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Five things physicians and patients should question in hospice and palliative medicine

AAHPM Special Article Five Things Physicians and Patients ShouldQuestion in Hospice and Palliative MedicineDaniel Fischberg, MD, PhD, Janet Bull, MD, David Casarett, MD, MA, MMM,Laura C. Hanson, MD, MPH, Scott M. Klein, MD, MHSA,Joseph Rotella, MD, MBA, Thomas Smith, MD, C. Porter Storey Jr., MD,Joan M. Teno, MD, MS, and Eric Widera, MD, for the AAHPM ChoosingWisely Task ForceDepartment of Geriatric Medicine (D.F.), John A. Burns School of Medicine, University of Hawaii,Honolulu, Hawaii; Four Seasons (J.B.), Flat Rock, North Carolina; University of PennsylvaniaHealth System (D.C.), Philadelphia, Pennsylvania; Division of Geriatric Medicine and University ofNorth Carolina Palliative Care Program (L.C.H.), University of North Carolina-Chapel Hill, ChapelHill, North Carolina; Hospice and Palliative Care (S.M.K.), Visiting Nurse Service of New York, NewYork, New York; Hosparus (J.R.), Louisville, Kentucky; Johns Hopkins Medical Institutions andSidney Kimmel Comprehensive Cancer Center (T.S.), Baltimore, Maryland; American Academy ofHospice and Palliative Medicine (C.P.S.), Glenview, Illinois; Warren Alpert School of Medicine(J.M.T.), Brown University, Providence, Rhode Island; and Division of Geriatrics (E.W.), University ofCalifornia-San Francisco, San Francisco, California, USA AbstractOveruse or misuse of tests and treatments exposes patients to potential harm. TheAmerican Board of Internal Medicine Foundation's Choosing WiselyÒ campaign isa multiyear effort to encourage physician leadership in reducing harmful orinappropriate resource utilization. Via the campaign, medical societies are asked toidentify five tests or procedures commonly used in their field, the routine use of which inspecific clinical scenarios should be questioned by both physicians and patients based onthe evidence that the test or procedure is ineffective or even harmful. The AmericanAcademy of Hospice and Palliative Medicine (AAHPM) was invited, and it agreed toparticipate in the campaign. The AAHPM Choosing Wisely Task Force, with input fromthe AAHPM membership, developed the following five recommendations: 1) Don'trecommend percutaneous feeding tubes in patients with advanced dementia; instead,offer oral-assisted feeding; 2) Don't delay palliative care for a patient with serious illnesswho has physical, psychological, social, or spiritual distress because they are pursuingdisease-directed treatment; 3) Don't leave an implantable cardioverter-defibrillatoractivated when it is inconsistent with the patient/family goals of care; 4) Don'trecommend more than a single fraction of palliative radiation for an uncomplicatedpainful bone metastasis; and 5) Don't use topical lorazepam (AtivanÒ),diphenhydramine (BenadrylÒ), and haloperidol (HaldolÒ) (ABH) gel for nausea.
These recommendations and their supporting rationale should be considered byphysicians, patients, and their caregivers as they collaborate in choosing those treatments Address correspondence to: Daniel Fischberg, MD, The Queen's Medical Center, 1301 Punchbowl Accepted for publication: December 24, 2012.
Ó 2013 U.S. Cancer Pain Relief Committee.
0885-3924/$ - see front matter Published by Elsevier Inc. All rights reserved.
Fischberg et al.
Vol. 45 No. 3 March 2013 that do the most good and avoid the most harm for those living with seriousillness.
