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August 18, 2010

Palliative Care Extends Life, Study FindsBy DONALD G. McNEIL Jr.

In a study that sheds new ligh t on the effects of end-of-life care, doctors hav e foun d tha t

patients with terminal lung cancer who began receiv ing palliativ e care imm ediately upon

diagnosis not only wer e happier, m ore m obile and in less pain as the end neared but they

also liv ed nearly thr ee months longer.

Th e findings, published online Wednesday by The New England Journal of Medicine,

confirm ed wh at palliat iv e care specialists had long suspected. The study also, experts said,

cast doubt on the decision to strike end-of-life prov isions from the health care ov erhau l

passed last y ear.

It shows that palliativ e care is the opposite of all tha t rh etoric about death panels, said

Dr. Diane E. Meier, director of the Center to Advance Palliativ e Care at Mount Sinai School

of Medicine and co-author ofan editorial in the jour nal accompany ing th e study . Its not

about killing Granny ; its about keeping Granny aliv e as long as possible with the best

quality of life.

In the thr ee-y ear study , 1 51 patients with fast-growing lun g cancer at Massachu setts

General , one of the nat ions top hospitals, were randomly assigned to get either oncology

treat ment alone or oncology treat ment with palliativ e care pain relief and other

measures intended to improve a patients quality of life. They were followed until th e end

of 2009, by which time about 7 0 percent were dead.

Those getting palliativ e care from the start , the aut hors said, reported less depression an d

happier liv es as measured on scales for pain, nausea, m obility , w orry and other problems.

Moreov er, ev en though substantially fewer of them opted for a ggressiv e chemotherapy as

their illnesses worsened and many more left orders that they not be resuscitated in a crisis,

they ty pically liv ed almost th ree months longer tha n th e group getting standard care,

wh o liv ed a median of nine months.

Doctors and patients tra ditionally see palliat iv e care as something extended to a

hospitalized patient in the last week of life, said Dr. Jennifer S. Temel, an oncologist and

author of the paper. We though t it made sense to star t them at the t ime of diagnosis. A nd

we were th rilled to see such a huge im pact. It shows that palliativ e care and cancer ca re

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arent m utually exclusiv e.

Dr. Atu l Gawa nde, a Harv ard Medical School sur geon and writer w ho just published a long

article in The New Yorker about hospitalized pat ients suffering before death, called the

study amazing.

The field was cry ing out for a randomized trial, he added.

Alth ough the study could not determ ine why the patients liv ed longer, th e authors and

other expert s had several th eories: depression is known t o shorten life, and patients wh ose

pain is treated often sleep better, eat better and talk m ore w ith relativ es. A lso, h ospitals

ar e dangerous places for v ery sick people; th ey may get fata l blood infections, pneumonia

or bedsores, or simply be ov erwh elmed by the powerful drugs and radiation attacking

their cancer.

Say ing t he study was of critical im porta nce, Dr. R. Sean Morr ison, president of the

Am erican Academy of Hospice and Palliat iv e Medicine, said it was the first concrete

ev idence of wha t a lot of us hav e seen in our practices when y ou contr ol pain and other

sy mptoms, people not only feel better, they liv e longer.

There is sometim es tension between medical specialties, since surgeons an d oncologists

often v iew cancer as a batt le, while palliativ e care specialists are seen as giv ing up.

Palliativ e care ty pically begins with a long conv ersation a bout wha t th e patient w ith a

term inal diagnosis wants out of his remainin g life. It inclu des th e options any oncologist

addresses: sur gery , ch emotherapy and r adiation and their side effects. But it also includeshow mu ch suffering a patient wishes to bear, effects on th e fam ily , and legal, insur ance

and religious issues. Team s focus on controlling pain, nausea, swelling, shortness of breath

and other side effects; they also address patients worries and m ake sure they hav e help

with ma king m eals, dressing and bathing w hen not hospitalized.

Hospice care is intensive palliativ e care including home nursing, but insurers and

Medicare usually cov er it only if the patient abandons medical tr eatm ent and two doctors

certify that death is less than six months away .

During t he debate ov er President Obama s 2009 health care bill, prov isions to hav e

Medicare and insur ers pay for optional consult ations with doctors on palliativ e and hospice

car e led to rumors, spread by talk-show hosts like Rush Limbaugh and Glenn Beckand by

the form er v ice-presidentia l can didate Sarah Palin, th at the bill empowered death

panels that would euthanize elderly Americans.

Legislators ev entua lly remov ed the provisions. In practice, Medicare and priv ate insurers

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do pay for some pallia tiv e care, said Dr. Gail Austin Cooney , a form er president of the

palliativ e medicine academy . But its piecemeal, she said. Th e billing is complicated,

and for m any phy sicians that s enough of a deterrent to not bother .

Dr. Cooney herself had such care along with sur gery and chemothera py for ovarian

cancer in 2008.

I decided I wanted every drop of chemotherapy they could giv e me, an d it was v ery

painful, dum ping the drugs directly into my belly , she said. She needed powerful

painkil lers, and also chose alternativ e-medicine options like acupuncture and energy

work for na usea and fatigue.

Im r igid I had m y last chemo treatm ent on Chr istm as Ev e because I wanted it on the

day I was due for it , she said. But I couldnt hav e completed the progra m with out the

psy chosocial support .

Palliativ e care experts now w ant to study patients with other cancers, heart disease,

stroke, dementia and emphysema. But the Nat ional Institu tes of Health is under budget

pressur e, and the other ma jor sour ce of money for m edical research, t he pharmaceutica l

industry , ha s little incentiv e to study palliativ e care. This trial was paid for by the

Am erican Society of Clinical Oncology and priv ate philanth ropy .

Philanth ropists tend to focus on curing cancer, Dr. Temel said. But we can t ignore

people who need end-of-life care.