Key Points
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Palliative care is an interprofessional approach to symptom management and decision making for patients with a wide range of serious illnesses and is not limited to patients who are imminently expected to die.
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Palliative care teams reduce costs and decrease the burden of symptoms for patients with serious illnesses.
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Physicians receive limited training in discussing difficult topics and tend to focus on details and use medical jargon in conversations with seriously ill patients.
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Patients and families want physicians to be truthful and empathetic and to participate in shared decision making.
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While patients and families desire a prognosis, they understand and accept that physicians have difficulty prognosticating the future for an individual patient.
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Opioids administered in small doses are effective in treating dyspnea and do not hasten death in patients receiving palliative care.
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The presence of treatment limitations should prompt a thorough discussion of the perioperative plan between the patient and the surgical team.
What Is Palliative Medicine?
Definition
The World Health Organization (WHO) defines palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” Importantly, palliative care does not necessarily need to be limited to the end of life. The Center to Advance Palliative Care states, “unlike hospice care, palliative care can be provided at the same time as curative treatments; it is appropriate at any age and at any stage of a serious illness.” Illness has many facets; symptom management, family support, and aid in decision making are common areas of focus for palliative care teams ( Fig. 52.1 ). Symptom management encompasses physical symptoms (i.e., pain, constipation, nausea and vomiting, and delirium) as well as emotional symptoms (i.e., depression, anxiety, and distress). Palliative care refers to the work of an interprofessional team, whereas palliative medicine refers to the medical subspecialty focused on providing symptom relief and decision-making support for patients with serious illnesses.
Primary Versus Specialist Palliative Medicine
There is a distinction made among the levels of palliative care: primary versus specialist. This distinction facilitates the differentiation among the skills expected from all physicians, including anesthesiologists, and from those more suitable to a specialist service. Examples of primary palliative medicine include basic pain and symptom management, as well as discussions about prognosis, goals of treatment, and resuscitation status. Specialty palliative medicine includes the management of refractory or complex symptoms, as well as the facilitation of conflict resolution among families, staff members, and treatment teams related to the goals of care ( Fig 52.2 ).
History of Palliative Medicine
The word palliative comes from the Latin word to clothe and refers to the “covering up” of symptoms such as pain. Modern palliative medicine grew out of the hospice movement started by Dr. Cicely Saunders in the late 1960s, and introduced in the United States in the 1970s. Since that time, the field has broadened from a focus on patients at the end of life to include patients with serious illnesses. There is also growing recognition that many hospice principles, such as the relief from suffering, apply to all patients regardless of prognosis ( Fig. 52.3 ). To meet this growing need, several academic medical centers have organized inpatient palliative care teams over the past decades.
Currently, 90% of hospitals with more than 300 beds and 67% of hospitals with 50 or more beds have palliative care teams. Hospice and palliative medicine became a recognized subspecialty in 2006, with the first board examinations offered in 2008. Physicians from 10 medical specialties, including anesthesiology, are eligible to complete a fellowship and take the board examination. Between 2008-2017, 125 anesthesiologists were also certified in hospice and palliative medicine. There are now over 7600 hospice and palliative medicine physicians in the United States, and 1% to 2% of graduating hospice and palliative care fellows each year are from anesthesiology.
Why is Palliative Medicine Needed?
The combination of an aging population and medical advancement has contributed to an increase in the number of patients with chronic illnesses. In the United States, Medicare expenditures currently exceed $600 billion, with 42% of Medicare expenses going to 5% of patients. Many of these patients have multiple comorbidities, repeated or prolonged hospitalizations, or a life expectancy of less than 1 year, which make many of them appropriate for hospice or palliative care services.
Patients with serious illnesses have a significant symptom burden, most often involving pain, dyspnea, anxiety, and depression, and their family members report similar concerns. Pain control during a life-limiting illness is often a major concern for patients and their families, and unfortunately, several surveys have found that they are often dissatisfied with the quality of pain control. Patients and families also describe poor communication with health professionals, particularly in the setting of conversations regarding prognosis. Palliative care, with its emphasis on symptom management and goal setting, attempts to address these concerns.
Why is Palliative Medicine Important to Anesthesiologists?
As patients who are older and more seriously ill undergo surgery, anesthesiologists should develop an understanding of the concepts of palliative medicine. Anesthesiologists have specific skills in symptom management that may benefit the patient, and they have a unique perspective on the surgical process that can provide insight to palliative medicine and surgery teams. As more patients and families interact with palliative care teams, anesthesiologists should be able to discuss related concerns and to develop an anesthetic plan that includes palliative concepts, including goals of care discussions and symptom management. Additionally, many pain and critical care anesthesiologists develop this specific expertise through their frequent management of seriously ill patients.
Global Palliative Care
Approximately one half of the countries in the world have at least one hospice or palliative care service, although most exist in larger and more developed countries. Methods and locations of palliative care delivery are widely variable throughout the world, depending on the country’s infrastructure. The variation in availability is vast, from 1 physician for every 1000 inhabitants in the tiny country of Niue near New Zealand to 1 per 8.5 million inhabitants in China and 1 per 90 million in Pakistan. The access to appropriate medications is often restricted and variable as well. An estimated 80% of people with pain worldwide are unable to access opioids, due to concerns about addiction or restrictive national opioid policies. The WHO has implemented a “Public Health Strategy for Palliative Care” that incorporates aspects of policy, drug availability, and education to customize and integrate palliative care throughout the globe.
Palliative Care Team
Guidelines suggest that professionals with skills to meet the patient’s and family’s physical, psychological, social, and spiritual needs participate in the creation of a specialized care plan. Ideally, teams are interprofessional and include a nurse, physician, social worker, and chaplain, as well as other professionals, depending on the need. Many professional disciplines have developed specialized certification or training in palliative care ( Box 52.1 ).
| Physician | Diagnoses, treats, and manages a wide variety of medical issues for patients Provides expert symptom management and consultation Provides expert skills and consultation in communication with patients who are seriously ill, their families, and other providers |
| Nurse | Participates in the diagnosis, treatment, and management of acute and chronic serious illnesses within his or her scope of practice Assesses the patient’s psychosocial and spiritual needs in the setting of a serious illness Participates in symptom management within his or her scope of practice Uses unique skillsets to communicate with the patient, family, healthcare team, and community |
| Social worker | Addresses the psychosocial needs of patients and their families affected by serious illness Participates in meetings with the medical team, patients, and families Assists in complex discharge needs and communicates with community resources |
| Spiritual advocate | Assists patients and families in identifying and addressing spiritual distress related to serious illness Provides or facilitates appropriate spiritual or religious rituals Provides liaison services to community spiritual resources |
| Additional professionals who provide expertise to the palliative care team | Anesthesia pain experts Pharmacists Rehabilitation therapists Psychiatrists |
Note: Roles and competencies may vary by region and training. Data from the following resources: National Association of Social Workers. The certified hospice and palliative social worker. https://www.socialworkers.org/Careers/Credentials-Certifications/Apply-for-NASW-Social-Work-Credentials/Certified-Hospice-and-Palliative-Social-Worker . Accessed March 19, 2019; Hospice and Palliative Nurses Association. http://www.hpna.org/DisplayPage.aspx?Title=Position Statements. Accessed June 20, 2013.
