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

Increasing advance care planning for patients on dialysis (February 2024)

Although patients on dialysis have high morbidity and mortality, advance care planning (ACP) is often not well integrated into the care of this population. In a cluster randomized trial conducted in 42 dialysis clinics that included nearly 430 patients on dialysis paired with a surrogate decision-maker, patient-surrogate pairs received either a 45- to 60-minute ACP discussion led by a dialysis clinic health care worker (eg, registered nurse or social worker) or usual care [1]. After two weeks, patient-surrogate pairs in the ACP group had greater congruence on end-of-life care goals and lower patient decisional conflict compared with those in the usual care group. Strategies that involve patient caregivers and dialysis unit staff can increase uptake of ACP among patients on dialysis. (See "Kidney palliative care: Principles, benefits, and core components", section on 'Advance care planning'.)

SYMPTOM MANAGEMENT

Mirtazapine in patients with cancer-related anorexia (April 2024)

Patients with advanced cancer are at risk for cancer-related anorexia and weight loss; studies are evaluating strategies to manage these issues. In a randomized trial in 86 patients with advanced non-small cell lung cancer, mirtazapine improved mean daily energy intake by 379 kcal versus placebo and reduced the proportion of patients with sarcopenia (57 versus 83 percent), although appetite scores were not higher [2]. Despite these results, previous data are inconsistent. As such, we prefer other strategies including dietary counseling and olanzapine for cancer-related anorexia. (See "Management of cancer anorexia/cachexia", section on 'Mirtazapine'.)

Palliative telehealth for patients with COPD, HF, and ILD (February 2024)

Although adults with advanced chronic obstructive pulmonary disease (COPD), heart failure (HF), and interstitial lung disease (ILD) have poor quality of life, data on the efficacy of palliative care measures are limited. In a trial of 306 patients who were at high risk of death due to advanced COPD, HF, or ILD, those assigned to receive six nurse phone calls for symptom management and six social worker phone calls for psychosocial care had higher quality of life (based on standardized questionnaires) at six months compared with those who received usual care [3]. Telephonic palliative care interventions may be an important tool for patients with advanced cardiopulmonary disease. (See "Palliative care for adults with nonmalignant chronic lung disease", section on 'Use and benefits of palliative care'.)

END OF LIFE AND HOSPICE CARE

Gradual or one-step weaning for ventilatory withdrawal (April 2024)

Few studies have compared the two main approaches used to withdraw ventilatory support at the end of life: gradual weaning (gradual reduction in oxygen and pressure support with intermittent medication as needed) and one-step weaning (immediate extubation with peri-extubation medication support). A recent randomized study compared one-step weaning with a nurse-led gradual weaning algorithm in 168 patients [4]. Less respiratory distress was experienced by the 48 patients in the gradual weaning group, despite receiving less opioids and benzodiazepines. This study supports our practice of gradual weaning for most patients undergoing withdrawal of life support. However, one-step weaning may be suitable for select patients (eg, severe neurological injuries and minimal ventilatory support needs). (See "Withholding and withdrawing ventilatory support in adults in the intensive care unit", section on 'Withdrawal of ventilatory support'.)