Uniformed Services University of the Health Sciences (Dr. Arnold); Naval Hospital Jacksonville, Fla (Drs. Hayes and Sullivan) michael.arnold@usuhs.edu
The authors reported no potential conflicts of interest relevant to this article.
The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States government.
Priorities for patients likely to live more than a year
For patients who likely have more than a year to live, the focus is on symptom management and preparation for future decline. Initiate and facilitate discussions about end-of-life topics. Cancer survivors are often open to discussions on these topics, which include advanced directives, home health aides, and hospice.13 Patients can set specific goals for their remaining time, such as engaging in travel, personal projects, or special events. Cancer patients have better end-of-life experiences and families have improved mental health after these discussions.14 Although cancer patients are more likely than other terminal patients to have end-of-life discussions, fewer than 40% ever do.15
Address distressing symptoms with a focus on maintaining function. More than 50% of advanced cancer patients experience fatigue, weakness, pain, weight loss, and anorexia,16 and up to 60% experience psychological distress.17Deprescribing most preventive medications is recommended with transition to symptomatic treatment.18
Priorities for patients with less than a year to live
For patients who may have less than a year to live, focus shifts to their wishes for the time remaining and priorities for the dying process. Most patients start out with prognostic views more optimistic than those of their physicians, but this gap narrows after end-of-life discussions.19,20 Patients with incurable cancer are less likely to choose aggressive therapy if they believe their 6-month survival probability is less than 90%.21 Honest conversations, with best- and worst-case scenarios, are important to patients and families, and should occur while the patient is well enough to participate and set goals.22
The national shortage of physicians providing outpatient palliative care services is a gap that family physicians should step into.
In the last months of life, opioids become the primary treatment for pain and air hunger. As function declines, concerns about such adverse effects as falls and confusion decrease. Opioids have been shown to be most effective over the course of 4 weeks, and avoiding their use in earlier stages may increase their efficacy at the end of life.23
Hospice benefit—more comfort, with limitations
Hospice care consists of services administered by nonprofit and for-profit entities covered by Medicare, Medicaid, and many private insurers.24 Hospice strives to allow patients to approach death in comfort, meeting their goal of a “good death.” A recent literature review identified 4 aspects of a good death that terminally ill patients and their families considered most important: control of the dying process, relief of pain, spirituality, and emotional well-being (TABLE 1).25
