Palliative care

Five Things Physicians and Patients Should Question


Released October 29, 2014

1

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.

Palliative care provides an added layer of support to patients with life-limiting disease and their families. Symptomatic patients can benefit regardless of their diagnosis, prognosis or disease treatment regimen. Studies show that integrating palliative care with disease-modifying therapies improves pain and symptom control, as well as patient quality of life and family satisfaction. Early access to palliative care has been shown to reduce aggressive therapies at the end of life, prolong life in certain patient populations, and significantly reduce hospital costs.

2

Don’t delay advance care planning conversations.

Advance care planning is a process, which includes choosing a surrogate or alternate decision-maker and communicating values or wishes for medical care. This helps prepare a person for in-the-moment medical decision-making, as well as guiding their surrogate or alternate decision-maker should the person lose capacity for decision-making. Advance care planning is appropriate for healthy adults and patients with their family and healthcare providers, early, recurrently, and as circumstances change. Evidence shows that advance care planning conversations improve patient and family satisfaction with care and concordance between patients’ and families’ wishes, increase the completion of advance care planning documents, reduce the likelihood of patients receiving hospital care and the number of days spent in hospital, and increase the likelihood of receiving hospice care.

3

Don’t use oxygen therapy to treat non-hypoxic dyspnea.

Oxygen is frequently used to relieve shortness of breath in patients with advanced illness; however, supplemental oxygen does not benefit patients who are breathless but not hypoxic. Supplemental flow of air has been found equally effective to oxygen in this context.

4

Don’t use stool softeners alone to prevent opioid induced constipation.

Docusate is a widely used stool softener. A review of the evidence found that docusate is no more effective than placebo in the prevention or management of constipation and suggests that the drug has very little utility when given alone for opioid-induced constipation. Compared with placebo, docusate did not increase stool frequency or soften the stool. Docusate also failed to alleviate the common symptoms of opioid-induced constipation such as difficulty passing stools, hard stools, abdominal cramping, and incomplete stool passage.

5

Don’t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, or if no benefit was perceived from previous transfusions.

Indications for blood transfusion depend on clinical assessment and are also guided by the etiology of the anemia. No single laboratory measurement or physiologic parameter can predict the need for blood transfusion. Transfusions are associated with increased morbidity and mortality in high-risk hospitalized inpatients. Adverse events range from mild to severe, including allergic reactions, acute hemolytic reactions, anaphylaxis, transfusion related acute lung injury, transfusion associated circulatory overload, and sepsis.


How the list was created

The Canadian Society of Palliative Care Physicians (CSPCP) established its Choosing Wisely Canada Top 5 recommendations by first establishing a small group of its members to compile a short list of 10 suggestions. Recommendations were based on experience and relevance to palliative care practice in Canada. The short list was circulated to the CSPCP board members and to all relevant national and provincial palliative care bodies representing a broad range of geographical regions, practice settings, institution types and experience for feedback. Following this review, members of the CSPCP were asked to participate in an online survey and rank the 10 suggestions in order of importance and relevance. The online survey was launched at the Annual International CSPCP conference. From the feedback of the survey the top 5 suggestions were chosen and refined. The recommendations were discussed and revised with the Choosing Wisely Canada campaign team to ensure the recommendations were in keeping with the overall campaign objectives. A literature search to support the recommendations was completed with the assistance of the independent Canadian Agency for Drugs and Technologies in Health (CADTH) and Health Quality Ontario (HQO). Item 1 was adapted with permission from the Five Things Physicians and Patients Should Question in Hospice and Palliative Medicine. © 2013 American Academy of Hospice and Palliative Medicine. Item 5 was adopted with permission from the Five Things Physicians and Patients Should Question. © 2014 Canadian Society of Internal Medicine.


Sources

1

Bakitas M, Lyons KD, Hegel MT, et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: the Project ENABLE II randomized controlled trial. JAMA. Aug 19 2009;302(7):741-749.

Brumley R, Enguidanos S, Jamison P, et al. Increased satisfaction with care and lower costs: results of a randomized trial of in-home palliative care. J. Am. Geriatr. Soc. Jul 2007;55(7):993-1000.

Ciemins EL, Blum L, Nunley M, Lasher A, Newman JM. The economic and clinical impact of an inpatient palliative care consultation service: a multifaceted approach. J. Palliat. Med. Dec 2007;10(6):1347-1355.

Delgado-Guay MO, Parsons HA, Li Z, Palmer LJ, Bruera E. Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team. Cancer. Jan 15 2009;115(2):437-445.

Earle CC, Landrum MB, Souza JM, Neville BA, Weeks JC, Ayanian JZ. Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? J. Clin. Oncol. Aug 10 2008;26(23):3860-3866.

