End of life care: Overview of symptom control
Authors
Eduardo Bruera, MD
Rony Dev, DO
Section Editors
Linda Emanuel, MD, PhD
Ezekiel J Emanuel, MD, PhD
Deputy Editor
Diane MF Savarese, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2012. | This topic last updated: Apr 13, 2011.
INTRODUCTION — Most patients in the terminal phase of a severe advanced illness such as cancer develop potentially devastating physical and psychosocial symptoms for weeks to months before death [1]. Patients admitted to tertiary palliative care units are likely to present with more frequent and severe symptoms compared with those admitted to community hospices or acute care hospital beds, although the frequency of symptoms is high in all groups (table 1). (See "Hospice: Philosophy of care and appropriate utilization".)
Palliative care is an interdisciplinary medical specialty that focuses on preventing and relieving suffering and on supporting the best possible quality of life for patients and their families facing serious illness. The primary tenets of palliative care are symptom management; establishing goals of care that are in keeping with the patient’s values and preferences; consistent and sustained communication between the patient and all those involved in his or her care; psychosocial, spiritual, and practical support both to patients and their family caregivers; and coordination across sites of care.
Early referral to palliative care in an earlier stage of an advanced life threatening disease may prepare patients and family caregivers for the high symptom burden during the last stages of life. In a study of patients with metastatic non-small-cell lung cancer, early palliative care consultation led to modest improvements in quality of life and mood, longer median survival, and less chemotherapy administered within 14 days before death [2]. (See "Palliative care: Benefits, services, and models of care", section on 'Palliative care services and benefits'.)
Challenges for symptom management at the end of life — Symptom management of terminally ill patients can be complicated by several factors [3]:
• Older age (two-thirds are age 65 years or older)
• Malnutrition, low serum albumin
• Frequent autonomic nervous system failure
• Decreased renal function
• Borderline cognition
• Lower seizure threshold (metastatic brain involvement, use of opioids)
• Long-term opioid therapy
• Multiple drug therapy
Some of these characteristics, such as malnutrition, low serum albumin, and decreased renal function, may seriously affect the pharmacokinetics of drugs used for symptom control; these patients usually tolerate lower doses of drugs compared with other medically or psychiatrically ill patients. The high frequency of autonomic nervous system failure increases the risk of some side effects from opioids, tricyclic antidepressants, and phenothiazines, including constipation, dry mouth, nausea, urinary retention, or postural hypotension [4]. The presence of borderline cognition and use of opioids and other psychoactive drugs are all risk factors for sedation and drug-induced delirium. In addition, the majority of the palliative indications for the drugs included in this chapter have not been approved by FDA; many of these drugs are not patent protected, and manufacturers are not interested in conducting further research leading to new indications for such agents.