Palliative care made standard practice in new guidelines

September 15, 2008

The American Thoracic Society End-of-Life Care Task Force has published new guidelines for treatment of patients with advanced respiratory diseases or critical illnesses.

Key Points

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.

"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.