Board of chaplaincy certification. Palliative care specialty certification competencies. http://bcci.professionalchaplains.org/content.asp?admin=Y&pl=45&sl=42&contentid=49 . Accessed June 20, 2013.
Center to Advance Palliative Care. http://www.capc.org . Accessed June 20, 2013.
Where Is Palliative Care Delivered?
In the United States, palliative care is often delivered by a consult service in hospitals or in an inpatient unit. Approximately two thirds of U.S. hospitals and 85% of middle-to-large hospitals have palliative teams, but again, access varies, depending on the geography and type of hospital. The south-central states have the least access to palliative care with less than one third of hospitals in Arkansas, Mississippi, and Alabama reporting a palliative care team. By contrast, the northeast has the best access to palliative care. All hospitals in New Hampshire and Vermont report palliative care programs, as do 89% in Rhode Island and 88% in Massachusetts. While cancer patients who are admitted to the hospital may have high mortality and often have symptoms that are difficult to manage, only 20% to 26% of U.S. cancer centers offer dedicated palliative care inpatient beds. Palliative care clinics are increasingly available, but home palliative care for patients who are not eligible for hospice is rare in the United States due to lack of reimbursement.
Inpatient Palliative Care Teams
Outcomes With Palliative Care Teams
Inpatient palliative care teams reduce hospital costs and resource utilization. A retrospective study of six hospitals with well-established palliative care teams showed a decrease of $1700 per admission for patients discharged alive and $5000 for patients who died. A study of Medicaid beneficiaries showed hospital costs decreased by an average of $6900 during an admission once palliative care teams became involved with reduced intensive care unit (ICU) length of stay and fewer ICU deaths. A cohort study of over 41,000 inpatients who received an inpatient palliative care consultation for goals of care showed significantly reduced future acute care costs, healthcare utilization, and 30-day readmissions when compared with a propensity-matched cohort that did not receive a palliative care consultation. Studies examining inpatients with advanced cancer have demonstrated greater cost savings when a palliative care consultation is requested earlier in the hospital stay, and in patients with more comorbidities. Earlier palliative care consultations also help to facilitate building consensus around goals of care and use of invasive means to support life. Inpatient palliative care teams improve patient-centered outcomes including quality of life, patient and caregiver satisfaction, and, to a variable degree, symptoms. Importantly, palliative care consultation does not increase in-hospital mortality, and even has been shown to lead to fewer days in the hospital and fewer inpatient deaths. This fact may be important for families and patients who incorrectly view palliative care as hastening death.
When to Consult Palliative Care Teams
Basic palliative care knowledge and skills are necessary for all clinicians; however, certain situations call for the expertise of a palliative care specialist. A variety of indicators have been developed to help physicians decide when a specialty palliative care assessment should be performed. Patients’ palliative care needs should be assessed first by the treating physician, then a consultation with a palliative medicine specialist should follow when warranted. The presence of a potentially life-limiting (e.g., multiorgan failure, major trauma, sepsis) or life-threatening condition (e.g., metastatic cancer, cirrhosis, chronic renal failure) serves as the foundation for specialty palliative care involvement. The palliative care candidate should also fit at least one additional criterion, such as frequent hospital admissions for the same condition, functional decline, or an ICU stay of 7 days or longer. More specific consultation criteria should take into account the local hospital system, resources, and patient population. Each hospital should develop a procedure for identifying patients who would benefit from palliative care consultation, which often includes assistance with symptoms that are difficult to control, complex decision making, and provider or family support.
Palliative Care in the Surgical Intensive Care Unit
The three main models of palliative care integration in the ICU are the consultative model, the integrative model, or a hybrid model. In the consultative model, a specialist palliative care team makes recommendations to the primary physician regarding the care of the patient. In the integrative model, the surgeon or intensivist identifies and addresses issues related to palliative care without specialist input. Hybrid models that combine the two approaches above also exist. The most effective model is not clear at this point and is often determined by hospital resources and culture.
Many quality improvement efforts have been proposed to improve palliative care integration into ICUs. One such effort involved screening of critically ill patients followed by direct communication between palliative care providers and intensivists for patients meeting prespecified criteria. This led to increased palliative care consultations in the medical intensive care unit (MICU) by 113% and in the surgical intensive care unit (SICU) by 51% over a 1-year timeframe. Although initial palliative care efforts and research have focused on MICUs, increased attention is being focused on providing palliative care to appropriate patients in the SICU.
Trigger Criteria in the Surgical Intensive Care Unit
Surgical patients who die in the ICU often follow one of two courses. The first is characterized by a prolonged hospital stay with multiple transitions between acute care and ICU settings and intervening periods of prognostic uncertainty, while the second often occurs in trauma patients or other more acutely ill surgical patients with a rapidly declining course. One study of patients in a trauma ICU showed that early assessment of patient and family preferences and early interdisciplinary meetings led to unchanged mortality, do not resuscitate (DNR) orders, and withdrawal of life support; however, the DNR and withdrawal orders were completed earlier in the hospital stay, and the ICU length of stay decreased in patients who ultimately died. Focus on identification of appropriate palliative care consultations early in the hospital course is increasingly important, particularly in the former group.
Use of trigger criteria, in which the presence of one or more predefined patient risk factors results in automatic palliative care consultations, has shown encouraging results. In a broad population of critically ill patients, the use of specific screening criteria to proactively initiate a palliative care referral decreases ICU resources utilization without affecting mortality. Employment of these screening or trigger criteria encourages proactive and systematic patient screening, thereby eliminating the biases of individual providers in identifying patients that would benefit from palliative care team involvement. For example, one study examined the effect of implementing a structured palliative care intervention followed by an interdisciplinary family meeting within 72 hours of admission for all liver transplant service patients admitted to the SICU. After the intervention, increases were seen in goals of care discussions on rounds, documented patient code status, and withdrawal of life support, whereas decreases were seen in time to placing a DNR order and ICU length of stay. There was no difference in mortality, and family members indicated that they had more time with their loved one.
The most effective trigger criteria for palliative care consultations in SICUs have not been defined. Creation of universal criteria is complicated by variation among surgical patient populations, along with many other factors. Many proposals include some combination of these considerations: lengths of stay in the ICU, the lack of improvement during the ICU stay, the patient’s age, and the patient’s illness. One study performed in the SICU used 10 triggers based on expert opinion. These triggers included multiorgan system failure, SICU stay longer than 1 month, more than three SICU admissions during one hospitalization, and death expected during a current SICU admission. This study showed no increase in palliative care consultation, but only 6% of the patients in this study met the trigger criteria, and although the attending physician was notified when a patient met the criteria, palliative care consultation was still left to the judgment of the attending physician. A more inclusive screening process or a mandated palliative care referral, as observed in some of the successful medical ICU studies, may have altered these results. Current recommendations suggest that referral criteria should be informed by available data but individualized for each hospital, or even each ICU, using input from stakeholders including palliative care providers, intensivists, hospital leadership, and nonphysician ICU care providers.