J Pain Symptom Manage 2013;45:595e605. Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Key WordsChoosing WiselyÒ, palliative care, quality of life, dementia, artificial nutrition andhydration, percutaneous endoscopic gastrostomy, PEG, heart failure, implantablecardioverter-defibrillator, ICD, bone metastasis, bone pain, single-fraction radiation, nausea,lorazepam-haloperidol-diphenhydramine gel, ABH gel In response to Brody's Top Five challenge, the American Board of Internal Medicine Foun- Advances in biomedical science and the de- dation developed a multiyear effort called velopment of novel therapies over the last 50 Choosing WiselyÒ. In 2012, nine medical societies years have been unprecedented. Yet despite developed and, in conjunction with Consumer these advances, Americans experience inferior Reports, publicized an initial series of Top Five quality of care, efficiency, access, and health out- lists. The American Academy of Hospice and comes compared with the citizens of most other Palliative Medicine (AAHPM) was invited to developed nations, all while health care costs participate, along with 15 additional medical so- rise at an unsustainable ratIn the U.S., health cieties, in the next wave of the campaign. Here, care expenditures now consume more than we report the five practices the AAHPM Choos- 17% of gross domestic prodAlthough the ing Wisely Task Force recommends patients and causes underlying the paradox of spending physicians question in the practice of hospice more while achieving less are complex, overuse and palliative medicine (HPM) ( and inappropriate use of tests, procedures, and This list is not meant to serve as a rigid tool therapies have been cited as major contributors, and should instead be used as a support for indi- accounting for perhaps 30% of all health care vidualized decision-making born of conversa- expenses.In 2008, the Congressional Budget tions between physicians and patients. It also Officeestimated that $700 billion annually should be understood that these recommenda- goes to health care spending that has not tions are not universally applicable to the situa- been shown to improve health outcomes. Of tions and settings they address. There may be greatest concern, ineffective and nonbeneficial times when they are inappropriate in light of spe- treatments may expose patients to harm from cific additional circumstances facing a patient.
adverse effects, overtreatment, and delayed de- These recommendations are provided for in- livery of effective and beneficial treatments. At formational purposes only and do not constitute a time of dramatically increased spending, an medical advice. They do not supersede the inde- aging population, and an increasing illness bur- pendent judgment of a medical professional, den, it is absolutely necessary for physicians and and the authors believe that an individual with patients to choose every treatment wisely.
specific medical questions should obtain medi- In light of these challenges and with the cal advice from their health care provider.
goal of maximizing quality of care while mini-mizing the costs, Brody challenged medical so-cieties to each create a ‘‘Top Five'' list of tests or treatments that are commonly ordered, ex- The president of AAHPM appointed a special pensive, and have been shown not to provide task force to coordinate the development of the any meaningful benefit to at least a major cat- Academy's list of ‘ Five Things Physicians and Pa- egory of patients for whom they are commonly tients Should Question in Hospice and Palliative ordered. Brodysummarized the concept of Medicine.' Chaired by a member of the Board the Top Five list as ‘‘a prescription for how, of Directors who previously oversaw AAHPM's within that specialty, the most money could Education and Training Strategic Coordinating be saved most quickly without depriving any Committee, the task force included representa- patient of meaningful medical benefit.'' tives of the Academy's Quality and Practice Vol. 45 No. 3 March 2013 Five Things Physicians and Patients Should Question in HPM Five Things Physicians and Patients Should Question in Hospice and Palliative Medicine 1. Don't recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral-assisted feeding.
In advanced dementia, studies have found that feeding tubes do not result in improved survival, prevention of aspirationpneumonia, or improved healing of pressure ulcers. Feeding tube use in such patients has actually been associated with pressureulcer development, use of physical and pharmacologic restraints, and patient distress about the tube itself. Assistance with oralfeeding is an evidence-based approach to provide nutrition for patients with advanced dementia and feeding problems; in thefinal phase of this disease, assisted feeding may focus on comfort and human interaction more than the nutritional goals.
2. Don't delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment.
Numerous studiesdincluding randomized trialsdprovide evidence that palliative care improves pain and symptom control,improves family satisfaction with care, and reduces costs. Palliative care does not accelerate death and may prolong life inselected populations.
3. Don't leave an ICD activated when it is inconsistent with the patient/family goals of care.
In about a quarter of patients with ICDs, the defibrillator fires within weeks preceding death. For patients with advancedirreversible diseases, defibrillator shocks rarely prevent death, may be painful to patients, and are distressing to caregivers/family members. Currently, there are no formal practice protocols to address deactivation; less than 10% of hospices haveofficial policies. Advance care planning discussions should include the option of deactivating the ICD when it no longersupports the patient's 4. Don't recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis.
As stated in the American Society for Radiation Oncology 2011 guideline, single-fraction radiation to a previously unirradiatedperipheral bone or vertebral metastasis provides comparable pain relief and morbidity compared with multiple-fractionregimens while optimizing patient and caregiver convenience. Although it results in a higher incidence of later need forretreatment (20% vs. 8% for multiple-fraction regimens), the decreased patient burden usually outweighs any considerationsof long-term effectiveness for those with a limited life expectancy.
