March 2014 Phoenix Pulmonary Journal Club: Palliative Care

Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, Dahlin CM, Blinderman CD, Jacobsen J, Pirl WF, Billings JA, Lynch TJ. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733-42. [CrossRef] [PubMed]

The March journal club focused on the role of palliative care in respiratory diseases such as chronic obstructive lung disease (COPD) and lung cancer. Palliative care is specialized care that focuses on life threatening disease and the relief of pain and stress. Although often initiated near the end of life, palliative care should not be  considered as end of life care. This study reviewed the impact of introducing palliative care in conjunction with oncologic care in the treatment of metastatic non-small cell lung cancer versus oncologic care alone. This was a nonblinded, randomized control trial of 151 patients done at the Massachusetts General Hospital.  Seventy-seven patients were randomly assigned to early palliative care + oncologic care (P + O) and 74 patients were assigned to oncologic care only (O). P + O patients were seen by palliative care services within 3 weeks of enrollment and met with services monthly until their death. Primary outcome was quality of life at baseline and at 12 weeks. The results showed that P + O patients had less depressive symptoms (16% P + O vs. 38% O), received less aggressive end of life care (33% P + O vs. 54% O) , and lived 2.7 months longer (11.6 m P + O vs. 8.9 m O). Although this was a small, nonblinded study it showed that palliative care does not need to be exclusive of ongoing oncologic care and that early referral and involvement can help foster goals of therapy and better symptom control.

Carlucci A, Guerrieri A, Nava S. Palliative care in COPD patients: is it only an end-of-life issue? Eur Respir Rev. 2012 Dec 1;21(126):347-54.  [CrossRef] [PubMed]

The role of palliative care in COPD is underutilized and rarely initiated until the end stages of disease. This review on the role of palliative care in COPD emphasizes that COPD is often a more debilitating disease than lung cancer with even higher rates of anxiety and depression. Palliative care should not be considered as transitional or end of life care, but integrated early to improve symptom control and quality of life. The timing as to when to get palliative care services involved in the outpatient COPD population is debatable, as the resources are limited. This paper suggests that looking at parameters that delineate a decreased 5 year survival in COPD, such as THE BODE INDEX, may be useful.  Patients that have a BODE index score of 7 or more would certainly be good candidates and perhaps starting with a score of 5 or more may even be more appropriate. Palliative care should be considered an integrated and complimentary tool in the management of advanced COPD.

Manoj Mathew, MD FCCP MCCM

Reference as: Mathew M. March 2014 Phoenix pulmonary journal club: palliative care. Southwest J Pulm Crit Care. 2014;8(3):194. doi: http://dx.doi.org/10.13175/swjpcc034-14 PDF