Outpatient Palliative Care
Outpatient palliative care clinics exist to follow patients after discharge or to provide outpatient symptom management and psychosocial support. The providers, availability, and focus vary widely. A landmark study by Temel in 2010 randomized 151 patients with metastatic non-small-cell lung cancer to early outpatient palliative care plus the standard oncologic care or standard oncologic care alone. Patients in the palliative care group had higher quality of life scores, as well as fewer symptoms of depression. Perhaps most surprisingly to some, the patients in the palliative care group lived a median of 2.7 months longer than those in the standard care group, despite receiving less aggressive care. These results and others have led to a recommendation by the American College of Chest Physicians that palliative care be introduced early in the course of disease for patients with stage IV lung cancer or a high symptom burden. A systematic review of patients with a variety of terminal illnesses showed that outpatient palliative care improved depression and quality of life, reduced aggressive care at the end of life, increased advanced directives, reduced hospital length of stay and hospitalizations, and improved family and caregiver satisfaction. A Cochrane review found that while the effect sizes were small, early palliative care interventions may improve quality of life and symptom intensity in patients with advanced cancer. In 2017, because of multiple new randomized controlled studies in other cancers, the American Society of Clinical Oncology Clinical Practice Guideline expanded their recommendations for early palliative care consultation to cover all advanced cancer, not just advanced lung cancer.
Differences Between Hospice Care and Palliative Care
In contrast to palliative care, the definition of hospice care as it applies to the type of patient, the involvement of the medical team, and the setting, varies between countries. In some countries, the terms hospice care and palliative care are interchangeably used, but in the United States, hospice care refers to a benefit provided by the governmental healthcare system. Patients are eligible to enroll in hospice care when their life expectancy is less than 6 months, and typically after life-prolonging treatments, such as chemotherapy, are stopped. Despite the logistic differences, the philosophy of hospice care generally focuses on reducing suffering, enhancing the quality of life, and supporting the patient and family ( Fig. 52.4 ).
Hospice Care in the United States
In the United States, hospice is a per-diem capitated payment system for a defined set of services for patients with a life expectancy of 6 months or less, as agreed on by two physicians. Medicare pays for approximately 80% of hospice care in the United States, and many private insurers have established similar guidelines. These services include visits to a patient’s residence by a nurse (the main provider of clinical care ), aide, social worker, and chaplain. Family members are also eligible to receive a year of bereavement counseling. Continuous care and short-term hospital admission are available for patients with uncontrolled symptoms. A core set of requirements for the hospice benefit exists ( Fig. 52.5 ). However, beyond these requirements, each hospice unit can decide which treatments to cover, and this coverage can vary widely. For example, some hospice organizations may cover palliative radiation treatments, whereas others may not. Patients who outlive their 6-month prognoses may have their benefits extended in 60-day increments after a face-to-face visit with a physician, recertifying that the patient continues to meet hospice criteria.
Who Is Eligible for Hospice Care?
To qualify for hospice, an attending physician and a hospice medical director must certify that the patient’s prognosis is less than 6 months if the disease runs its normal course. Medicare has created guidelines that describe eligibility criteria for hospice services, although the opportunity for interpretation does exist. For example, the criteria for a patient with chronic lung disease include disabling dyspnea at rest, poor response to bronchodilators, hypoxemia at rest, and repeated hospitalizations for emergency department visits. As a result of the subjectivity of some of the guidelines, some hospices may accept patients that other hospices deem ineligible. Patients are not required to have a DNR order to be enrolled in hospice.
Recipients of Hospice Care
Although patients with cancer were previously the primary recipients of hospice care, the proportion of patients receiving hospice care with noncancerous diagnoses such as dementia, chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF) has increased from 16% in 1990 to 69% in 2010. This increase is particularly problematic, considering the lack of good prognostic criteria for a 6-month life expectancy in some disorders, which can complicate hospice referral timing. During this same period, the percentage of patients with Medicare who died while receiving hospice care increased from 5.5% to 44%, yet the length of enrollment in hospice remains abbreviated. The median length of stay in hospice was 18 days in 2010, and approximately one third of all hospice patients lived for less than 1 week after admission to hospice care. Based on utilization review, 14.3% of Medicare patients with cancer did not enroll until the last 3 days of life. This trend toward late admission suggests that many patients are referred to hospice well after they are eligible.
Outcomes of Hospice Care
Hospice care decreases patient symptom burden and increases caregiver satisfaction, with 98% of family members recommending hospice care to others. A survey of over 1500 bereaved family members showed that 70% of respondents whose family member received hospice services considered the care “excellent” with less than 50% of those with decedents receiving home health services considering the care “excellent.” Studies related to cost effectiveness vary in their conclusions. Yet, a few studies suggest that the length of hospice use is correlated with cost savings. A 2007 study by Taylor suggested cost savings with a hospice stay of 53 to 107 days, whereas a 2013 study by Kelley showed cost savings with shorter hospice stays as well. In a study looking at projected savings for beneficiaries with poor-prognosis cancers, increasing hospice utilization from 60% to 80% and increasing duration from 2 to 6 weeks could save $1.79 billion annually.
Palliative Care and Anesthesiologists
Anesthesiologists, as well as subspecialists in pain management and critical care medicine, are likely to interact with patients who are receiving palliative care services. Awareness of the goals of care in the palliative and hospice setting and what services are provided will help the anesthesiologist develop an appropriate plan based on the individual patient’s goals. Critical care anesthesiologists are often called upon to aid in the determination of hospice eligibility and to help families discuss care plans. Pain medicine physicians may provide medication management and interventional procedures alongside palliative care physicians or as part of hospice benefit.
Surgery in Seriously Ill Patients
Palliative surgery has been defined as “the deliberate use of a procedure in a patient with an incurable disease with the intention of relieving symptoms, minimizing patient distress, and improving the quality of life.” A 2004 study of over 1000 patients with advanced cancer undergoing palliative surgery showed a 30-day morbidity of 29% and mortality of 11%, with 80% of patients experiencing improved symptoms at 30 days. A similar study by the same author in 2011 showed a significant improvement from their earlier study. Of 227 patients, there was a morbidity of 20% and mortality of 4%, with 90% experiencing symptom resolution. The study authors attribute some of this change to better patient selection through shared decision making with patients and families.
Communicating Surgery Risk in Seriously Ill Patients
Decision making concerning surgery near the end of life is complex; while some surgeries may increase quality of life or allow a patient to achieve a specific goal, others may result in excessive pain, functional decline, prolonged ICU or hospital stay, or increased use of resources without a clear benefit. A need exists to improve the quality of preoperative communication, to support decision making by surgeons and patients, and to prioritize advance care planning for patients undergoing high-risk surgery. Despite the recognized risk of performing surgery in high-risk patient populations, many patients do not have a complete understanding of the wide range of possible outcomes associated with surgery. The mental frameworks often employed by surgeons and their patients can contribute to both a lack of understanding of possible outcomes and the formation of a contractual obligation to engage in maximal life-sustaining measures after surgery. Both of these issues may result in provision of care that is not well-aligned with patient goals and preferences.