5. Don't use topical lorazepam (Ativan), diphenhydramine (Benadryl), and haloperidol (Haldol) (ABH) gel for nausea.
Topical drugs can be safe and effective, such as topical nonsteroidal anti-inflammatory drugs for local arthritis symptoms.
Although topical gels are commonly prescribed in hospice practice, antinausea gels have not been proven effective in anylarge, well-designed, or placebo-controlled trials. The active ingredients in ABH are not absorbed to systemic levels that couldbe effective. Only diphenhydramine (Benadryl) is absorbed via the skin and then only after several hours and erratically atsubtherapeutic levels. It is, therefore, not appropriate for ‘‘as needed'' use. The use of agents given via inappropriate routesmay delay or prevent the use of more effective inter ICD ¼ implantable cardioverter-defibrillator.
Standards Task Force, Research Committee, the AAHPM Executive Committee and submit- Ethics Committee, Public Policy Committee, ted to the American Board of Internal Medi- and External Awareness Task Force, as well as cine Foundation.
at-large appointees who represent distinguishedleaders in the field.
AAHPM aimed for an inclusive list develop- ment process that would afford every member The five recommendations are the following: of the Academy the opportunity to participate 1. Don't recommend percutaneous feeding in the identification or evaluation of potential tubes in patients with advanced dementia; recommendations. The task force solicited in- instead, offer oral-assisted feeding.
put from AAHPM's 17 special interest groups,and task force members also offered their own Dementia is the fifth leading cause of death suggestions for the list.
among Americans aged 65 years and older, and Considering the potential impact and evi- recent research suggests that this is an underes- dence to support the proposed recommenda- timateDementias are progressive diseases of tions, the task force settled on seven finalists, cognitive and physical decline. In advanced de- and a rationale and evidence base were further mentia, 86% of patients develop an eating prob- developed for each. All AAHPM members lem that increases risk for malnutrition and were invited to comment on and rank these recurrent infections. Because they may view it seven recommendations. The members' feed- as a choice between feeding and not feeding, back informed the task force's final delibera- families are often faced with what they perceive tion, which included narrowing the list to five as a difficult decision on whether to insert a feed- recommendations and refining their verbiage.
ing tube.However, framing the decision in Finally, the list was reviewed and approved by these stark terms ignores the relative risks and Fischberg et al.
Vol. 45 No. 3 March 2013 benefits of tube feeding compared with contin- untreated pain and other symptoms, high care- ued oral feeding in advanced dementia.
giver burden, poor communication with their A substantial body of research provides evi- health care providers, infrequent discussions dence of the risks and benefits of percutaneous about and documentation of medical goals endoscopic gastrostomy (PEG) feeding tube in- and preferences, and high rates of hospitaliza- sertions in people with advanced demen- tion and burdensome treatments at the end of tia.Observational studies have found Despite these risks, the decision to fo- that feeding tubes do not result in improved cus on reducing the suffering of those dealing survival, prevention of aspiration pneumonia, with a serious illness is often delayed until after or improved healing of pressure ulcers.
potentially curative or life-prolonging treat- Teno et al.conducted an analysis of national ment options have been exhausted, with stud- Medicare claims and the Minimum Data Set, us- ies showing that palliative care consultations ing techniques that accounted for selection occur very late in the disease trajectory bias, and found no survival benefit of feeding There is now convincing evidence that the de- tube insertions in people with advanced cogni- livery of palliative care concurrent with the tive impairment. For nursing home residents disease-directed treatment can improve the with advanced dementia, the one-year survival quality of life, symptom control, and family sat- rate after a feeding tube insertion is only isfaction with care, all while reducing costs 33.9%, with a median survival of 56 day associated with aggressive end-of-life care. Pal- It also should be noted that PEG feeding liative care does not shorten life expectancy tubes are not without risk. Although the mortal- and can improve survival in select populations.
