Board Review

A 50-year-old man with a new diagnosis of non–small cell lung cancer is seen in follow-up. At the time of diagnosis, his disease was found to be metastatic to the liver, bone, and brain. He has completed whole-brain radiation for his brain metastases, and he is scheduled to begin chemotherapy. He states that he currently feels well, and his bone pain is well controlled with as-needed acetaminophen and NSAIDs.

In discussing his management, he indicates that he understands that his disease is incurable, and his overall goal is to live as long as possible comfortably so that he can spend as much quality time with his children as he can.

Which of the following is the most appropriate approach to management of this patient's care?

A) Admit the patient to hospice

B) Begin palliative care following completion of active treatment

C) Begin palliative care if pain control becomes ineffective

D) Begin palliative care now

E) Continue current management

Answer: D - Begin palliative care now

Objective: Initiate palliative care in an appropriate patient.

Key Point

Palliative care that is initiated early and integrated throughout the disease trajectory results in prolonged life of higher quality in patients with serious illness when compared with patients who do not receive palliative care.

Palliative care should be initiated now in this patient with serious, life-limiting illness. Palliative care focuses on achieving individualized goals of therapy and coordinating management of care to achieve those goals. Historically, palliative care was equated only with end-of-life care or considered appropriate only when other, potentially curative therapies had failed. However, contrary to this view, palliative care may be provided concurrently with life-prolonging therapies or with therapies with curative intent. It may be appropriately accessed at any time during a patient's illness, from diagnosis to death. Ideally, palliative care is initiated early and integrated throughout the disease trajectory to help optimize the focus of care on the patient's values and goals of treatment, an important aspect of managing complex and serious disease. Provision of early palliative care has been shown to result in prolonged life of higher quality. For example, patients with metastatic non–small cell lung cancer randomized to early palliative care had improved quality of life, less aggressive care at the end of life, and lived on average 2.7 months longer than those patients randomized to standard care (median survival 11.6 months versus 8.9 months). This is a survival benefit comparable to first-line chemotherapy in patients with non–small cell lung cancer. It is a common and unfortunate misconception that palliative care decreases life expectancy.

Hospice is a specialized type of palliative care that is reserved for patients in the terminal phase of their disease, arbitrarily defined as the last 6 months of life. Since this patient is interested in pursuing life-prolonging treatment, initiation of hospice care would not be appropriate.

Although one of the main goals of palliative care is aggressive symptom management, uncontrolled symptoms are not a requirement for palliative care involvement. Palliative care has much to offer patients outside of the domain of symptom management, including care coordination, help in establishing goals of care and navigating complex decision making, and assistance with coping. Therefore, there is no need to wait until the patient has pain or completes active treatment before accessing palliative care.

Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010 Aug 19;363(8):733-42. Link Out