Cleveland Clinic Journal of MedicinePalliative Care: An Update for Internists

Enhancing Palliative Care: Evidence-Based Strategies for Symptom Management, Advance-Care Planning, and Communication Training

The need for palliative care (PC) is increasing due to the aging population and advancements in therapies for chronic diseases. This review provides internists with crucial updates on palliative care practices, summarizing key research from 2020 to help improve patient care. By focusing on practical implications, the article highlights evidence-based strategies for symptom management, advance-care planning, and the role of interdisciplinary approaches in optimizing quality of life for patients with serious illnesses.

Key Points:

• Advance-Care Planning Opportunities: Transitions in health status are key moments for internists to engage in advance-care planning and complete physician orders for life-sustaining treatment (POLST) forms, promoting goal-concordant care.
• Non-Cancer Palliative Care: Internists should consider palliative care for patients with chronic non-cancer diagnoses, as it can improve healthcare experiences and reduce utilization near the end of life.
• COVID-19 Implications: Awareness of the impact of COVID-19 on older adults’ loneliness and social isolation is crucial, given its associated negative health outcomes.
• Symptom Management in Advanced Cancer: Evidence supports the use of as-needed olanzapine for chronic nausea and methylphenidate for fatigue in patients with advanced cancer.
• PC Interventions for Non-Cancer Illnesses: Palliative care interventions can reduce emergency department use, hospitalizations, and symptom burden, and increase advance-care planning in patients with chronic illnesses such as heart failure, COPD, and dementia.
• Reducing Burdensome Interventions: Palliative care consultations in the last six months of life can reduce emergency department visits, hospital admissions, and ICU admissions, and increase the likelihood of dying at home or in a nursing home rather than in a hospital.
• POLSTs and ICU Admissions: Treatment-limiting POLSTs are associated with lower rates of ICU admissions, although a significant proportion of patients still receive care discordant with their POLST.
• Early Palliative Consultations in ICU: Early targeted PC consultations in the ICU can increase transitions to do-not-resuscitate/do-not-intubate orders, increase hospice referrals, and reduce the duration of mechanical ventilation.
• Resident Training in PC: Brief coaching sessions for internal medicine residents can enhance their preparedness and ability to facilitate and document goals-of-care discussions with hospitalized patients.
• 3 Wishes Project: The 3 Wishes Project improves end-of-life care in the ICU by honoring patient identity and legacy through compassionate acts, enhancing family and clinician experiences.
• Loneliness and End-of-Life Outcomes: Loneliness in older adults is linked to higher symptom burden and poorer end-of-life outcomes, highlighting the need for routine screening and documentation of loneliness.
• Family Visitation and Postoperative Delirium: Family-based interventions can reduce postoperative delirium and improve outcomes in older hospitalized patients, suggesting the importance of family involvement in care.
• Interpreter Engagement in End-of-Life Conversations: Medical interpreters should be involved in end-of-life discussions to ensure culturally appropriate communication, with pre-meetings and debriefings to reduce their emotional burden.
• Olanzapine for Chronic Nausea: Olanzapine at 5 mg daily is effective and well-tolerated for managing chronic nausea in advanced cancer patients.
• Methylphenidate for Cancer-Related Fatigue: As-needed methylphenidate significantly reduces fatigue and improves activity levels in advanced cancer patients.

In a systematic review and meta-analysis of 28 randomized clinical trials of patients with primarily noncancer illness, receipt of palliative care interventions, compared with usual care, was statistically significantly associated with less acute health care use and modestly lower symptom burden, but there was no significant difference in quality of life. (JAMA)

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