ity rate with the insertion of a PEG feeding tube The evidence that palliative care improves is small, people with advanced dementia who symptom control and leads to greater family sat- had a PEG tube insertion during an acute care isfaction with care has been shown in both obser- hospitalization had more than two times the vational and randomized control trials. Ringdal risk of developing a Stage II or higher pressure et al.conducted a randomized trial of compre- ulcer.A small study based on bereaved family hensive palliative care services for patients with member interviews reported that 25.9% of dece- incurable cancer and life expectancy of two to dents with feeding tubes were physically re- nine months. One month after the patients' strained and 29.2% were pharmacologically deaths, families of the patients who received pal- restraiFurthermore, they reported that liative care were more satisfied with most aspects nearly 40% of patients dying with dementia of the care received. The most positive effects were bothered by the feeding tube.
were in pain control, speed of symptom treat- Oral-assisted feeding represents a viable ment, communication, quality of family confer- evidence-based option to maintain weight ences, and availability and thoroughness of and caloric intake for patients with dementia.
physicians. Engelhardt et arandomized 275 High-calorie supplements can support weight patients with chronic obstructive pulmonary dis- stabilization or weight gain for people with de- ease, heart failure, or cancer and with recurrent mentia; assisted feeding programs, modified hospital admissions to usual care or concurrent foods, and appetite stimulants have a potential palliative care case management. Palliative care benefit but limited evidence.Feeding for patients had increased satisfaction with care comfort is an appropriate option in the final and communication and increased use of ad- phase of illness in demenFamilies prefer vance directives (69% vs. 48%, P ¼ 0.006). Addi- and accept the option of oral-assisted feeding, tionally, in a retrospective study, more time rather than tube feeding, when they receive ef- between the initial palliative care consultation fective information and educati and the patient's death was associated with bet-ter family perceptions of care, most notably for 2. Don't delay palliative care for a patient with communication and emotional suppor serious illness who has physical, psychologi- Focusing on the relief of suffering and pro- cal, social, or spiritual distress because they moting shared decision-making through concur- are pursuing disease-directed treatment.
rent palliative care has been shown to lower Studies have shown that individuals dealing costs and reduce rates of intensive care use and with a serious illness are at significant risk for hospitalizations. Gade conducted a multicenter Vol. 45 No. 3 March 2013 Five Things Physicians and Patients Should Question in HPM randomized trial of interdisciplinary hospital- diseases, defibrillator shocks rarely prevent death, based palliative care, enrolling 517 patients with may be painful, and are typically distressing to life-limiting illnesses. Individuals randomized to caregivers and family members. In addition, pa- palliative care reported higher quality of care tients who are at the end of life often experience and better quality of communication. They also electrolyte disturbances, hypoxemia, acidosis, experienced fewer intensive care unit admissions and organ failure, making these devices less effec- and a net cost savings of $4855 per patient, with no Barriers to timely deactivation have been difference in mortality.In an eight-hospital shown to include both patient and physician fac- study of 4908 palliative care patients and more tors. Patients may be unwilling to discuss deactiva- than 20,000 propensity score-matched controls, tion, yet remain fearful about potential shocks.
palliative care consultations were associated with Often, they believe that physicians should make $1696 direct cost savings per patient for patients the decision regarding deactivation,and re- discharged alive and $4908 direct cost savings search shows that patients may not even realize per patient for patients who died in the h that deactivation is an option.
In a controlled study of palliative care for New Although most physicians believe that deacti- York Medicaid patients, palliative care access vation should be discussed with patients, this resulted in similar or greater cost savings.
rarely occurs. Furthermore, physicians' lack of Finally, there is some evidence that concurrent comfort in discussions with patients has been palliative care may prolong life in select popula- shown to be a major barrier to deactivation.
tions. In a landmark study, Temel et al When discussions do occur, it is often in the randomized 151 outpatients with metastatic last days of a patient's lifeGiven these short- non-small cell lung cancer to either standard comings, advance care planning discussions care or concurrent palliative care. Patients who should include the option of deactivating the received concurrent palliative care showed sig- ICD when it no longer supports a patient's goals, nificant improvements in quality of life and and Do Not Attempt Resuscitation orders should mood. Despite lower use of aggressive end-of- be consistent with deactivation of these devices.
life care, individuals randomized to concurrent Still, fewer than 10% of U.S. hospices have palliative care showed a significant increase in ICD deactivation policies.In a national survey survival compared with standard care (median of hospice organizations, only 42% of hospice survival 11.6 vs. 8.9 months; P ¼ 0.02).
