Physicians Need ‘Coherent Game Plan’ for Care of Dying

CLEVELAND, Ohio—Decisions involving patients with advanced cancer must take place within a conceptual framework that takes into account quality of care, quality of life, and quality of death, Declan Walsh, MD, MSc, said at a conference on palliative medicine held at the Cleveland Clinic Foundation.

Physicians need to think critically, anticipate crises in the course of the disease, and take a “proactive approach,” said Dr. Walsh, director of the Cleveland Clinic’s Harry R. Horvitz Center for Palliative Medicine.

Deciding when to forego available medical intervention is an important part of palliative care decision-making. Physicians need to have a “coherent game plan,” he said. Otherwise a “sense of drift” sets in as the patient is carried along by the energy of the hospital from one intervention to the next.

Protocols and Strategies

The debate over physician-assisted suicide, Dr. Walsh said, puts additional pressure on medicine to improve the dying process. “The principles of palliative medicine must be brought into the medical system more fully,” he said. “We need to develop protocols and strategies for the dying patient. We need to civilize the system.”

The first difficult decision that must be made during the care of the dying patient, he said, is to decide that the patient is, indeed, dying. Too many patients “die by default,” he said.

Assessing the extent of disease is important, of course, but just having an evaluation by an organ specialist is not enough, he said. The palliative medicine team should function as the “quarterback” of a team of providers in making decisions regarding the care of the patient.

The job of the physician and the care team, Dr. Walsh said, is to evaluate the patient, sort out the physical complications, come up with a decision plan, and then communicate that to both the patient and the family.

To Intervene or Not?

Too often technical intervention is provided as a substitute for good medical and nursing care, he said. Physicians should consider quality of life and performance status of the patient and then ask whether they should intervene. It is inappropriate “to do well what should not be done at all,” Dr. Walsh said, paraphrasing author Gore Vidal.

The consequences of initiating interventions that ultimately can result in a more uncomfortable death must be considered. In some cases, he said, this means that the physician should refrain from the use of technical interventions.

For example, dying of pneumonia is relatively quick and painless. The physician overseeing the care of a dying patient who develops pneumonia must decide whether to continue antibiotics, to refrain from prescribing antibiotics, or to withdraw antibiotics.

The comfort of the patient remains a top priority. In this situation, chlorpromazine could be given to manage dyspnea and agitation. “The drug is cheap and effective and can be given by mouth, by suppository, and intravenously,” he commented.

In another example, Dr. Walsh urged his audience to consider the consequences of treating a patient with advanced cervical cancer who develops obstructed ureters.

Without a stent, the patient will die quickly of renal failure. With a stent, the patient will die slowly because there is no large organ involvement with this cancer. Her death will likely be painful, and the odor caused by the cancer as it advances is likely to isolate her from friends, family, and even hospital staff . Is stenting the ureters the proper choice? Perhaps not.

Odor Management

Odor management is a common problem in pelvic and gynecologic cancers. Since odor can isolate patients from their family and from the care staff, its treatment is a high priority, Dr. Walsh said.

He recommends the following: low-dose metronidazole, charcoal-impregnated dressings, proper stoma care, and chlorophyll tablets applied topically or taken by mouth.

The short-term analgesic midazolam (Versed) can be used for pain relief while changing dressings. Its use avoids the problems of sedating a patient with an opioid for the sole purpose of changing a dressing.

Symptom management is a hallmark of palliative care. However, the large number of symptoms associated with advanced cancer—and the interaction of these symptoms—makes symptom management very difficult.

No Easy Answers

While there are no easy answers to symptom management, there are some key principles to follow. Once a detailed history has been taken, a regular review of symptoms is important. Palliative care physicians don’t need to use a lot of medications, but they do need to know how to use a small number of drugs “very well and very aggressively,” Dr. Walsh said. Knowledge of various routes of administration is also crucial, as is anticipating and combating side effects.

It is important to evaluate which symptoms are going to be treated as a priority. Physicians and patients may disagree on what is a priority, Dr. Walsh said. In that situation, “it’s very important to address the patient’s issues,” he said. “This will instill confidence in the patient and build a better team relationship.”