Treatment of Seriously Ill Patients Who Are Near the End of Life: Recommendations from the American College of Physicians

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The summary below is from the full reports titled "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" and "Evidence for Improving Palliative Care at the End of Life: A Systematic Review." They are in the 15 January 2008 issue of Annals of Internal Medicine(volume 148, pages 141-146 and pages 147-159). The authors of the first report are A. Qaseem, V. Snow, P. Shekelle, D.E. Casey Jr., J.T. Cross Jr., and D.K. Owens for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians; the authors of the second report are K.A. Lorenz, J. Lynn, S.M. Dy, L.R. Shugarman, A. Wilkinson, R.A. Mularski, S.C. Morton, R.G. Hughes, L.K. Hilton, M. Maglione, S.L. Rhodes, C. Rolon, V.C. Sun, and P.G. Shekelle.

Who developed these guidelines?

The American College of Physicians (ACP) developed these recommendations. Members of the ACP are internists, who are specialists in the care of adults.

What is the problem and what is known about it so far?

When patients are near the end of life, the goals of medical care often move from attempting to cure disease to making the patient comfortable. This type of care is known as palliative care. Palliative care involves meeting the physical, psychological, social, and practical needs of seriously ill patients. Although palliative care is important, high-quality studies about ways to improve the end-of-life experience are lacking.

How did the ACP develop these recommendations?

The authors reviewed published information about palliative end-of-life care to try to identify ways that doctors can improve care for seriously ill patients who are dying.

What did the authors find?

High-quality information about palliative and end-of-life care is limited. In addition, much of what has been studied has focused on cancer. Studies in patients with cancer may not always apply to patients who are near the end of life because of other types of illness, such as heart disease, lung disease, or dementia. The authors also found that it is difficult to predict the best timing for palliative care, so doctors and patients need to make decisions about the timing of how to incorporate these approaches in their medical treatment on a case-by-case basis. Studies support the use of anti-inflammatory drugs, narcotics, and bisphosphonate drugs for pain due to cancer. Some of these treatments work only in specific patients. For example, radiation treatment is especially helpful when cancer causes bone pain. Studies also show that narcotics and oxygen can lessen the discomfort of the shortness of breath experienced by many patients with advanced lung disease. Antidepressant drugs and psychological treatments improve symptoms of depression in patients with cancer. Although strong studies are not available, some recent studies show how advance care planning can be helpful in improving the end-of-life experience for seriously ill patients.

What does the ACP suggest that patients and doctors do?

Doctors should regularly check patients dying of a serious illness for pain, shortness of breath, and depression.

Doctors should prescribe pain treatments for patients who are near the end of life and have pain, including anti-inflammatory drugs, narcotic drugs, and bisphosphonates for patients with cancer.

Doctors should prescribe treatments, such as narcotic drugs and oxygen, for patients with advanced lung disease and those near the end of life who are having shortness of breath.

Doctors should prescribe depression treatments for patients who are near the end of life, including antidepressant drugs and psychological treatments, for patients with cancer.

All patients with serious illness should talk with their families, friends, and physicians about their goals and values and how to consider those in the medical situations they may face.

What are the cautions related to these recommendations?

It is difficult to predict how long a seriously ill patient will live. Exactly when to consider some of these treatments and how to balance these approaches with other treatments a person may be receiving is uncertain. Recommendations may change as new studies become available.