patients with ICDs had their devices deacti- An artificial boundary between disease- vated, and only 25% of hospices surveyed had directed treatment and palliative care is unwar- a magnet available for emergency deactivation; ranted based on the aforementioned findings.
of those that did, only 64% provided training When patients experience burdensome symp- in its useHospices that have a policy on toms, difficult treatment choices, or emotional ICDs are more likely to have patients with deac- distress related to serious illness, palliative care tivated devices compared with those without should be offered in combination with disease- a policy (73% vs. 38%, P < 0.001).In spite of modifying therapies. The resulting treatment their relatively sparse use, such policies could approach can promote physical and emotional be brought to scale in U.S. hospices, and a sam- support, improve shared decision-making, sup- ple policy is available to aid organizations in cre- port family members, and coordinate care ating ICD policies and procedures.Finally, it is across settings.
recommended that hospices develop relation-ships with local electrophysiologists or device 3. Don't leave an implantable cardioverter- manufacturers to assure that reprogramming defibrillator (ICD) activated when it is in- of a device can occur to reduce barriers to deac- consistent with the patient/family goals tivation for home-bound patients.
The ethical principles around ICD deactiva- As patients approach the end of life, the bene- tion are well established. Informed patients fits and burdens of ICDs need to be readdressed with decisional capacity, or their legally autho- in alignment with the patient and family goals of rized decision-makers, can choose to refuse any care. About a quarter of patients with ICDs expe- and all treatments, including life-sustaining rience a shock from their device within weeks of ones. Furthermore, there is no ethical distinc- death.For patients with advanced irreversible tion between withdrawing treatment (e.g., Fischberg et al.
Vol. 45 No. 3 March 2013 deactivating an ICD) and withholding treatment are frequently consulted to manage their pallia- (e.g., not placing an ICD in the first placeIn tion. Cancer patients referred to HPM specialists the face of a progressive disease, a patient may often have limited performance status, coexist- feel that the benefit of having an ICD prevent ing visceral metastases, and shortened life expec- a fatal arrhythmia is outweighed by the burden tancy. Such patients are likely to be burdened by of treatment. Not allowing deactivation forces short-term side effects, repeated trips to the radi- a patient to suffer potential unwanted continued ation center, and transfers on and off the radia- intervention and violates the ethical principles tion treatment table. Because limited prognosis of autonomy, beneficence, and nonmalefi- mitigates concern for a late recurrence of pain cence.The outcome of deactivation allows requiring retreatment, the primary goal of palli- for a patient's natural death from disease pro- ation is to restore quality of life as quickly as pos- gression. If for some reason a physician has a con- sible with the least burden to the patient and scientious objection to deactivating a device, the family. Therefore, for most patients considering physician has the obligation to transfer the pa- palliative radiation for painful uncomplicated tient to a physician who does no bone metastasis, SF (8 Gy) EBRT is the bestrecommendation.
4. Don't recommend more than a single frac- The survival of patients with bone metastasis tion (SF) of palliative radiation for an un- is associated with the origin of the primary can- complicated painful bone metastasis.
cer and presence of visceral metastases or Bone is the most common site of cancer me- skeletal-related events (SRE). Breast and pros- tastasis, and although bone metastasis is most tate cancer patients with metastasis only to prevalent in breast and prostate cancers (found bone have median life expectancies measured in w70% at autopsy), it also is common in mul- in years. However, the median survival for pa- tiple myeloma and cancers of thyroid, kidney, tients with lung cancer metastatic to bone is and bronchial origin. Because bone metastasis only 9.7 months.The development of SRE is the leading cause of cancer-related pain, (pathological fracture, cord compression, hy- HPM specialists are frequently consulted to percalcemia, or any condition requiring bone treat symptoms and address suffering associ- surgery or radiation) increases mortality. A ated with bone metastases.