Communication frameworks exist that can assist in conducting preoperative conversations with patients considering high-risk surgery. The “Best Case/Worst Case” tool uses a shared decision-making model with a visual aid to explain the best case scenario, the worst case scenario, and the most likely outcomes related to both surgery and conservative management ( Fig. 52.6 ). This tool allows the surgeon to elicit treatment preferences that are informed by realistic outcomes. Optimal use of the Best Case/Worst Case tool takes patient-specific comorbidities and risk factors combined with surgery-specific risk into account when explaining possible outcomes to patients considering high-risk surgery. A qualitative analysis of the Best Case/Worst Case tool using focus groups of both surgeons and older patients who had been involved in making a medical decision for themselves or their family members within the last year was conducted. From a patient perspective, the tool was seen as favorable overall in that it establishes a choice, allows visualization of distinct paths to help in decision making, and encourages deliberation based on a variety of treatment preferences. Surgeons pointed out that use of this tool provides a useful structure to guide the conversation, allows discussion of patient preferences, and may legitimize non-operative treatment options as still providing care rather than doing nothing. Use of tools such as this one may improve a patient’s understanding of potential complications and consequences of choosing a specific therapy, which allows them to elect the treatment option that is best aligned with his or her goals near the end of life.
Anesthetic Concerns in the Patient Receiving Palliative Care
Preoperative Considerations
A patient’s decision-making capacity may change during a hospitalization or over time and should be assessed before seeking consent from the patient for anesthesia. As noted in Chapter 8 , when a standing DNR order exists in a patient awaiting surgery, a discussion of the patient’s goals and the creation of a plan for intraoperative and postoperative management that meets the patient’s goals should occur prior to surgery. In the case of the perioperative reversal of a DNR order, a plan for when to reinstitute that order should be developed and discussed with the surgeon and nurse as appropriate.
A thorough preoperative evaluation of the patient’s disease should also take place with attention to the patient’s cognitive status, recent medications (including chemotherapy), presence of metastases, and wounds. Knowledge of the patient’s preoperative functional status and prognosis may impact the anesthetic plan and also may inform an accurate assessment of risks and benefits. Details on special considerations in specific disease states such as cancer, COPD, and others are included in Chapter 32 . Considering the number of patients receiving palliative care who may be on large doses of opioids perioperatively, anesthesiologists are advised to follow the guidelines in Chapter 51 regarding perioperative pain management.
Intraoperative Concerns
Resuscitation status should be communicated to any perioperative providers caring for the patient. Consideration should be given to postoperative nausea and vomiting prophylaxis, and the care of fragile skin in this population. Patients may have coagulopathies, thrombocytopenias, or neutropenias that may preclude them from receiving regional or neuraxial anesthesia, thereby impacting their intraoperative pain management.
Anesthetic Choice and Cancer
Recent studies have attempted to clarify the role of anesthesia in cancer progression and recurrence. Studies of the effect of regional anesthesia on those with cancer are mixed but suggest a possible mortality benefit, although meta-analyses have not found either a beneficial nor detrimental effect of regional versus general anesthesia regarding cancer recurrence. Additional discussion is available in Chapter 45 . Studies that examine the choice of specific systemic anesthetics on cancer are mostly in vivo or in vitro, but available data also suggest differences in responses to tumor cells among the different drugs ( Table 52.1 ).
| Drug | Potential Effect on Antitumor Host Defenses |
|---|---|
| Ketamine | Reduces natural killer (NK) cell activity and the number in animal models |
| Thiopental | Reduces NK cell activity and the number in animal models |
| Propofol | Reduces NK cell number in animal models |
| Volatile agents | Inhibits interferon stimulation of NK cell cytotoxicity in animal models |
| Reduces NK cell number in humans; is associated with worse outcomes when compared with local anesthesia for melanoma excision | |
| Nitrous oxide | Associated with acceleration in the development of lung and liver metastases in animal models No effect on cancer outcomes after surgery for colorectal carcinoma in humans Inhibits the formation of hematopoietic cells that may be important for tumor cells |
| Local anesthetic drugs | Lidocaine inhibits epidermal growth factor (EGF) receptor and tumor cell proliferation in vitro ; ropivacaine inhibits growth of cancer cells |
| Morphine | Inhibits cellular immunity including NK cell activity in animal models Inhibits NK cell activity in humans |
| Fentanyl | Inhibits NK cell activity in humans |
| Tramadol | Stimulates NK cell activity in animal models |
| Stimulates NK cell activity in humans | |
| Cyclooxygenase-2 (COX-2) inhibitors | Display anti-angiogenesis and antitumor effects in animal models |
Postoperative Course
Standard postoperative care is adequate for most patients in palliative care. Risks for postoperative pain, delirium, and nausea and vomiting may be increased, depending on the individual patient. Providers should communicate any limitations in care and when limitations revert to their preoperative status.
Communication
Communication about goals of care and treatment preferences influence many outcomes in patients with serious illness. Better communication has been associated with improvement in quality of life, decreased use of life-prolonging therapies near the end of life, provision of care that is more consistent with patient preferences, and earlier hospice referrals. The American College of Physicians describes communication with seriously ill patients as a “low-cost, high-value intervention.” The American College of Physicians recommends that communication be initiated early in the course of life-threatening illness, and ideally by a physician with an established relationship with the patient.
Advance Care Planning
The Patient Self-Determination Act, which took effect in the United States in 1991, requires healthcare providers and institutions to advise patients of their right to an advance directive and to develop institutional policies and education regarding advance directives. However, since the introduction of advance directives, multiple issues have been identified, such as amending preferences as the illness and circumstances change. Understanding a patient’s goals requires open communication with the patient and physician and sometimes repeated conversations to clarify and update the goals of treatment as the patient’s condition changes. More information on advance directives and decision-making surrogates can be found in Chapter 8 .
Outcomes of Advance Care Planning
The landmark 1995 Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) was a 2-year prospective observational study, followed by a 2-year randomized trial of 9105 patients in five U.S. teaching hospitals, with the goal of improving end-of-life decision making. The study enrolled patients with advanced stages of nine illnesses and a 6-month mortality of 45% to 48%. The observation period showed that 49% of patients who did not want cardiopulmonary resuscitation (CPR) did not have a written DNR order, and that the physicians were often unaware of the patients’ wishes. In the intervention, prognostic data were made available to physicians, and a nurse was available to facilitate information sharing, advance care planning, and pain assessment. This intervention did not have any negative impact on physician communication, pain, use of hospital resources, or other measured outcomes. Although more advance directives were documented, only 14% of the patients spoke with a physician when completing their advance directive, and only 25% of the physicians were aware of their patients’ advance directives a week after hospital admission. Similar studies did not demonstrate that advance directives influenced the types of care or the resources used. These studies suggest that efforts toward increasing advance directives alone are insufficient to drive any changes in care.
