When it comes to the avoidance of unnecessary tests, procedures or treatments, there is arguably no setting in which it is more important to choose wisely than end-of-life care. Hospice practitioners and palliative care specialists, by definition, seek to avoid unnecessary pain, anxiety, or expense for their patients.
It was perhaps an extension of their everyday responsibilities, then, for members of the American Academy of Hospice and Palliative Medicine (AAHPM) to formulate a list of potentially unnecessary treatments and practices in their profession. The list was made as part of the ABIM Foundation’s Choosing Wisely initiative, an effort started in 2012 to highlight the issue of overused and unnecessary tests and procedures. Through this collaborative effort, organizations representing a variety of medical specialties compiled and submitted their recommendations.
HemOnc Today presents AAHPM list of possibly unnecessary or overused practices in the field of hospice care and palliative medicine.
1. The use of percutaneous feeding tubes in patients with advanced dementia.
According to the AAHPM, the use of feeding tubes in patients with advanced dementia does not prevent aspiration pneumonia, improve survival, or promote the healing of pressure ulcers. Conversely, feeding tubes have been associated with the development of pressure ulcers, the need for physical or pharmacological restraints, and unnecessary patient anxiety. Read more
2. Delaying palliative care in patients with serious illness and psychological distress because they are pursuing disease-directed treatment.
There is a common misconception that the provision of palliative care hastens death or implies “giving up,” thus making it seem undesirable to patients seeking to prolong life through active treatment. However, studies have reported that palliative care can improve pain and symptom control, increase family satisfaction with care, and decrease expenses. Read more
3. Leaving an implantable cardioverter-defibrillator (ICD) activated when it goes against the patient/family’s goals.
The AAHPM reports that in roughly one fourth of patients with ICDs, the defibrillator administers a shock within weeks of death. In patients with advanced or terminal diseases, these defibrillator shocks rarely obviate death, may be painful to patients, and are often alarming to caregivers and family members. However, fewer than 10% of hospices have official policies regarding the deactivation of ICDs. The AAHPM recommends discussing the patient’s care goals and their preferences regarding deactivating an ICD. Read more
4. The use of more than a single fraction of palliative radiation for bone metastases.
The AAHPM echoed the stance of the American Society for Radiation Oncology (ASTRO) in its Choosing Wisely list, which stated that more than a single fraction of radiation to an uncomplicated, painful peripheral bone or vertebral metastasis may be unnecessary. The AAHPM noted that although single-fraction radiation results in a higher likelihood for later retreatment, the reduced pain burden to the patient usually supersedes the focus on long-term effectiveness. Read more
5. The use of topical gels such as lorazepam, diphenhydramine haloperidol or ABH for nausea.
Although topical gels can be effective in palliation scenarios such as the treatment of local arthritis symptoms, the effectiveness of topical anti-nausea gels have not been conclusively proven in any large, well designed or placebo-controlled trials. Of the aforementioned agents, only diphenhydramine is transdermally absorbed, and then only after several hours and at subtherapeutic levels, according to the AAHPM. The use of anti-nausea drugs administered through inappropriate delivery methods may serve only to delay the initiation of more effective agents. Read more