From the Guidelines
Placing a permanent stent in the bile duct for a hospice patient with cancer is generally not appropriate, as the focus should be on comfort and quality of life rather than interventions that may cause additional suffering without meaningful benefit. The decision to proceed with any invasive procedure, including bile duct stenting, should be made with caution and only after thorough discussion with the patient, family, and hospice team, considering the patient's goals of care, expected survival time, and whether the potential benefits of the procedure outweigh the risks and discomfort 1.
Considerations for Bile Duct Obstruction
In patients with cancer and hospice care, the primary goal is to manage symptoms effectively without causing undue distress or complications. For bile duct obstruction symptoms like jaundice, itching, or pain, medications can provide relief without invasive procedures. These might include:
- Antihistamines for itching (such as hydroxyzine 25mg every 6 hours as needed)
- Pain medications (like morphine or hydromorphone)
- Anti-nausea medications (such as ondansetron 4mg every 8 hours as needed)
Risks of Bile Duct Stenting
Bile duct stenting is an invasive procedure that carries risks of complications such as infection, bleeding, and pancreatitis, which could worsen the patient's condition during their limited remaining time 1.
Recent Guidelines
Recent guidelines from the French Association for the Study of the Liver (AFEF) recommend using uncovered metal stents for biliary drainage in palliative care, which offer longer patency, but emphasize the importance of discussing each case among specialists to determine the best approach for the patient's needs 1. However, in the context of hospice care, the emphasis on quality of life and symptom management suggests that invasive procedures like permanent stent placement should be approached with caution and considered on a case-by-case basis.
From the Research
Appropriateness of Permanent Stent for Bile Duct in Cancer Patients with Hospice Care
- The decision to insert a permanent stent for a patient's bile duct who has cancer and is under hospice care depends on various factors, including the patient's overall health, prognosis, and quality of life goals 2.
- Studies have shown that palliative treatment, including stent insertion, can improve symptom relief and quality of life for patients with malignant bile duct obstruction 3, 4, 5.
- For patients with a prognosis of 6 months or less, hospice care is appropriate, and the focus is on maximizing time at home and avoiding hospitalization 2.
- In terms of stent type, both metallic and plastic stents have been shown to be effective for palliative treatment of bile duct obstruction in patients with ampullary cancer, although the choice of stent may depend on cost-effectiveness and patient-specific factors 6.
- A study comparing endoscopic stent placement with hepaticojejunostomy found that hepaticojejunostomy may be superior to endoscopic stenting in terms of preventing recurrent jaundice, especially in patients whose disease is first found to be unresectable intraoperatively 5.
- The technical success rate and clinical efficacy of percutaneous transhepatic hybrid biliary endoprostheses using both plastic and metallic stents have been demonstrated to be useful as non-invasive palliative treatment to relieve jaundice in patients with malignant obstructive jaundice 4.