Palliative Care Prolongs Life

Thanks to Wikimedia commons for picture, A puffer fish kissing the glass. No intentional relationship to the post, Just loved the picture.

A study published today in the New England Journal of Medicine by Jennifer Temel and colleagues at the Massachusetts General Hospital (MGH) showed that patients with advanced lung cancer treated with early outpatient palliative care lived longer than patients randomized to usual care. 

What?

A randomized controlled trial of outpatient palliative care showed a survival benefit.

Palliative care prolongs life?  Really?  REALLY???

Here is my take on the study, and I’m interested in yours.  151 patients with metastatic non-small cell lung cancer were randomized within 8 weeks of diagnosis to either monthly visits to an outpatient palliative care clinic plus usual oncology care or usual oncology care alone.  Patients in the usual oncology care group could attend the outpatient palliative care clinic if requested, but only 14% did.  The characteristics of the two groups looked similar before randomization for all of the things you would care about, like functional status, presence of brain mets, and baseline measures of quality of life, symptoms, and mood.  The outpatient palliative care clinic was staffed by great docs and NPs, like Vicki Jackson, MD, and Connie Dahlin, NP. They used the National Consensus Project for Palliative Care guidelines.  The main focus of the study was improvement in quality of life, symptoms, mood, and health services use.  After 3 months, here’s what they found:

• Higher quality of life ratings in the palliative care group (score of 98 on Functional Assessment of Cancer Therapy-Lung scale) versus usual care (score of 92)
• Better symptom control in the palliative care group (score of 21 on the Lung Cancer Subscale) versus usual care (score of 19).  A composite score showed similar improvements.
• Fewer subjects meeting criteria for major depressive disorder in the palliative care group (17% vs 4%).

By the end of the study follow up period (about 30 months)

• 70% of subjects had died
• 53% of subjects in the palliative care arm had documented resuscitation preferences compared to 28% in the usual care arm.
• Fewer hospitalizations and emergency department visits among the palliative care group
• Trend toward greater use of hospice in the palliative care group (69% vs 60%)
• Median survival in the palliative care group was 11.6 months from enrollment vs. 8.9 months in the usual care group

So how can we account for these findings?  What mysterious things are they doing in that palliative care clinic at MGH?  They must be so much better than anyone else, at Man’s Best Hospital, how could we possibly achieve outcomes like this?

If you read the fine print, I don’t think it’s rocket science.  I worked in that clinic during fellowship, and I don’t think it’s all that different from what outpatient palliative care providers are doing in other parts of the country.

Here’s what I think happened:

• The guidelines for the outpatient palliative care group state they should attend to pain, cough, dyspnea, and depression. Those outcomes they assessed using the scores above with the fancy names…guess what they measure?  Pain, cough, dyspnea, and depression.
• The guidelines say the palliative care providers should inquire about prognostic understanding and clarify treatment goals.  The study investigators wisely assessed documented rates of advance care planning.
• Why did they live longer?  The study authors would like us to think it’s all of the great things palliative care does to improve patients symptoms and quality of life.  Sean Morrison agrees, “When you control pain and other symptoms, people not only feel better, they live longer.”  Probably a good part of it.  The other part may be avoiding hospitalization, and to an even greater extent chemotherapy at the end of life (33% of subjects in the palliative care group received chemotherpay within 30 days of death, compared with 42% in the usual care group). 

To what extent these survival differences are due to avoidance of “aggressive” care like chemotherapy and hospitalization, and to what extent differences are due to improved symptom care and mood remain to be studied.  Why is this a key point?  Because outpatient palliative care providers are trying to make a name for themselves as providers of outstanding symptom management for patients with advanced illness.  If the survival benefit was due to avoidance of chemo, maybe the palliative care team isn’t so necessary.  On the other hand, you could argue it was the quality of the communication and clarification of goals in the palliative care group that led to less chemotherapy.  In any case, the prolonged survival findings add convincing evidence of a causal relationship hinted at in this retrospective study of hospice use, and this prospective trial of a nursing-led telephone outpatient palliative care intervention.

What can you tell your patients?

• Early outpatient palliative care in addition to usual oncology care for metastatic non-small cell lung cancer improves physical symptoms, depression, sense of well-being, and not only doesn’t shorten life, it may prolong life.

What do you tell your administration when you want to fund an outpatient palliative care clinic?

• Early outpatient palliative care leads to reduced use of high intensity high cost care, such as chemotherapy, emergency department visits, and hospitalization at the end-of-life. 

For further thoughts on this topic, please see the write up on Pallimed by Lyle Fettig and the editorial by Amy Kelley and Diane Meier in NEJM.  This study did not address costs directly, a topic we discussed on a previous GeriPal post, called “What if palliative care doesn’t save money?”

What are your thoughts?  Please add a comment.

by: Alex Smith