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

15 January 2008 | Volume 148 Issue 2 | Pages 141-146

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 anti-inflammatory 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.)

Author and Article Information

From the American College of Physicians, Philadelphia, Pennsylvania; Veterans Affairs Greater Los Angeles Healthcare System and RAND, Santa Monica, California; Atlantic Health, Morristown, New Jersey; Medstudy, Colorado Springs, Colorado; and Veterans Affairs Palo Alto Health Care System and Stanford University, Stanford, California.

Note: Clinical practice guidelines are guides only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment. All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

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Disclaimer: The authors of this article are responsible for its contents, including any clinical or treatment recommendations. No statement in this article should be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Grant Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.

Potential Financial Conflicts of Interest: Grants received: V. Snow (Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Novo Nordisk, Pfizer, Merck & Co., Bristol-Myers Squibb, Atlantic Philanthropies, sanofi pasteur).

Requests for Single Reprints: Amir Qaseem, MD, PhD, MHA, American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, aqaseem{at}acponline.org.

Current Author Addresses: Drs. Qaseem and Snow: American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.

Dr. Shekelle: 1776 Main Street, Santa Monica, CA 90401.

Dr. Casey: 475 South Street, PO Box 1905, Morristown, NJ 07962.

Dr. Cross: 1761 South 8th Street, Suite H, Colorado Springs, CO 80906.

Dr. Owens: 117 Encina Commons, Stanford, CA 94305.

*This paper, written by Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Paul Shekelle, MD, PhD; Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; and Douglas K. Owens, MD, MS, was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP): Douglas K. Owens, MD, MS (Chair); Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Paul Dallas, MD; Nancy C. Dolan, MD; Mary Ann Forciea, MD; Lakshmi Halasyamani, MD; Robert H. Hopkins Jr., MD; and Paul Shekelle, MD, PhD. Approved by the ACP Board of Regents on 14 July 2007.