When palliation is the goal


Do people live longer with aggressive care, or do they fare just as well when their care is more focused on helping them be comfortable?

As the dying process becomes increasingly prolonged through the sometimes dubious wonders of medical intervention, it’s an important question to ask.

A new study, published online this week in the New England Journal of Medicine, suggests the glimmer of some answers. It tracked two groups of cancer patients – a cohort randomized to receive early palliative care and a control group that didn’t – and found that patients newly diagnosed with lung cancer reported a better quality of life when palliative care was provided early in the course of their treatment. And despite receiving less aggressive end-of-life care, they also lived slightly longer than patients who did not have early palliative care. They were more likely to have their end-of-life wishes documented in their medical chart as well.

The study involved 151 patients at Massachusetts General Hospital and was conducted over the course of three years, from 2006 to 2009. Since it involved a small, specific patient population, it’s hard to know whether the same findings might apply more broadly. Nevertheless, the study offers some interesting insight on the benefits of palliative care – plus the data to actually measure this.

The study’s authors conclude:

Early integration of palliative care for patients with metastatic non-small-cell lung cancer is a clinically meaningful and feasible care model that has effects on survival and quality of life that are similar to the effects of first-line chemotherapy in such patients. As compared with the study participants who received standard care, those who were assigned to early palliative care had improved mood, more frequent documentation of resuscitation preferences, and less aggressive end-of-life care. Although our findings must be replicated in a variety of care settings and cancer populations, the results nonetheless offer great promise for alleviating distress in patients with metastatic disease and addressing critical concerns regarding the use of health care services at the end of life.

It makes a pretty strong case for the more widespread use of palliative care, preferably sooner rather than later in the course of a serious disease. And therein lies one of the most important implications of this study: defining the role of palliation in the care of the patient.

Palliative care seems to suffer from an identity crisis. It traditionally has been viewed as something that’s offered to patients when standard treatment is no longer effective. In the public’s mind – and in the mindset of many health care professionals as well – it’s often synonymous with “hospice” rather than being an entity unto itself. This perception frequently gets reinforced by the tendency to lump hospice and palliative care into the same discussion – to wit, the name of the leading organization in the U.S. for promoting high-quality care at the end of the life, the National Hospice and Palliative Care Organization.

How, exactly, should palliative care be defined? The NHPCO describes it this way: “treatment that enhances comfort and improves the quality of an individual’s life during the last phase of life.” The Center to Advance Palliative Care defines the aim of palliative care as “to relieve suffering and improve quality of life for patients with advanced illness and their families.” And the American Academy of Hospice and Palliative Medicine defines the goal as “to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies.” (emphasis added)

Should palliative care continue to be targeted mainly to people in later stages of an illness with a bleak prognosis? Or should we start offering it farther upstream? If it’s offered sooner, when is the appropriate time to introduce it to the patient and family? Should it be an option for everyone with a serious illness, even when the patient is expected to recover? If health care professionals can’t totally agree on the role of palliative medicine or where it belongs on the continuum, how is the public supposed to know?

(I’d also argue that longer survival shouldn’t be the only measure, or maybe even the most important measure, for justifying the effectiveness of palliative care. For many patients, quality of life matters far more.)

In an accompanying editorial on the study, the New England Journal of Medicine suggests it’s time to rethink our concept of palliative care: “The new approach recognizes that life-threatening illness, whether it can be cured or controlled, carries with it significant burdens of suffering for patients and their families and that this suffering can be effectively addressed by modern palliative care teams.”

Dr. Lyle Fettig at the PalliMed blog goes so far as to call the NEJM study a “game changer” that’s likely to have “important and long-lasting” implications for palliative medicine.

Let’s hope it sparks some serious conversation, because it’s long overdue.

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