Many barriers exist to advance care planning, including timing, setting, and quality of communication. Even though physicians often perceive successful communication about treatment planning with patients, data suggest that patient perceptions of treatment options and prognosis often vary considerably. For example, between 50% and 75% of patients with incurable cancer perceived that chemotherapy, radiation therapy, or surgery could lead to survival. It is not clear whether this discordance results from failure in physician communication, inability of the patient to understand and accept the information presented, or a combination of the two. Many professional organizations suggest that end-of-life care planning should begin in the outpatient setting when the patient has approximately 1 year to live. However, in reality, these discussions often do not occur until much later in the patient’s course, such as when an invasive intervention such as mechanical ventilation is needed.
A variety of factors prevent use of advance directives around the time of high-risk surgery, including surgeon perception. Over half of the surgeons in a national survey indicated that they would not operate on a patient who expressed a desire to limit life-sustaining interventions postoperatively. However, patients who have previously undergone high-risk surgery have indicated retrospectively that a greater preoperative emphasis on three critical points would have been helpful: (1) the need for surgery versus alternative treatment options, (2) expectations for postoperative recovery, and (3) use of perioperative advance directives. This study highlights the need for communication with patients and their families around the surgical management and represents an opportunity for anesthesiologists to play a role in facilitating these conversations.
Physician Communication Skills Training
The physician’s approach to communication about difficult issues can affect how patients and families perceive illness, death, and treatment options. These skills are being taught as part of medical school curriculum with increasing frequency, but retention of skills tends to be low. Most physicians are less comfortable discussing code status than they are with other topics, such as consent for procedures. Between 40% and 75% of physicians, depending on their level of training, assess their own knowledge of delivering “bad news” as inadequate. Despite the fact that the American Board of Surgery includes basic knowledge and skills in palliative care as a requirement for board certification in surgery, only 9% of surveyed surgical residents believed they “received adequate training in palliation” during residency. Similarly, as many as 90% of internal medicine residents expressed a desire for additional training in discussing topics such as DNR orders. Despite this lack of training, residents often are the ones to talk about these issues with patients, highlighting the importance of education in this area.
Physician Communication Skills
Physicians often rate their communication skills favorably, but surveys of other practitioners and of patients suggest that physicians may not be able to self-assess accurately. One study in an ICU showed that 90% of surgeons were satisfied with their communication skill concerning prognosis, but only 23% of intensivists and 3% of nurses rated the same skill favorably. Similarly, patients’ perceptions of their cancer stage and prognosis were often incorrect in one study, although oncologists thought they were clear in their explanations of the illness. Recordings of physician discussions with patients and families show that physicians focus on technical detail, avoid emotional topics, and tend to dominate the conversations, despite increased family satisfaction when the family spoke more and physicians exhibited more supportive behaviors. Even when a conversation takes place between a physician and a patient, the physician and patient may not agree on the outcome. One study of patients with metastatic cancer showed that physicians misunderstood their patients’ preferences for CPR 30% of the time. Currently, no comparable studies regarding anesthesiologists have been conducted. These findings highlight the importance of assessing a patient’s understanding of his or her disease process before a procedure is performed or during an ICU stay.
The Surgical “Contract”
When caring for surgical patients, it is important to understand the conceptual frameworks that frequently influence both providers and patients in their approach to care. First, many patients perceive that surgery will “fix” their acute abnormality and restore normalcy to their lives, rather than potentially contribute to further functional or cognitive decline. The potential for the latter problems is rarely discussed preoperatively. In addition, the relationships between surgeons and their patients are unique from other relationships in medicine, because many surgeons perceive an implicit “contractual” agreement to pursue maximal life-sustaining measures after surgery. Surgeons are said to subscribe to a covenantal ethic, meaning that the surgeon takes on individual responsibility for the patient’s life once he or she performs surgery. An ethnographic study examining differences in end-of-life management of surgical patients in three ICUs—one unit run by trauma surgeons, one unit co-managed by surgeons and intensivists, and one unit run by intensivists—identified divergent priorities between surgeons and intensivists. While many intensivists considered use of scarce resources more globally in their decision making, surgeons tended to focus on the individual patient only and delay withdrawal of life-sustaining treatment even when it was requested by family. Surgeons and intensivists often also delivered differing messages regarding treatment and prognosis. A study evaluating recorded preoperative conversations conducted by surgeons performing high-risk surgery found that surgeons often described high-risk surgery as “big surgery” and focused on the technical aspects of surgery during their preoperative conversations. If they discussed need for life support after surgery, they focused on standard recovery rather than potential longer-term complications (e.g., prolonged mechanical ventilation or dialysis). Furthermore, while many surgeons perceived that a contractual agreement to pursue aggressive postoperative care had been made, only rarely did they make this contract explicit with their patients. Other communication breakdowns may occur at the level of the patient (i.e., anxiety, fear, or inability to understand) or the medical system (i.e., time constraints, lack of advance care planning) and also contribute to decisions to proceed with nonbeneficial surgery. Having a good understanding of these unique communication challenges in surgical patients at the end of life may help to facilitate communication with patients, families, and the care team.
What Do Families Consider Important in End-of-Life Communication?
A majority of family members consider trust in the treating physician and truthful communication about the patient’s illness as two of the most important factors in receiving quality end-of-life care. Families have greater satisfaction when a higher level of decision making is shared. In family meetings, family satisfaction increases with the number of empathetic statements made by a physician during a meeting. Virdun and associates conducted a meta-synthesis of 16 qualitative studies examining factors that patients and families describe as important during inpatient end-of-life care. Within the theme of effective communication and shared decision making, family members identified honest and clear communication using simple, understandable language; provision of information necessary to help make decisions; and engaging both the patient and family members in care planning as priorities.
A variety of patient and family preferences influence the quantity of information desired and how to receive it. These preferences may be informed by a combination of personal, cultural, and family characteristics; however, physicians should not assume a preference based on a patient’s race or ethnicity. Many practitioners use a question such as, “How much would you like to know?”, although no studies of patient perceptions of that approach have been conducted. One study of patients with cancer indicated that some patients’ preferences for involvement in decision making changed over the course of the illness. A few studies have noted that caregivers wanted more information than the patients. Some patients may indicate that they do not want to know about their condition and name a surrogate decision maker instead.
Spirituality at the End of Life
Spirituality refers to the ways in which a person expresses meaning or purpose and affects an individual’s sense of connectedness to the world around them. Religion may be a component of spirituality for some people, but many other aspects of spirituality also exist. Swinton and colleagues conducted a qualitative study where patients, family members, and clinicians involved in the care of 70 patients dying in the ICU underwent semistructured interviews. Respondents perceived dying as a spiritual process. They reflected that spirituality comprises an important part of a patient’s narrative before, during, and after death. Serious illness and the prospect of death can bring a number of spiritual issues to the foreground for patients and families, from questioning the meaning of one’s life to a religion’s teaching on specific medical interventions. Patients typically want physicians to ask about their spiritual preferences and describe their spiritual needs as frequently remaining unmet. A simple screening question such as, “Is religion or spirituality important in your life?” has been proposed and may help identify patients in whom a spiritual need exists. Asking about religion and spirituality may provide a context for the healthcare team, since many patients and families make decisions based these beliefs. Physician understanding of the reasoning behind their patients’ decisions is likely to improve end-of-life care.