study of breast cancer patients in the Danish This recommendation is based on the Cancer Registry reported a five-year survival evidence-based practice guideline published by rate of 75.8% for patients without bone metas- the American Society for Radiation Oncology tasis, 8.3% for those with bone metastasis, and (ASTRO) for palliation of bone metastases only 2.5% for those with SRE.Any patient The ASTRO guideline reports the findings of who receives radiation for painful bone metas- a systematic review of the literature concerning tasis (by definition an SRE) has a shortened the comparative effectiveness of SF vs. multiple- life expectancy, perhaps best expressed as fraction (MF) regimens of external beam radio- months to a year or two.
therapy (EBRT) for palliation of uncomplicated EBRT provides relief of associated pain in painful bone metastases (those not associated 50%e85% of patients with bone metastasis, de- with spinal cord compression or an unstable pending on what methods of pain assessment and definition of relief are applied. Up to Compared with an MF regimen, SF palliative a third of patients experience complete relief EBRT provides equivalent short-term symptom of pain at the treated site. SF treatment of relief, fewer side effects, and less inconve- 8 Gy to a previously unirradiated bone metasta- nience for patients. There is a higher incidence sis provides equivalent pain relief to various of symptom recurrence for SF compared with schedules of MF treatment (30 Gy in 10 frac- MF regimens (20% vs. 8%), but recurrences tions, 24 Gy in six fractions, or 20 Gy in five usually can be irradiated a second time. These fractions). There is no significant difference findings are the same for both peripheral bone between SF and MF regimens in the risk of de- and vertebral metastases.
veloping subsequent cord compression or As previously noted, bone metastases are pathological fracture. The only therapeutic a common source of pain and morbidity in pa- difference between SF and MF treatments tients with advanced cancer, and HPM specialists is the incidence of recurrent pain requiring Vol. 45 No. 3 March 2013 Five Things Physicians and Patients Should Question in HPM retreatment at the site (20% for SF compared centersand many patients cannot swallow with 8% for MFRadiation oncologists may drugs. Topical drugs can be safe and effective, be more willing to retreat a site of recurrent such as topical nonsteroidal anti-inflammatory pain if the previous treatment was SF rather drugs for local arthritis symptoms.Topical antinausea gels commonly are prescribed Acute radiation reactions are generally worse in hospice practice, with one large hospice and more prolonged with MF than with SF treat- pharmacy reporting two-thirds of patients get- ment. The incidence of a temporary postradia- ting a prescription for an antinausea gel.
tion flare in pain may be higher with SF but can However, antinausea gels have not been pro- be managed with anti-inflammatory drugs.
ven effective in any well-designed or placebo- MF is more expensive than SF treatment.
controlled trials, and the available evidence is Given the equivalent short-term efficacy, SF is from small patient seri a more cost-effective option for most patients.
The active ingredients in one commonly pre- Several authors have noted significant interna- scribed antinausea gel, ABH, are not absorbed tional variation in the use of SF treatment to to systemic levels that could be effective by any palliate bone metastasis.Specifically, physi- known mechanism. Smith et had 10 cians in the U.S. use MF for painful bone me- healthy volunteers apply the standard 1.0 mL tastasis more often than their counterparts in dose (2 mg of lorazepam, 25 mg of diphenhy- other countries, despite the evidence of thera- dramine, and 2 mg of haloperidol in a pluronic peutic equivalence. The creators of the AS- lecithin organogel), rubbed on the volar sur- TRO guideline expressed a hope that it face of the wrists as is done in practice. Blood would drive a change in the patterns of care.
samples were obtained at 0, 30, 60, 90, 120, Even if the costs of SF and MF regimens were 180, and 240 minutes. No lorazepam (A) or hal- equal, however, the decreased patient burden operidol (H) was detected in any sample from alone would be sufficient reason to recom- any of the 10 patients, down to a level of mend SF treatment for most patients seen in 0.05 ng/mL. Most volunteers had undetectable the HPM setting.
levels of diphenhydramine at most time points, Physicians should tailor their recommenda- with a maximum concentration observed in tions to the individual patient's condition, a single volunteer of 0.30 ng/mL at 240 min- prognosis, and goals of care. MF treatment utes. The therapeutic level of diphenhydramine may be a reasonable option for a patient likely has been estimated at 25e112 ng/There- to live more than a few months who would fore, none of the lorazepam (A), haloperidol have difficulty accessing retreatment if pain (H), or diphenhydramine (B) in ABH gel is ab- were to recur. Some patients with favorable tu- sorbed in sufficient quantities to be effective in mor type, excellent performance status, and the treatment of nausea and vomiting.
aggressive care goals may prefer MF treatment.
