Palliative Care

General Principles

1. Definition
• palliative care is the treatment of suffering and the promotion of quality of life for seriously or terminally ill patients
• no specific therapy, including surgery, is excluded from the treatment plan
• expected outcome is relief of distressing symptoms, lessening of pain, and improvement in quality of life
• hospice care is a specific form of palliative care intended for patients with a life expectancy of six months or less


1. Role of the Surgeon in Palliative Care
• surgeons take care of many critically ill and terminally ill patients, and many patients and families want their surgeon to continue taking care of them, even if cure is not possible
• nonabandonment is a core surgical principle
• surgeons are fully capable of communicating with patients about goals of care, prognosis, and code status
• surgeons can also manage chronic pain and common nonpain syndromes such as dyspnea, nausea, vomiting, anorexia, delirium, and anxiety
• hospice and palliative care is a subspeciality of the American Board of Surgery


2. Indications
• patients with conditions that are progressive and life-limiting
• patients or surrogates who decline further invasive treatments with a stated preference for comfort measures only


3. Communication of Prognosis
• changing the goal of care from cure to palliation is both emotionally and clinically challenging
• physicians have a responsibility to provide a clear prognosis regarding incurable disease
• functional status is the most powerful predictor of survival
• Karnofsky Performance Scale is commonly used in palliative care to assess patient needs as well as prognosis
• Palliative Performance Scale is a validated expansion of the Karnofsky Performance Scale







4. Symptom Management
• the most common symptoms that affect the comfort of dying patients are respiratory distress, pain, and cognitive failure
• additional distressing symptoms include progressive debility, fatigue, weight loss, dry mouth, difficulty in clearing secretions
• symptom management is complicated by several factors: older age, malnutrition, decreased renal function, impaired cognition


1. Pain Management
• moderate to severe pain will require opioids
• nonopioids are also valuable in certain situations (Gabapentin for nerve pain)
• oral route is preferred if possible
• transdermal patches are very effective
• scheduled dosing, not PRN
• in general, opioids should not be stopped for increasing somnolence or decreased respirations since these symptoms are common in dying patients, independent of medications
• opioids should not be stopped abruptly because withdrawal symptoms may be triggered


2. Dyspnea
• particularly common in patients with lung cancer, lung metastases, or pleural effusions
• defined as air hunger
• patient’s symptoms often don’t correlate with objective measures of respiratory rate, oxygen saturation, or arterial blood gas analysis
• best treated with opioids
• supplemental humified O₂ by nasal cannula may also bring subjective relief
• upper airway secretions may be managed with anticholinergic agents


3. Delirium
• manifested by increasing somnolence along with periods of disorientation and confusion
• for many patients, delirium is the final complication that precedes death
• increasing agitation, delusions, or hallucinations may require neuroleptic medications (Haldol)


4. Fatigue
• multidimensional symptom, often with multiple contributing causes: anemia, mood disorders (anxiety, depression), anorexia/cachexia, deconditioning, medical comorbidities, insomnia, drug-drug interactions
• management includes treatment of any reversible causes: anemia → RBC transfusions or erythropoietin; deconditioning → exercise; depression → antidepressants; hypogonadism → testosterone replacement therapy
• prednisone or dexamethasone is helpful in some patients


5. Nausea and Vomiting
• often multifactorial
• common causes include mechanical small bowel or colon obstruction, ascites, constipation, gastroparesis, hypercalcemia, increased intracranial pressure
• colonic stents may palliate inoperable colon obstructions
• prokinetic agents such as metoclopramide may be helpful if a reversible cause is not found


6. Dysphagia
• common in patients with head and neck cancer or esophageal cancer
• patients are at risk for aspiration
• initial management involves modification of food consistency
• endoscopic methods of palliation may be considered: stricture dilation, stent placement, laser ablation of tumor


7. Cachexia
• hypercatabolic state associated with accelerated loss of skeletal muscle
• common in cancer patients and patients with chronic inflammatory conditions
• the profound weight loss in patients with cachexia cannot be entirely explained by poor caloric intake


8. Anorexia
• loss of appetite, altered taste, and loss of interest in food are common in patients with advanced diseases
• switching to small, frequent feedings rather than several large meals may increase caloric intake
• appetite stimulants such as steroids, Megestrol acetate (Megace) and cannabinoids may be beneficial


9. Dry Mouth
• can alter taste and make it difficult to eat and swallow
• many different drugs are implicated: anticholinergics, antidepressants, opioids, beta-blockers, antihistamines
• sucking on ice chips or chewing sugarless gum to increase salivation may help
• artificial saliva may also be helpful


10. Depression
• widely misdiagnosed and undertreated
• distinguishing sadness and grief from clinical depression is challenging
• the first step in treating depression is to relieve uncontrolled symptoms, especially pain
• supportive psychotherapy and antidepressant medications should be initiated early


11. The Role of Artificial Nutrition and Hydration
• family members often experience high levels of stress when a terminally ill patient becomes unable to take food and fluids orally, fearing that dehydration and malnutrition will increase suffering and hasten death
• however, there is no evidence that artificial nutrition prolongs life or improves functional status in terminally ill patients
• hydration may palliate some symptoms (delirium, dry mouth)
• the decision to use IV hydration or not should be made jointly with the patient, family, and health care professionals