Communication Frameworks
The prior studies, which demonstrate frequent misunderstandings and poor communication, emphasize the need for an understanding of the importance of effective communication among all participants. A number of frameworks have been developed to aid physicians in discussions with patients and families. No study has compared their relative effectiveness on patient or family outcomes, and very few assessed the effect of a specific communication framework on outcomes. Commonalities in the approaches include active listening, validating patient concerns, and assessing understanding. A recommended comprehensive conversation guide developed by synthesizing data collected in multiple qualitative studies includes the following elements: set up the conversation, assess understanding and preferences, share prognosis, explore key topics (i.e., goals, fears and worries, sources of strength, critical abilities, tradeoffs, and family), close the conversation, document your conversation, and communicate with key clinicians ( Fig. 52.7 ).
Family Meetings
Family conferences in the ICU have increasingly been used to facilitate information sharing between families and providers. In the ICU setting, meetings held within 72 hours of admission have shown decreased lengths of stay without increased mortality. One of the few studies that evaluated a standardized communication approach was a single-site study of families of patients who were seriously ill and randomized to either a standardized communication template with a bereavement brochure or the standard care. The communication intervention structured around the mnemonic of VALUE (value, acknowledge, listen, understand, elicit questions) emphasizes empathy, understanding of the patient as a person, and allowing family members to ask questions. Family members in the study arm had decreased symptoms of psychological distress in a survey 3 months later ( Box 52.2 ).
Value: Value and appreciate what the family member says. “Thank you for helping me understand how your husband’s condition has changed over the past year.”
Acknowledge: Acknowledge emotions. “This is often a sad time for families.”
Listen: Actively listen. Remember to be silent and to give the family member time to speak.
Understand: Gain an understanding of the patient. Ask who the patient is as a person. “Can you tell me about your father, what kind of person he is and what’s important to him?”
Elicit questions: Ask family members if they have questions. “We have discussed a lot of information. Do you have any questions?”
Many physicians struggle with how to begin family meetings. Common approaches include: introducing the family and team members, eliciting the level of understanding from family members, and briefly summarizing the purpose of the meeting; for example, “What have you been told about what’s going on with your dad?”.
Breaking Bad News
The six-step SPIKES (setting, perception, invitation, knowledge, empathy, sequelae) protocol is a framework for breaking bad news. Several of the elements, such as finding a quiet meeting space, asking what the patient or family understands, and making a plan for the future, apply in many situations ( Box 52.3 ). A meta-synthesis of available qualitative data suggested that breaking bad news is a skill that requires the provider to reassess and adapt the conversation based on a number of factors including the provider-patient relationship, responses from the patient and family, the environment, and cultural or social factors.
Setting : Arrange for a quiet, private space large enough for all participants.
Perception: Assess the participants’ understanding. “What have the doctors told you about your wife’s illness?”
Invitation : Ask how much information is desired. “Some people like all the details, others just like the big picture. What would you like?”
Knowledge: Tell the participants what is known, using language that is easy to understand and avoiding the use of complex medical phrases.
Empathy : Acknowledge emotions. “I wish things were different.”
Sequelae: Agree on the next steps. “Let’s meet tomorrow afternoon so I can update you on her condition.”
Responding to Emotion
The NURSE (name, understand, respect, support, explore) protocol is a framework for responding to emotion, including anger. Patient and family anger directed toward healthcare providers is common in the setting of serious illness. Crucial concepts in responding to anger include not becoming defensive or personalizing the anger, respectfully listening, and setting appropriate boundaries for safety. Although difficult to accomplish in the moment, viewing anger as a coping mechanism in the grieving process is often helpful ( Box 52.4 ).
Name: State the emotion you believe the patient or caregiver is exhibiting. “It seems like you are angry.”
Understand: Empathize with and legitimize the emotion. “I can’t imagine how hard this must be for you.”
Respect : Praise the patient or caregiver for his or her strength. “You’ve done so much for your mother during this difficult time.”
Support: Show support. “I want to help.”
Explore: Ask the patient or caregiver to elaborate on the emotion. “Can you help me understand what was so frustrating today?”
Requests for Nondisclosure
Family members may ask physicians to withhold a diagnosis from the patient. The cultural norms for disclosing a patient’s diagnosis vary widely among cultures and countries. In the United States, the culture of disclosure has rapidly changed, and now most physicians expect to disclose the prognosis to the patient. No evidence is available that recommends how to deal with requests for nondisclosure, but expert opinions recommend empathetically responding to the family member, trying to understand the family’s concerns about disclosing the prognosis, and asking the patient how and if he wants to be involved. For example, “Some people want to be told about any health issues and make their own decisions, while others prefer for a family member to be told the medical information and to make the decisions. What would you like?”
Time-Limited Trials
In cases where the benefit of a clinical intervention is unclear for a specific patient, a time-limited trial, in which the physician and patient or family agree to reevaluate the benefit after a specified period, may be helpful. Time-limited trials give families a sense of when the healthcare team expects to know whether an intervention is helping and creates the expectation that the issue will be readdressed.
Resuscitation Status
Outcomes of Cardiopulmonary Resuscitation
CPR was introduced around 1960, initially as a treatment for intraoperative events and then expanded outside the surgical unit. Outcomes of CPR have improved, with over half the patients who suffer in-hospital cardiac arrest surviving the initial resuscitation and nearly one quarter surviving to discharge. Survival is better for patients with a shockable initial rhythm (37%) when compared with pulseless electrical activity (12%) or asystole (11%), with time to defibrillation representing a critical factor in patient outcome.
Approximately 85% of cardiac arrests in surgical patients occur postoperatively, and this patient population may have a higher likelihood of survival than other groups of patients. In one large study of older surgical patients who survived to discharge after in-hospital CPR, approximately one half had moderate-to-severe neurologic defects and 60% were alive 1 year later. Induced mild hypothermia improves neurologic outcome after cardiac arrest, but benefits are better demonstrated in the out-of-hospital arrest population. Data increasingly suggest that there are gender differences between outcomes after cardiac arrest. A study comparing outcomes in men and women after cardiac arrest showed that women who survived to discharge after cardiac arrest had worse cognitive, functional, and psychiatric outcomes after multivariate adjustment for multiple confounders.
Resuscitation Status Discussions
Discussion of resuscitation status can be challenging to some providers. Anesthesiologists may be involved in conducting discussions related to resuscitation status with patients in the ICU or in the perioperative period. Ideally, the discussion about code status takes place in the context of a conversation about the patient’s overall health and goals. For example, one patient might decide on life prolongation as a goal, in which case a physician might recommend resuscitation attempts even if unlikely to succeed, whereas another patient with the same illness might prioritize physical independence as a goal, in which case the physician might recommend a DNR order to decrease the likelihood of prolonged ICU time or an unacceptable physical status. The impact of this approach is unknown. A small simulated study that played a standardized video of a code status discussion to cancer patients showed no difference between asking the patient his or her desired resuscitation status or making a suggestion for DNR order. The few studies that formally examine the best way to approach discussions regarding resuscitation do not clearly demonstrate a single best approach. For example, one study examined using the terminology “allow natural death” instead of “do not resuscitate” with terminal cancer patients and did not show that either term was favored over the other.
