From Choosing Wisely, Advice for Palliative Care Specialists and Guidance for Cancer Patients
Mary K. Caffrey
The Choosing Wisely initiative, created by the American Board of Internal Medicine (ABIM) Foundation as a multidisciplinary vehicle to drive discussions about unnecessary tests and costs in medicine, has drawn support from more than 60 different specialties, including the American Society of Clinical Oncology (ASCO).1
With its focus on sparing patients from procedures that are duplicative, wasteful, and potentially harmful, Choosing Wisely seems a perfect match for the movement toward palliative care. And it has received buy-in from the American Academy of Hospice and Palliative Medicine (AAHPM), which in February 2013 released a list of 5 items that doctors should question before pursuing.
Of greater importance, Choosing Wisely produced a consumer document on end-of-life decision making in partnership with ASCO and Consumer Reports. Updated in July 2014, this 2-page essay, “Care at the End of Life for Advanced Cancer Patients: When to Stop Cancer Treatment,” introduces patients to evidence-based concepts about what is possible in cancer care, the role of a clinical trial, and how palliative can improve quality of life.2 In clear, consumer-friendly language, the Choosing Wisely document speaks to cultural difficulties Americans have discussing end-of-life issues. Last year’s Institute of Medicine (IOM) report, Dying in America, said these barriers not only prevent patients from receiving palliative care, but also prevent better distribution of healthcare resources in the United States.3
“The controversy on this topic and the political desire to avoid it do not alter the fact that every person will face the end of life one day, and many have had hard experience with the nal days of a parent, a spouse, a child, a sibling, another relative, or a dear friend,” the IOM report states.3
The phenomenon is not limited to cancer care. On March 15, 2015, Andrew Ziskind, MD, a cardiologist and healthcare administrator, told a session at the annual meeting of the American College of Cardiology that American cultural attitudes and fear of “death panels” are quite different from prevailing attitudes in Europe. These cultural hurdles have to be overcome, he said, because the pursuit of care at all costs, even when good outcomes are not expected, causes overutilization across the healthcare system.
WHAT CHOOSING WISELY TELLS PATIENTS
The consumer document tells patients that even with the best cancer care, at some point it may be best to stop. If cancer continues to spread after 3 treatments, the document states, especially in solid tumor cancers such as breast, colon, or lung cancer, physicians have found that “Treatment after treatment offers little or no benefit.”2
Rather, patients should discuss with their doctor the following:
• What is the real prognosis? How long can I be expected to live with treatment? How long can I be expected to live without treatment?
• What are the goals of treatment? (Patients should discuss whether they are trying to stop the cancer from advancing, or whether they want to ease symptoms.)
• What can I do to improve my quality of life?
While the term “palliative care” appears only after halfway down the second page, the document states, “If you decide that you don’t want more cancer treatment, then it’s time to focus on a kind of palliative care called hospice care.” It goes on to describe hospice care as offering help with pain management and symptom relief, grief counseling for family and friends, social worker services, and respite care for caregivers. However, the document does not state that palliative care can start earlier in the cancer treatment process, being designed for patients nearing the end of life.
CHOOSING WISELY FOR PALLIATIVE CARE PROFESSIONALS
An important aspect of Choosing Wisely is that the lists of procedures and tests to reconsider are developed within each professional society; the ABIM Foundation initiative distributes the information across medical disciplines, and there is some overlap. The items that the AAHPM put forward in February 2013 were as follows4:
• Don’t recommend percutaneous feeding tubes in patients with advanced dementia; instead, offer oral assisted feeding. The academy cited studies that found feeding tubes do not improve survival, prevent pneumonia, or heal pressure ulcers—in fact, they have been associated with ulcer development. Assistance with feeding also promotes human interaction, which is as important as nutrition. • Don’t delay palliative care for a patient with serious illness who has physical, psychological, social, or spiritual distress because they are pursuing disease-directed treatment. The group cited randomized trials indicating that palliative care improves pain and symptom control and family life, and controls costs.
• Don’t leave an implantable cardioverter-debrillator (ICD) activated when it is inconsistent with patient and family goals. The ICD may activate within weeks preceding death, for 25% of patients, causing pain and distress. There are no formal protocols to address deactivation, and fewer than 10% of hospitals have policies. Thus, advance care planning discussions should address this issue.
• Don’t recommend more than a single fraction of palliative radiation for an uncomplicated painful bone metastasis. Guidelines state that single-fraction radiation to a previously unradiated peripheral bone or vertebral metastasis provides comparable pain relief and morbidity.
• Don’t use topical Ativan, Benadryl, or Haldol (ABH) gel for nausea. Some topical drugs, such as non-steroidal anti-inflammatory drugs for arthritis symptoms, are safe and effective. Meanwhile, anti-nausea gels have not been proved effective in any large and well-designed trials. EBO