This is an important issue for quality of care, Patients with complications such as cord com- safety, and cost. The advantage of ABH and pression or instability in weight-bearing bones other gels is the easy patient-controlled appli- require a multidisciplinary approach including cation and the low cost. But the use of agents orthopedic surgery, neurosurgery, radiation given via ineffective routes may delay or pre- oncology, and palliative medicine working in vent the use of more effective interventions, concert. In addition to EBRT, practitioners causing suffering and even more expense by should consider other treatment modalities precipitating hospital admission. Therefore, for painful bone metastasis, including anti- the use of ABH and similar gels is not recom- inflammatory drugs, other analgesic drugs, mended until there is evidence of their bisphosphonates, radiopharmaceuticals, and 5. Don't use topical lorazepam (AtivanÒ), di- phenhydramine (BenadrylÒ), and halo- Over the past 10 years, the field of palliative peridol (HaldolÒ) (ABH) gel for nausea.
care has grown and evolved with a remarkable, Nausea and vomiting account for 18% of unprecedented rapidity. Palliative care now palliative care consultations at some cancer can claim recognized medical and nursing Fischberg et al.
Vol. 45 No. 3 March 2013 subspecialties with defined domains of knowl- concerns that come with seriously ill patient edge and skills and an expanding evidence populations create challenges that can be sub- base. Perhaps equally important, palliative stantialAlso, unlike many fields, there is not care is gaining widespread recognition as a spe- yet a clear consensus about all the outcomes cialty that helps patients, families, and provi- that should define ‘‘effectiveness'' in palliative ders to achieve an improved quality of life.
care. However, none of these challenges is insur- Much of this growth is attributable to the mountable.In fact, there is a growing body of way that palliative care promotes open and evidence that evaluates palliative care interven- honest communication with patients and their tions using both prospective randomized con- families about treatment goals.Indeed, trolled trialsand retrospective propensity a chief contribution of palliative care to the na- tional dialogue about end-of-life care has been More such studies are needed in two areas.
the recognition that such communication can First, a productive line of research would rigor- help patients to avoid treatment that they do ously evaluate novel treatments. The ability to not wantMore generally, this focus on com- generate new treatments and advance the sci- munication, decision-making, and patient- ence of comfort is perhaps the most visible ev- centered outcomes has raised questions about idence of palliative care's success as a field.
the risks and potential benefits of interven- However, a second parallel effort also is tions that are used routinely.
needed. Just as it is essential to develop and This article highlights two such interven- test novel interventions, it will be equally im- tionsdfeeding tubes for those with advanced portant to critically examine the risks and po- dementia and ICDs near the end of lifedthe tential benefits of the existing palliative benefits of which are highly questionable.
treatments that are widely used but unproven.
The discussion above argues convincingly Research along both these pathways will help that their use should be the focus of much to ensure that the palliative care evidence more careful decision-making by patients and base continues to grow and that the actual health care providers. More broadly, this arti- practice of palliative care is consistent with cle suggests opportunities for palliative care the evidence that exists.
providers to find ways to shape practices thatare more consistent with the existing evidence.
But palliative medicine is not immune to Disclosures and Acknowledgments questions about its own practice. For instance, This article was written and reviewed by the the use of MF radiation therapy and ABH gel authors on behalf of AAHPM's Choosing in palliative care settings offers a valuable cau- Wisely Task Force. The task force and develop- tionary lesson. Just as providers in other fields ment of this article were provided institutional may reach for unproven treatments in the support by AAHPM. The authors and the task hope of prolonging life, palliative care pro- force members declare no relevant conflicts of viders also may rely on unproven interventions interest related to this project.
out of a desire to enhance the quality of life.
The authors would like to express their grat- This lesson highlights the fact that as the itude to AAHPM staff members Jacqueline Ko- field of palliative care continues to develop, cinski, MPP, and Patrick Hermes, MS, and all there is an urgent need to ensure its evidence members of the AAHPM Choosing Wisely base keeps pace with those of other fields. In Task Force, whose hard work, careful consider- particular, palliative care will need to carefully ation, and expert contributions made this arti- examine its own treatments, making a substan- cle possible.
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