Perioperative Limitations on Treatment
The American Society of Anesthesiologists has published guidelines related to orders for the limitation of treatment in the perioperative setting. The ethics of perioperative DNR orders are discussed more comprehensively in Chapter 8 .
Prognosis
Multiple studies have examined the ability of physicians to prognosticate survival for a given patient. In a meta-analysis of eight studies in patients with a median survival of 4 weeks, physicians overestimated the prognosis by approximately 30%. Predictions were more accurate in patients with poorer performance status. In a prospective cohort study of 365 physicians and 504 patients receiving hospice care, the physicians overestimated survival by a factor of 5, and 63% of their predictions were overestimates. The longer a physician knew a patient, the more difficult it was for that physician to prognosticate. Physicians in the ICU tend to be overly pessimistic. In a study of 851 patients receiving mechanical ventilation, only 71% of patients for whom a physician estimated a likelihood of survival of less than 10% at some point during their stay in the ICU died in the ICU. A meta-analysis suggested that physicians are more accurate at predicting mortality than algorithmic scoring systems (described in the “Prognostic Tools” section) in the first 24 hours after ICU admission; however, neither physicians nor scoring systems are reliably accurate for individual patients. Overall, physician estimates do correlate with survival and are more accurate in predicting mortality than other outcomes such as return to cognitive baseline. For example, a study of 521 patients in a MICU found that physicians and nurses were unable to predict satisfaction with the quality of life 6 months after admission. In general, nurses tended to be more pessimistic than physicians and suggested withdrawal of life-sustaining treatment more often in patients who ultimately survived ( Figs. 52.8 and 52.9 ). Prognostic tools that include clinician assessment are better than tools that rely on objective data alone, but the best predictions arise when multiple providers (physicians and/or nurses) agree on the prognosis.
Difficulty with prognostication has led some physicians to avoid giving any kind of timeframe to eliminate the possibility of being wrong. However, 87% of 179 surrogate decision makers wanted the physician to give a prognosis, even if it was uncertain. Most understood the inherent unpredictability of prognostication and preferred that physicians make the prognostic uncertainty clear during the discussion. Prognosis, even in the face of uncertainty, can help families prepare for bereavement and make important decisions about coordinating work, visitors, and finances. Good data suggesting how to present prognoses to patients are not available. One approach to prognostication involves giving ranges such as hours to days, days to weeks, weeks to months, and months to years, with those categories roughly tracking with functional status. These ranges, along with an explanation from the physician about the difficulty of prognosticating, can often give families sufficient guidance with which to make important decisions. However, interpretation of a given prognosis may vary with the patient and family. One study that gave surrogate decision makers in the ICU hypothetical physician statements about prognosis and asked them to interpret them showed that surrogates tended to be optimistic, especially with worse prognoses.
Disease Trajectories
Most disease trajectories can be included in one of the following functional categories: sudden extreme disability or near death; a period of good functionality, followed by a rapid, steady decline; a waxing and waning course with periods of decompensation followed by improvements; and a slow decline, starting at a low functional level ( Fig. 52.10 ). These frameworks can be useful when discussing prognoses with patients, particularly in talking to patients with conditions that are difficult to predict such as COPD and CHF.
Prognostic Tools
Multiple web-based prognostic tools exist, but they are typically specific to particular cancers. But an important consideration is that the type of cancer is actually less important than a variety of patient factors (e.g., functional status and laboratory values) as the disease becomes more advanced ( Fig. 52.11 ). In general, a patient with cancer who spends more than half of the day in bed has a median survival of 6 months ( Box 52.5 ).
Solid Cancers in General
Any locally advanced or metastatic solid cancer with one or more of the following presentations:
- ▪
Patient spends more than one half of the day in bed
- ▪
Serum calcium > 11.2 mg/dL
- ▪
Episode of extremity venous thromboembolism or pulmonary embolism
- ▪
Two or more brain metastases plus intracranial metastases
- ▪
Spinal cord compression with decreased ability to walk
- ▪
Malignant pericardial effusion
Carcinoma of Unknown Primary Origin
Any metastatic adenocarcinoma or undifferentiated carcinoma of unknown primary origin with one or more of the following presentations:
- ▪
Patient is ambulatory and can care for him or herself but cannot work
- ▪
Hepatic, bone, or adrenal metastases
- ▪
Recurrence of disease after chemotherapy
- ▪
Serum albumin < 3.5 mg/dL or weight loss of ≤ 10% in 6 months
Multiple tools, which are covered in depth in Chapter 84 , have been proposed to help the clinician predict mortality in the ICU. These tools may be more useful in the research setting than for prediction of outcome in an individual patient.
Many conditions have courses that are difficult to predict. Table 52.2 gives characteristics associated with noncancer patients such as heart failure, dementia, hepatic cirrhosis, and COPD, with a median survival of 6 months or less, although it should be noted that the prognostic accuracy of these factors is not known.
| Diagnosis | Presentation | |
|---|---|---|
| Heart Failure | ||
| Hospitalization for moderate-to-severe symptomatic heart failure, NYHA Class III or IV, with three or more of the presentations listed. |
| |
| Dementia | ||
| Advanced dementia with dependency in all activities of daily living, bedbound status, urinary and bowel incontinence, decreased ability to communicate verbally, and admission to a hospital or skilled nursing facility with one or more of the presentations listed. |
| |
| Hepatic Cirrhosis | ||
| Decompensated hepatic cirrhosis and one or more of the presentations listed. |
| |
| Decompensated hepatic cirrhosis with hospitalization for an acute illness related to liver disease and one or more of the presentations listed. |
| |
| Chronic Obstructive Pulmonary Disease | ||
| Hospitalization for a severe COPD exacerbation, with Pa O 2 ≤55 mm Hg, Pa CO 2 ≥50 mm Hg, and supplemental oxygen dependence, with three or more of the presentations listed. |
| |
Congestive Heart Failure
CHF often has a waxing and waning course. The Seattle Heart Failure Model estimates mean 1- to 3-year survival but does not appear to be able to predict whether individual patients are in the last year of life. Factors associated with a poor prognosis include hospitalization, tachycardia, hypotension, decreased ejection fraction, and increased creatinine level. In patients hospitalized for acute decompensation of heart failure, older age and COPD were associated with decreased 1-year survival.
Dementia
The course of dementia is difficult to predict, and a patient’s 6-month mortality is higher once the patient develops the common problems of infection and an inability to eat. Probability of death within 6 months increases with advancing age, shortness of breath, immobility, and insufficient oral intake, among other presentations.
