Guidelines To Improve Care Of Three Symptoms At End Of Life

The guidelines say that clinicians should regularly assess people with serious illness at the end of life for symptoms of pain, shortness of breath, and depression; that they should use proven therapies to treat these conditions; and should ensure that advance care planning occurs for all patients with serious illness.

"Many Americans will face a serious illness at the end of life and their families will be involved in their care," said Amir Qaseem, MD, PhD, MHA, Senior Medical Associate in the Clinical Programs and Quality of Care Department of the Medical Education and Publishing Division at ACP. "We wanted to pull together best available evidence on improving care that relieves or soothes symptoms at the end of life. Evidence review showed that the three most common symptoms were pain, difficult breathing and depression, so our guidelines address these."

Elaborating on the recommendations to use therapies of proven effectiveness to manage pain, shortness of breath, and depression, the guidelines say that clinicians should regularly assess patients with serious illness at the end of life.

• For patients with cancer, pain has been proven to be controlled with anti-inflammatory drugs, narcotic drugs and bisphosphonates.
• In patients at the end of life with difficult breathing, unrelieved dyspnea can be relieved by narcotic drugs and oxygen for short-term relief of hypoxemia.
• Patients with depression can be treated with antidepressants and psychosocial intervention.

ACP, through its Clinical Efficacy Assessment Subcommittee, has been developing guidelines since 1981. ACP guidelines have relied on evidence or clinical documentation rather than consensus or expert opinion.

In the case of the EOL guidelines, the reviewing committee found that high-quality evidence on end-of-life care is limited, and most of the evidence comes from literature on patients with cancer. Therefore the new evidence-based guidelines could not address many other important aspects of EOL care, such as symptoms specific to heart disease, lung disease, or dementia, or therapies such as nutritional support, complementary and alternative therapies, and spiritual care.

The EOL guidelines were passed by the ACP Board of Regents on July 14, 2007.

"End of life care has been identified by the Institute of Medicine as one of the priority areas to improve quality of health care. We hope that these guidelines would benefit physicians taking care of patients with seriously disabling or symptomatic chronic conditions."

The guidelines grade the evidence recommendations using the American College of Physicians' clinical practice guidelines grading system. All of the ACP recommendations on EOL care are considered strong recommendations, meaning that benefits clearly outweigh the risks. All of the EOL recommendations are considered to have moderate quality of evidence because most of the published literature is on patients with cancer.

Recommendation 1: In patients with serious illness at the end of life, clinicians should regularly assess patients for pain, dyspnea, and depression. (Grade: strong recommendation, moderate quality of evidence.)

Recommendation 2: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage pain. For patients with cancer, this includes nonsteroidal antiinflammatory drugs, opioids, and bisphosphonates. (Grade: strong recommendation, moderate quality of evidence.)

Recommendation 3: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage dyspnea, which include opioids in patients with unrelieved dyspnea and oxygen for short-term relief of hypoxemia. (Grade: strong recommendation, moderate quality of evidence.)

Recommendation 4: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage depression. For patients with cancer, this includes tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial intervention. (Grade: strong recommendation, moderate quality of evidence.)

Recommendation 5: Clinicians should ensure that advance care planning, including completion of advance directives, occurs for all patients with serious illness. (Grade: strong recommendation, low quality of evidence.)

Journal reference: Ann Intern Med. 2008;148:141-146.