Key Points
- ATSpalliative care guidelines support quality of life at any stage of illness.
- General recommendations for symptom management include treatment of dyspnea, pain, and other physical complications.
- For dying patients, pain assessment should be considered another "vital sign."
- Guidelines include opioid dosing recommendations.
- Treatment of neuropathic pain may require other agents, as will anxiety and depression.
In an effort to enhance incorporation of palliative care into routine clinical management, the American Thoracic Society (ATS)
End-of-Life Care Task Force unveiled new guidelines as part of the society's official clinical policy statement. Published
in the April 15 issue of the American Journal of Respiratory and Critical Care Medicine, the document primarily focuses on the palliative care of patients with advanced respiratory diseases or critical illnesses.
"The goal of palliative care is to maintain and improve the quality of life of all patients and their families during any
stage of illness, whether acute, chronic, or terminal," co-chair Paul N. Lanken, MD, and members of the ATS task force wrote.
"The guidelines provide general recommendations for symptom management, including dyspnea, pain, and other physical complications,"
said Corrine Chahine-Chakhtoura, MS, PharmD, BCPS, clinical specialist in critical care and director of pharmacotherapy education
and residency programs at Saint Michael's Medical Center, Newark, N.J.
For pharmacological treatment of dyspnea in adults and children, the document advocates the use of opioids and anxiolytics.
Opioids may be administered orally, intravenously, or subcutaneously. The task force cautions that although the use of nebulized
opioids has been reported anecdotally as a treatment for dyspnea, systematic reviews have shown they are no more effective
than nebulized placebo. Chahine-Chakhtoura said that the guidelines urge clinicians to titrate opioid doses based on symptom
assessment using a dyspnea scale, with the aim of providing adequate dyspnea relief and minimizing sedative effects.
Starting opioid dosages and their duration of effect in opioid-naïve patients with moderate to severe pain or dyspnea
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Evidence shows that family members of patients often feel that pain is inadequately treated at the end of life. The document
supports the principle that for the dying patient, pain assessment using a functional scale should be considered another "vital
sign" and recommends various therapeutic options for pain management. Initial dosing of opioids to treat pain is summarized
in the table below. These dosing recommendations do not apply to patients who have previously used opioids because dosages
for such patients will be higher and must be individualized. There is no upper limit — the dose should be increased as needed
to produce the desired effect or until intolerable side effects occur. Transdermal opioids are suggested only for chronic
stable pain.
"Clinicians must be aware of common adverse events associated with opioids," Chahine-Chakhtoura said. Because constipation
is a predictable opioid side effect, the guidelines suggest initiating a bowel stimulant and stool softner with the opioid.
For nausea associated with opioids, antiemetics such as prochlorperazine or metoclopramide may be used.
Although opioids are advocated as first-line agents for pain management, the task force recognizes that neuropathic pain treatment
may require agents such as tricyclic antidepressants, anticonvulsants, and corticosteroids.
Studies demonstrate that patients with advanced respiratory diseases are at higher risk of psychological illnesses, such as
depression, anxiety, and panic attacks. For pharmacological management of depression, the guidelines support the use of methylphenidate
when rapid relief is essential. Therapeutic options for anxiety include benzodiazepines and buspirone, whereas drugs of choice
for panic attacks are selective serotonin reuptake inhibitors (SSRIs).
Developing a local program
The task force encourages clinicians to develop palliative care programs locally in their institutions. Chahine-Chakhtoura
believes that pharmacists can play an integral role in the implementation and success of a palliative care program. "They
can work with other clinicians in appropriate patient-specific therapy selection and monitoring, and provide medication counseling
to patients and their caregiver," Chahine-Chakhtoura said. She suggests that the first step is becoming familiar with available
educational resources related to palliative care. Two prominent Web sites are the Center to Advance Palliative Care ( http://www.capc.org/) and the Robert Wood Johnson Foundation-supported Promoting Excellence in End-of-Life Care ( http://www.promotingexcellence.org/).
MONICA SHAH is a writer and hospital pharmacist based in New Jersey.
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