What are the key components of palliative care for patients with serious illnesses?

Key Components of Palliative Care for Patients with Serious Illnesses

Palliative care should be provided to any patient with advanced serious chronic illness or life-limiting illness, irrespective of transplant candidacy, based on needs assessment rather than prognosis alone, delivered concurrently with curative or life-prolonging treatments, and tailored to the stage of disease. 1

Core Symptom Management

• Regular and periodic assessment of pain, dyspnea, and depression is essential for all patients with serious illness at the end of life 1, 2

• Pain management should include:

  • NSAIDs, opioids, and bisphosphonates for cancer-related pain 1, 3
  • Bisphosphonates are particularly effective for bone pain in breast cancer and myeloma 3, 2
  • Morphine is considered an essential medication for quality end-of-life care, requiring careful titration based on symptom severity 3
  • Palliative sedation may be considered for refractory pain after consultation with specialists 3, 2

• Dyspnea management should include:

  • Opioids for patients with severe and unrelieved dyspnea in cancer and cardiopulmonary disease 3, 2
  • Oxygen therapy for short-term relief of hypoxemia in conditions like advanced COPD 3
  • β-agonists for treating dyspnea in chronic obstructive pulmonary disease 2

• Depression management should include:

  • Tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial interventions, particularly in cancer patients 3, 2
  • Regular assessment and management of depression symptoms in patients with serious chronic diseases 2

Advance Care Planning

• Advance care planning, including completion of advance directives, should occur for all patients with serious illness 3, 2
• Specific elements to address include:
  • Surrogate decision makers
  • Resuscitation preferences
  • Emergency treatment preferences
  • Issues related to the patient's specific clinical course 3, 2
• Care plans should be reassessed when significant clinical changes occur 2

Continuity of Care and Coordination

• A multidisciplinary team approach improves quality of life, functional status, and reduces hospital readmissions and costs 1
• Coordination between primary physicians and specialists, nurse case management, education, and patient and family activation improves quality of life and reduces readmissions 1
• Palliative care should be integrated across all care settings and throughout the trajectory of illness 4

Family and Caregiver Support

• Adult caregivers should be routinely screened for practical and emotional needs 1, 3
• Family members should be allowed and encouraged to be with the patient 3, 2
• Support for caregivers includes:
  • Listening to concerns
  • Attention to grief
  • Regular information updates about the patient's condition
  • Opportunity to meet after the patient's death to express grief and discuss concerns 2
• Bereavement services should extend to families up to one year after the patient's death 5

Timing of Palliative Care

• Palliative care can begin at any stage of illness, including at diagnosis, and can be provided concurrently with curative or life-prolonging treatments 5
• Early palliative care consultation improves both quality and duration of life 5
• Palliative care differs from hospice care, which is specifically for patients with a prognosis of 6 months or less and typically involves discontinuing curative treatments 5

Common Pitfalls to Avoid

• Delaying palliative care consultation until end-of-life 5
• Undertreatment of dyspnea due to concerns about respiratory depression from opioids, despite evidence supporting their safety and efficacy when appropriately dosed 3
• At the end of life, reducing opioid doses solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for adequate symptom management 3
• Failing to complete advance care planning early in the course of serious illness 5
• Neglecting to address the psychological, social, and spiritual aspects of care alongside physical symptom management 1, 6

Special Considerations

• For patients at home and at risk of catastrophic events, sedating medications should be prepared in advance with a clear plan for emergency administration 2
• End-of-life decisions should be discussed using a multidisciplinary approach, considering the patient's directives, family feelings, and representatives' desires 2
• The palliative care team should be involved as early as possible for managing severely ill patients 2