Chronic Obstructive Pulmonary Disease
The BODE Index, which is used to predict the risk of death in COPD, measures b ody mass index, airflow o bstruction, d yspnea, and e xercise capacity ; however, its use of a 6-minute exercise capacity test makes it impractical for the bedside anesthesiologist. More than 3 days of mechanical ventilation and an inability to extubate the trachea successfully suggest a poor prognosis.
Liver Disease
In decompensated liver disease, the Model for End-Stage Liver Disease score is often used to predict a prognosis. Hepatic encephalopathy and hepatorenal syndrome are also predictors of a poor prognosis.
Renal Disease
Patients with chronic kidney disease on dialysis will live 16% to 33% as long as age- and sex-matched patients who are not on dialysis. Probability of survival at 10 years for patients on dialysis who are older than 65 years of age is 3.1%. Poor functional and nutritional status, as well as comorbid conditions, suggest a poor prognosis. Withdrawal of dialysis accounts for up to 20% of deaths in patients on dialysis each year, and the average patient lives 8 to 12 days after dialysis withdrawal.
Symptom Management
Alternative Routes of Drug Delivery
Many patients near the end of life are unable to swallow oral medications as a result of oral lesions, nausea, the dying process, or other reasons. Many patients in palliative and hospice care have difficult intravenous access as a result of frequent medical care, dehydration, or other issues. To avoid multiple attempts at intravenous cannulation, palliative medicine practitioners and most hospices use subcutaneous infusions for the delivery of medications, especially opioids. An assumption of safety is based, in part, on studies showing that many intramuscular injections are actually administered into the subcutaneous tissue. In addition, other types of drugs such as benzodiazepines, some antiemetic medications, antibiotics, neuroleptics, and even fluids can be subcutaneously administered in the palliative care setting. While the subcutaneous administration of opioids is safe, the optimal conversion ratio from one route to another is a subject of debate. Other studies support the transmucosal, sublingual, and rectal administration of opioids. Finally, neuraxial drug delivery via continuous epidural infusions or intrathecal pumps can be utilized, particularly for intractable pain.
Pain
Pain management in patients who are seriously ill can be quite different from other patients with pain. Some of these patients have pain that is best managed by a pain management specialist, and some will need adjuvant medications ( Table 52.3 ). In cancer patients, 15% to 90% with solid tumors have pain, depending on the type and stage of cancer, as well as the age, race, and sex of the patient. Most cancer pain is due to the cancer itself, but approximately one fifth of patients develop pain related to the cancer treatment. The majority of cancer pain can be managed with the WHO “Cancer Pain Stepladder.” Zech published a prospective study of 2118 cancer patients using this stepladder during which 76% of the patients received pain relief with minimal side effects. However, pain management may be significantly more challenging for patients with advanced cancer. Sixty to 90% of this population report pain that significantly impacts function, mood, and sleep. Pain of this severity may benefit from more advanced techniques such as interventional pain medicine (see Chapter 51 ), psychological interventions, or palliative chemotherapy or radiation therapy.
| Examples | Comment | |
| Multipurpose Analgesics | ||
| Glucocorticoids | Dexamethasone, prednisone | Are used for bone pain, neuropathic pain, lymphedema pain, headache, and bowel obstruction |
| Antidepressants | ||
| TCAs | Desipramine, amitriptyline | Are used for opioid-refractory neuropathic pain; often used with comorbid depression; secondary amine compounds (e.g., desipramine) have fewer side effects and might be preferred |
| SNRIs | Duloxetine, milnacipran | Good evidence exists for their use in some conditions but are overall less effective than TCAs; better side-effect profile than TCAs and are often tried first |
| SSRIs | Paroxetine, citalopram | Evidence for their use is scarce; if pain is the target, then other subclasses are preferred |
| Other | Bupropion | Little evidence exists for its effectiveness but less sedating than other antidepressants; is often tried early when fatigue or somnolence is a problem |
| α 2 -Adrenergic agonists | Tizanidine, clonidine | Are seldom used systemically because of side effects, but tizanidine is preferred for a trial; clonidine is used in neuraxial analgesia |
| Cannabinoid | THC/cannabidiol, nabilone, THC | Good evidence exists for THC/cannabidiol when used in cancer pain; evidence is scarce for other commercially available compounds |
| Topical Agents | ||
| Anesthetic | Lidocaine patch, local anesthetic creams | Sometimes used in localized pain |
| Capsaicin | 8% patch; 0.25%-0.75% creams | High concentration patch is indicated for postherpetic neuralgia |
| NSAIDs | Diclofenac and others | Evidence exists for their use in focal musculoskeletal pains |
| TCA | Doxepin cream | Is used in treating itching; can be tried for pain |
| Others | Compounding creams with various drugs have been empirically tried, but no evidence exists for effectiveness | |
| Used for Neuropathic Pain | ||
| Multipurpose drugs | As above | As above |
| Anticonvulsants | ||
| Gabapentinoids | Gabapentin, pregabalin | Are used first for opioid-refractory neuropathic pain unless comorbid depression; may have multipurpose uses in view of the evidence in postsurgical pain; both drugs act as N-type calcium channel blockers in the CNS, but individuals vary in response to one or the other |
| Others | Oxcarbazepine, lamotrigine, topiramate, lacosamide, valproate, carbamazepine, phenytoin | Evidence is scarce for all drugs listed; newer drugs are preferred because of reduced side-effect liability, but individual variation is great; all drugs are considered for opioid-refractory neuropathic pain if antidepressants and gabapentinoids are ineffective |
| Sodium-Channel Drugs | ||
| Sodium-channel blockers | Mexiletine, intravenous lidocaine | Good evidence exists for intravenous lidocaine |
| Sodium-channel modulator | Lacosamide | New anticonvulsant with very scarce evidence of analgesic effects |
| GABA agonists | ||
| GABA A agonist | Clonazepam | Evidence is scarce but used for neuropathic pain with anxiety |
| GABA B agonist | Baclofen | Evidence for the treatment of trigeminal neuralgia is the basis for trials in other types of neuropathic pain |
| N -methyl- d -aspartate inhibitors | Ketamine, memantine, and others | Evidence is scarce for ketamine, but experience is positive with intravenous use in advanced illness or pain crisis; little evidence exists for oral drugs |
| Used for Bone Pain | ||
| Bisphosphonates | Pamidronate, ibandronate, clodronate | Good evidence exists for their use; similar to NSAIDs or glucocorticoids, usually considered first-line treatment; also reduces other adverse skeletal-related events; concern about osteonecrosis of the jaw and renal insufficiency might restrict its use |
| Calcitonin | Evidence is scarce but is usually well tolerated | |
| Radiopharmaceuticals | Strontium-89, samarium-153 | Evidence is good, but their use is restricted because of bone-marrow effects and the need for expertise |
| Used for Bowel Obstruction | ||
| Anticholinergic drugs | Hyoscine compounds, glycopyrronium | Along with a glucocorticoid, are considered first-line adjuvant treatments for nonsurgical bowel obstruction |
| Somatostatin analog | Octreotide | Along with a glucocorticoid, is considered a first-line adjuvant treatment for nonsurgical bowel obstruction |
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