Fowler R, Hammer M. End-of-life care in Canada. Clin. Invest. Med. 2013;36(3):E127-132.

Gade G, Venohr I, Conner D, et al. Impact of an inpatient palliative care team: a randomized control trial. J. Palliat. Med. Mar 2008;11(2):180-190.

Greer JA, Pirl WF, Jackson VA, et al. Effect of early palliative care on chemotherapy use and end-of-life care in patients with metastatic non-small-cell lung cancer. J. Clin. Oncol. Feb 1 2012;30(4):394-400.

Morrison RS, Penrod JD, Cassel JB, et al. Cost savings associated with US hospital palliative care consultation programs. Arch. Intern. Med. Sep 8 2008;168(16):1783-1790.

Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann. Intern. Med. Jan 15 2008;148(2):141-146.

Temel JS, Greer JA, Admane S, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small-cell lung cancer: results of a randomized study of early palliative care. J. Clin. Oncol. Jun 10 2011;29(17):2319-2326.

Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N. Engl. J. Med. Aug 19 2010;363(8):733-742.

2

Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised controlled trial. BMJ. 2010;340:c1345.

Houben CH, Spruit MA, Groenen MT, Wouters EF, Janssen DJ. Efficacy of advance care planning: a systematic review and meta-analysis. J. Am. Med. Dir. Assoc. Jul 2014;15(7):477-489.

Newton J, Clark R, Ahlquist P. Evaluation of the introduction of an advanced care plan into multiple palliative care settings. Int. J. Palliat. Nurs. Nov 2009;15(11):554-561.

Poppe M, Burleigh S, Banerjee S. Qualitative evaluation of advanced care planning in early dementia (ACP-ED). PLoS One. 2013;8(4):e60412.

3

Chronic obstructive pulmonary disease (COPD) evidentiary framework. Ont Health Technol Assess Ser. 2012;12(2):1-97.

Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet. Sep 4 2010;376(9743):784-793.

Booth S, Kelly MJ, Cox NP, Adams L, Guz A. Does oxygen help dyspnea in patients with cancer? Am. J. Respir. Crit. Care Med. May 1996;153(5):1515-1518.

Bruera E, Sweeney C, Willey J, et al. A randomized controlled trial of supplemental oxygen versus air in cancer patients with dyspnea. Palliat. Med. Dec 2003;17(8):659-663.

Philip J, Gold M, Milner A, Di Iulio J, Miller B, Spruyt O. A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. J. Pain Symptom Manage. Dec 2006;32(6):541-550.

Uronis HE, Currow DC, McCrory DC, Samsa GP, Abernethy AP. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br. J. Cancer. Jan 29 2008;98(2):294-299.

4

Ahmedzai SH, Boland J. Constipation in people prescribed opioids [Internet]. Clin Evid. 2010 [cited 2014 Jun 2]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907601/pdf/2010-2407.pdf.

Fosnes GS, Lydersen S, Farup PG. Effectiveness of laxatives in elderly–a cross sectional study in nursing homes. BMC Geriatr. 2011;11:76.

Hawley PH, Byeon JJ. A comparison of sennosides-based bowel protocols with and without docusate in hospitalized patients with cancer. J. Palliat. Med. May 2008;11(4):575-581.

Ruston T, Hunter K, Cummings G, Lazarescu A. Efficacy and side-effect profiles of lactulose, docusate sodium, and sennosides compared to PEG in opioid-induced constipation: a systematic review. Can. Oncol. Nurs. J. Autumn 2013;23(4):236-246.

Tarumi Y, Wilson MP, Szafran O, Spooner GR. Randomized, double-blind, placebo-controlled trial of oral docusate in the management of constipation in hospice patients. J. Pain Symptom Manage. Jan 2013;45(1):2-13.

5

Bracey AW, Radovancevic R, Riggs SA, et al. Lowering the hemoglobin threshold for transfusion in coronary artery bypass procedures: effect on patient outcome. Transfusion (Paris). Oct 1999;39(10):1070-1077.

Carson JL, Carless PA, Hebert PC. Transfusion thresholds and other strategies for guiding allogeneic red blood cell transfusion. Cochrane Database Syst Rev. 2012;4:Cd002042.

Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N. Engl. J. Med. Feb 11 1999;340(6):409-417.

Marik PE, Corwin HL. Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit. Care Med. Sep 2008;36(9):2667-2674.

Papaioannou A, Morin S, Cheung AM, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. Nov 23 2010;182(17):1864-1873.

Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N. Engl. J. Med. Jan 3 2013;368(1):11-21.

Susantitaphong P, Altamimi S, Ashkar M, et al. GFR at initiation of dialysis and mortality in CKD: a meta-analysis. Am. J. Kidney Dis. Jun 2012;59(6):829-840.