Palliative care can lead to higher quality of live and longer survival

Every once in awhile amidst the weekly deluge of medical articles comes a show-stopper that has the potential to change the way we practice.

Rarer yet is the article that not only changes how we practice, but calls into question why we do what we do.

This recent article from the New England Journal of Medicine is just such an article. Before you bolt, let me simplify it for you.

Here’s the quick take.

The authors enrolled 150 patients with advanced lung cancer and split them up between usual care, which included chemotherapy, and an intervention arm, in which they received the same standard of care treatment plus early enrollment in palliative care.

Now lung cancer, mind you, is one of the bad ones. By the time it’s advanced, i.e. spread either across the chest or elsewhere into a different part of the body (“metastasis”), the prognosis is poor. Survival is less than one year, on average.

Palliative care is medical care that treats for patient comfort foremost, and does not seek to cure the underlying chronic illness, be it cancer or other advanced disease, like congestive heart failure or emphysema.

It’s often confused with hospice, which is the level of care (or physical place) for patients with a less than 6 month prognosis. Hospice usually involves being less aggressive with the medical care, while palliative care aggressively seeks comfort for the patient, sometimes involving complex treatment. The confusion comes because palliative care is not mutually exclusive to hospice (indeed, they often overlap), nor is it mutually exclusive with standard disease treatment, as evidenced in this article. Cure and comfort can both be vigorously pursued.

In fact, one reason why palliative care gets invoked so infrequently is that families and medical folks often conflate palliation with hospice.

The study results were, in some ways, not so surprising: The patients that received early palliative care along with their cancer treatment had lower self-reported scores for depression and anxiety, and higher scores on “quality of life” scales.

But surprisingly, the group that received palliative care early survived longer. An average of about two months longer. Not so much, you say. But mathematically, more than 25% longer. Remember, average survival in advanced lung cancer is about a year. When you’re talking survival in months, an extra two months is a lot: more grandkids, more valedictories, more closure, more goodbyes; maybe even more off the bucket list.

 

And this was achieved without more chemotherapy. Just more contact (on average, 4 visits to palliative care). And more addressing of symptoms.

Isn’t providing comfort and symptom control why we went into medicine in the first place?

Sometimes doing less in the way of fighting for a cure offers more in terms of meaning. And as this study shows, more of life itself.

John Schumann is an internal medicine physician at the University of Chicago who blogs at GlassHospital.

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  • Killroy71

    If there was a drug that helped these patients live two months longer, without being sicker from aggressive care, you better believe that would make headlines.

    My uncle died last month of lung cancer about 2 months after getting the diagnosis. He was going to have it treated aggressively – but I didn’t have high hopes since he was 80, a smoker, and already had COPD. Hope he got some palliation along the way.

    Thank you for clarifying the concept of palliative care – it is NOT mutually exclusive with standard of care for any condition.

  • http://astridvanwoerkom.wordpress.com/ Astrid

    This seems, to me, like an “Oh duh!” study, but apparently not to many doctors.

  • Bobbo

    Forget health care reform. The biggest thing that can be done to control healthcare costs is to increase palliation and hospice.

    Get terminal patients out of ICUs and into their beds and let them die in peace. Most will be happier and maybe even live longer. I’m not a religious person, and I don’t believe that there is any greater meaning to how we die, but I know when I go I don’t want it to be with a tube in every natural orifice and a few artificial ones. Maybe an IV for some happy-meds though :) .

    Good luck to the politician that promotes “death panels” and “unplugging grandma” though.

  • http://myheartsisters.org Carolyn Thomas

    Thanks so much Dr. John for sharing this study.

    After working for the past decade in hospice palliative care (words that are not mutually exclusive here in Canada), I have observed many times the dilemma of encouraging patients (and more importantly, their doctors) to consider early registration for palliative care. We live in a death-denying society. Most patients (and their doctors) see even the offer of palliative care as voluntarily putting one foot firmly into the grave.

    Palliation refers to “comfort care” – so the extended two months of life reported in this study is not surprising at all to me. For example, pain management knowledge for many physicians, incuding oncologists, is shockingly limited. Often we see patients admitted to our in-patient unit who have been living with intractable pain for months. Months! And this pain can include both the pain caused by the disease plus the pain inflicted by treatment. I once asked a cancer clinic radiologist about the painful burns I’d seen on a lung cancer patient’s chest. “We prefer to call them ‘skin irritations’; we don’t like to use the word ‘burn”, she corrected me, to which I replied: “Honey, I’ve seen these with my own two eyes – these are BURNS!”

    First order of business in palliative care: get on top of pain and other distressing symptoms. Suddenly, for the first time in too long, patients may be getting a full night of pain-free sleep. They feel better! They think better. They look better.

    But those working in palliative care know that it’s not just physical pain that demands attention for our patients. We often talk of “total pain” management, which includes emotional, spiritual, mental and physical pain. Palliative care can include psychosocial counselling for both patient and their family members, help with decision-making, visits from trained volunteers to provide support and companionship, music and art therapy, and so much more.

    This study, for example, shows that fewer patients in their “standard care” group than in the palliative care group had their resuscitation preferences documented in their charts (28% vs. 53%).

    Oncologists might ask why such an important basic decision is not part of standard treatment protocol already.