Palliative Care Guidelines

Introduction

• The goal of palliative care is to improve the quality of life for patients with advanced illness, with a focus on comfort and symptom management rather than invasive life-sustaining interventions, as recommended by the American Academy of Hospice and Palliative Medicine 1, 2

Symptom Management

• The American Thoracic Society recommends systematically assessing and documenting symptoms, particularly dyspnea, using validated scales 3, 4
• Opioids are the cornerstone of pain management for moderate to severe pain, according to the American College of Physicians and the European Society for Medical Oncology, with the World Health Organization (WHO) analgesic ladder providing a systematic approach to pain management 5, 6, 7

• The WHO analgesic ladder consists of three steps:

  Step	Pain Level	Treatment
  1	Mild (1-3/10)	Acetaminophen and/or NSAIDs
  2	Moderate (4-6/10)	Weak opioids plus acetaminophen/NSAIDs
  3	Severe (7-10/10)	Strong opioids plus acetaminophen/NSAIDs

• Regular around-the-clock dosing with breakthrough dosing is recommended for opioid administration, with careful monitoring of patient response and adjustment of medication as needed, according to the World Health Organization and the European Society for Medical Oncology 7, 8
• Opioids are first-line treatment for unrelieved dyspnea, according to the American College of Physicians, the European Society for Medical Oncology, and the American Thoracic Society 5, 6, 8, 9
• Oxygen therapy should be provided for patients with hypoxemia, as recommended by the American College of Physicians and the American Thoracic Society, and can also be used for subjective relief 5, 8, 1
• Non-pharmacologic interventions, such as positioning and relaxation techniques, can also be effective, as recommended by the American Thoracic Society and other guideline societies 9
• Benzodiazepines, such as lorazepam and midazolam, are recommended for dyspnea with an anxiety component, according to the European Society for Medical Oncology 6, 9
• Mouth care is essential, and patients should be examined for dryness and cracking, with frequent mouth care provided using water-soaked gauzes, water sprays, and ice chips when permissible, as recommended by the World Health Organization 1
• Consider artificial saliva and involve family members in providing simple mouth care, as recommended by the World Health Organization 1
• Consider appetite stimulants, such as megestrol acetate 400-800 mg/d, olanzapine 5 mg/d, dexamethasone 2-8 mg/d, or cannabinoids, if aligned with goals of care, as recommended by the American College of Physicians and the European Society for Medical Oncology 9

Advance Care Planning

• The European Respiratory Society recommends routinely reviewing advance care planning documents during each visit, including identifying or confirming substitute decision-makers and documenting patient preferences regarding life-sustaining treatments 10, 11
• The American Heart Association suggests discussing goals of care in the context of current disease status and documenting discussions in the patient's chart 11
• Ensure advance care planning occurs for all patients with serious illness, as recommended by the American College of Physicians, and discuss goals of care early and reassess when significant clinical changes occur 5

Caregiver Support

• The American College of Physicians recommends screening caregivers for practical and emotional needs and assessing caregiver burden to provide appropriate support 5
• The American Thoracic Society suggests considering respite care options if needed to support caregivers 3
• Family presence with the patient should be encouraged, as recommended by the American Academy of Hospice and Palliative Medicine, with strong evidence supporting its benefits, and family should be reassured that medications for symptom relief are unlikely to shorten life 8
• Regular updates about the patient's condition and expected changes should be provided, as per the American Medical Association guidelines, with moderate evidence supporting these recommendations, and guidance on how family can provide comfort, such as touch and mouth care, should be offered 8

Psychosocial and Spiritual Support

• The American Stroke Association recommends addressing psychological, social, cultural, and spiritual/religious concerns and providing counseling for both patients and families 12
• The American Thoracic Society warns against focusing only on physical symptoms and neglecting psychological, social, and spiritual needs 3, 12

Continuity of Care

• The American College of Physicians recommends ensuring continuity between primary care, specialists, and palliative care teams and coordinating with multidisciplinary team members as needed, including nurses, social workers, and rehabilitation specialists 5, 12

Common Pitfalls

• The American College of Physicians cautions against delaying advance care planning and recommends that these discussions occur early and be revisited regularly 10, 11
• Inappropriate medication continuation should be avoided, as recommended by the National Comprehensive Cancer Network, with a high strength of evidence, and medications such as diabetes medications, allopurinol, tamsulosin, and potassium chloride should be discontinued unless necessary 9
• All vitamins and supplements should be discontinued, as per the Academy of Nutrition and Dietetics guidelines, with a high strength of evidence, and medications such as omeprazole and famotidine should be discontinued unless active GI symptoms are present 9