Palliative Care Myth Busters

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Author: Michelle Mitchell, MS-IV
Geisinger Commonwealth School of Medicine

Palliative care concepts have increasingly become integrated into care in the emergency department (ED). As the health of patients with advanced and end-stage disease continues to decline, they often present to the ED for symptom management and pain relief. Therefore, emergency medicine physicians should be knowledgeable about basic palliative care treatments, as well as some common myths surrounding palliative care.

Myth: Palliative care is hospice care.
According to the World Health Organization, palliative care “is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.” [1] Palliative care is therefore directed primarily at symptom management, and is not limited to patients who are approaching end-of-life. In fact, the American Society of Clinical Oncology (ASCO) now recommends obtaining palliative care consults early in the disease process, concurrent with curative care.[2] There have also been studies that have demonstrated that palliative care increases survival and quality of life when implemented early in patients with metastatic cancer.[3]

A subset of palliative care is hospice care, which is care directed at patients who have a life expectancy of six months or less. Hospice care also means that the patient has chosen to forgo curative care, and instead focus on symptoms relief and management. If a patient lives longer than 6 months, he or she can renew hospice care, initially for two 90-day periods followed by an unlimited number of 60-day periods.

As a generalization, all hospice care is palliative care, but not all palliative care is hospice care.

Myth: Do Not Resuscitate (DNR)/Do Not Intubate (DNI) code status means the patient does not want treatment
It may be easy to equate DNR/DNI to not providing any care to the patient. However, this thought process is far from the case. There is always care you can provide a patient, no matter his or her code status. All other clinically indicated care, besides chest compressions and intubation, can be performed. For example, if a patient presents to the ED septic secondary to pneumonia, intravenous fluids and antibiotics can be administered. Additionally, the physician should also address related dyspnea, which could include applying a nasal cannula, or providing morphine for the treatment of air hunger. In certain circumstances, a patient may arrive to the ED with a living will that has more specific information, such as limiting antibiotics or trialing certain treatments for a short period of time. It is important to read and follow the patient’s living will in its entirety before initiating care.

Myth: Tube feedings will prolong a patient’s life with advanced illness and prevent aspiration pneumonia.
Enteral tube feedings have proven to be appropriate for patients who need nutrition for short, defined periods of time following a reversible process, such as an esophageal injury. However, the evidence for tube feedings in patients with advanced illnesses is not as clear. For patients with advanced dementia, there has been no evidence that gastronomy tubes prolongs life or decrease suffering.[4] Additionally, it has been demonstrated in multiple observational studies that gastronomy tubes do not reduce the risk of aspiration pneumonia in patients with dementia.[5] Common causes of aspiration pneumonia include the reflex of gastric contents and the aspiration of a patient’s own oral secretions; neither of which is prevented by the placement of a feeding tube. While gastronomy tubes save lives, they are not appropriate for every patient.

References:

1. WHO definition of palliative care. World Health Organization website. http://www.who.int/cancer/palliative/definition/en/. Accessed January 30, 2017.

2. Ferrell BR, Temel JS, Tenin J. Integration of palliative care. J Clin Oncol 2016.

3. Temel JS, Greer JA, Muzikansky A, et al. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. N Eng J Med. 2010;363(8):733-742.

4. Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. The Cochrane database of systematic reviews. Apr 15 2009(2):Cd007209.

5. Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet 1996;348:1421-1424. Lancet, 1997;349:364.