	Bruera E, Neumann CM. Management of specific symptom complexes in patients receiving palliative care. Can Med Assoc J 1998; 158: 1717-1726[Abstract].
19.	Davis C. The role of nebulized drugs in palliating respiratory symptoms of malignant disease. Eur J Palliat Care 1995; 2: 9-15.
20.	Mazzocato C, Stiefel F, Buclin T. Psychopharmacology in supportive care of cancer: a review for the clinician. Support Care Cancer 1999; 8: 89-97.
21.	Breitbart W, Marotta R, Platt M, Weisman H, Derevenco M, Grau C, et al. A double-blind trial of haloperidol, chlorpromazine, and lorazepam in the treatment of delirium in hospitalized AIDS patients. Am J Psychiatry 1996; 153: 231-237[Abstract/Free Full Text].
22.	Block SD, for the ACP-ASIM End-of-Life Care Consensus Panel. Assessing and managing depression in the terminally ill patient. Ann Intern Med 2000; 132: 209-218[Abstract/Free Full Text].
23.	Chochinov HM, Wilson KG, Enns M, Lander S. Are you depressed? Screening for depression in the terminally ill. Am J Psychiatry 1997; 154: 674-676[Abstract].
24.	Hanson LC, Tulsky JA, Danis M. Can clinical interventions change care at the end of life? Ann Intern Med 1997; 126: 381-388[Abstract/Free Full Text].
25.	Teno J, Lynn J, Wenger N, Phillips RS, Murphy DP, Connors Jr AF, et al, for the SUPPORT Investigators. Advance directives for seriously ill hospitalized patients: effectiveness with the Patient Self-Determination Act and the SUPPORT intervention. J Am Geriatr Soc 1997; 45: 500-507[Medline].
26.	Hammes BJ, Rooney BL. Death and end-of-life planning in one midwestern community. Arch Intern Med 1998; 158: 383-390[Abstract/Free Full Text].
27.	Molloy DW, Guyatt GH, Russo R, Goeree R, O'Brien BJ, Bédard M, et al. Systematic implementation of an advance directive program in nursing homes. JAMA 2000; 283: 1437-1444[Abstract/Free Full Text].
28.	McCann RM, Hall WJ, Groth-Juncker A. Comfort care for terminally ill patients: the appropriate use of nutrition and hydration. JAMA 1994; 272: 1263-1266[Abstract].
29.	Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet 1996; 348: 1421-1424[CrossRef][Medline].
30.	Grant MD, Rudberg MA, Brody JA. Gastrostomy placement and mortality among hospitalized Medicare beneficiaries. JAMA 1998; 279: 1973-1976[Abstract/Free Full Text].
31.	Volicer L, Hurley A. Hospice care for patients with advanced progressive dementia. New York: Springer Publishing, 1998.
32.	Ganzini L, Nelson HD, Schmidt TA, Kraemer DF, Delorit MA, Lee MA. Physicians' experience with the Oregon Death with Dignity Act. N Engl J Med 2000; 342: 557-563[Abstract/Free Full Text].
33.	Wineberg H. Oregon's Death with Dignity Act: 14 months and counting. Arch Intern Med 2000; 160: 21-23[Free Full Text].
34.	Quill TE, Meier DE, Block SD, Billings JA. The debate over physician-assisted suicide: empirical data and convergent views. Ann Intern Med 1998; 128: 552-558[Abstract/Free Full Text].
35.	Block SD, Billings JA. Patient requests to hasten death: evaluation and management in terminal care. Arch Intern Med 1994; 154: 2039-2047[Abstract].
36.	Quill TE, Dresser R, Brock DW. The rule of double effecta critique of its role in end-of-life decision making. N Engl J Med 1997; 337: 1768-1771[Free Full Text].
37.	Sulmasy DP, Pellegrino ED. The rule of double effect: clearing up the double talk. Arch Intern Med 1999; 159: 545-550[Free Full Text].
38.	Quill TE, Byock IR, for the ACP-ASIM End-of-Life Care Consensus Panel. Responding to intractable terminal suffering: the role of terminal sedation and voluntary refusal of food and fluids. Ann Intern Med 2000; 132: 408-414[Abstract/Free Full Text].
39.	Krakauer E, Penson RT, Truog RD, King LA, Chabner BA, Lynch TJ. Sedation for intractable distress of a dying patient: acute palliative care and the principle of double effect. Oncologist 2000; 5: 53-62[Abstract/Free Full Text].
40.	Quill TE. "You promised me I wouldn't die like this!" A bad death as a medical emergency. Arch Intern Med 1995; 155: 1250-1254[CrossRef][Medline].