What's new in palliative care

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

GENERAL PRINCIPLES OF PALLIATIVE CARE

Delayed functional improvement after intracerebral hemorrhage (September 2022)

Functional improvement after intracerebral hemorrhage (ICH) can be slow and the temporal trajectory is often uncertain. In an analysis of individual patient data from two clinical trials in nearly 1000 patients with intracerebral or intraventricular hemorrhage, 72 percent of patients had a poor functional outcome at 30 days [1]. By one year, 46 percent had recovered further and achieved a good functional outcome, including 211 (30 percent) who were functionally independent. Acute ICH complications such as sepsis, new ischemic stroke, prolonged mechanical ventilation, hydrocephalus, and the need for a gastrostomy feeding tube were predictors of poor outcome at one year. These results support the practice of providing aggressive acute treatment of patients with ICH and sustained rehabilitation to help avoid premature withdrawal of support and improve long-term outcomes. (See "Spontaneous intracerebral hemorrhage: Secondary prevention and long-term prognosis", section on 'Functional recovery'.)

SYMPTOM MANAGEMENT

Limited role for glucocorticoids in cancer-related fatigue (February 2023)

Patients with advanced cancer often experience fatigue related to both their disease and its treatments. In a meta-analysis of three randomized trials in 165 patients with advanced cancer-related fatigue, one week of dexamethasone resulted in a small improvement in symptoms versus placebo, but this difference did not reach statistical significance [2]. Given limited supporting evidence and known adverse events with glucocorticoids, we reserve their use in the treatment of cancer-related fatigue for patients who are in the terminal phase of advanced cancer. (See "Cancer-related fatigue: Treatment", section on 'Glucocorticoids'.)

Joint guideline on integrative medicine for pain management in oncology (February 2023)

A joint guideline is available from the American Society of Clinical Oncology (ASCO) and the Society for Integrative Oncology (SIO) that provides evidence-based recommendations on integrative medicine for pain management in oncology patients [3]. The evidence quality was judged low to intermediate for most interventions, and most recommendations were weak or moderate. The recommendations are summarized in the table (table 1) and outlined in the algorithm (algorithm 1); specific recommendations sorted by type of pain and stratified according to the quality of evidence and strength of the recommendation are outlined in the table (table 2). (See "Rehabilitative and integrative therapies for pain in patients with cancer", section on 'Clinical practice guidelines'.)

Lack of benefit of CBD oil for relief of symptoms in advanced cancer (December 2022)

Cannabidiol (CBD) is a naturally occurring molecule without psychoactive properties that can be procured by patients from legal marijuana dispensaries, online companies, or street suppliers. Although CBD oil is used by patients for a variety of conditions, there are few data on the risks and benefits in patients with cancer. A single phase II randomized trial of CBD oil for relief of symptoms in advanced cancer concluded that, compared with placebo, CBD oil did not add value to the reduction in symptom distress (including pain, nausea, vomiting, appetite loss, depression, or anxiety) provided by specialist palliative care [4]. Use of CBD oil cannot be recommended for symptom management in advanced cancer. (See "Management of poorly controlled or breakthrough chemotherapy-induced nausea and vomiting in adults", section on 'CBD oil' and "Management of cancer anorexia/cachexia", section on 'Cannabis and cannabinoids' and "Cancer pain management: Role of adjuvant analgesics (coanalgesics)", section on 'Choosing an agent for a therapeutic trial'.)

Long-acting morphine not effective for severe breathlessness in COPD (December 2022)

Chronic breathlessness is a frequent symptom in patients with chronic obstructive pulmonary disease (COPD). Opiates are sometimes used for palliation of breathlessness, but the appropriate dosing and potential efficacy are uncertain. In a recent placebo-controlled trial of approximately 160 patients with moderate-to-severe COPD and severe breathlessness, extended release morphine (8 to 32 mg daily, increased stepwise) failed to improve breathlessness intensity or daily activity level but did increase serious treatment-related adverse events, including hospitalizations and death [5]. These findings support our practice of not using long-acting opioids for COPD-related dyspnea, except for individuals in hospice settings. (See "Management of refractory chronic obstructive pulmonary disease", section on 'Opioid therapy, for palliation'.)

SELECTED END-STAGE CONDITIONS

Patient decision aids and conservative kidney management (January 2023)

Patient decision aids (PDAs) are tools used to facilitate informed decision-making and have been proposed as a way to promote conservative kidney management (CKM), an underutilized alternative to dialysis for many older patients with end-stage kidney disease (ESKD). In a trial that randomly assigned over 360 patients aged 70 years or older with nondialysis stage 4 or 5 chronic kidney disease to dialysis education with an interactive web-based PDA (Decision-Aid for Renal Therapy [DART]) or to usual care, scores assessing decisional quality and knowledge about ESKD were better in the DART group at three and six months of follow-up [6]. The preference for CKM increased from approximately 12 percent at baseline to 20 percent at six months in the DART group but remained stable for patients in the usual care group; however, differences in CKM preference between groups were not statistically significant. Although additional studies are required, PDAs such as DART may hold promise as a way of increasing the use of CKM. (See "Kidney palliative care: Conservative kidney management", section on 'Timing and content of the discussion'.)