PALLIATIVE CARE

The purpose of palliative care is to provide care for patients with life-limiting illnesses. The focus of care for the patient at this time is to keep them comfortable. This type of care can be started at the beginning of the patient’s diagnosis (as opposed to hospice care, which is initiated when all acute care and curative treatments have been ceased).

The goals of palliative care are to:

Provide relief from symptoms, including pain
Affirm life and neither hasten nor postpone death
Support holistic patient care and enhance quality of life
Offer support to patients to live as actively as possible
Offer support to the family during the patient’s illness
(Harding et al., 2020)

Common palliative treatments for patients with lung cancer include addressing:

Nausea during systemic therapy treatments
Postoperative or any other kind of pain
Depression throughout the course of the illness
Constipation from narcotic pain medications
(Hospice Alliance, 2020)

Palliative Pharmacology Treatment

The purpose of palliative care is to foster comfort and as much independence as possible when a patient receives a life-limiting diagnosis and through the course of their care. When there is a question whether a patient in palliative care needs medications or not, the medications are given.

Pain is the most frequent symptom in terminal illnesses. The most common classification of analgesics for this patient population is narcotics. Narcotics are highly effective for treating severe pain but can cause several side effects such as respiratory depression, hypotension, itching, constipation, and more. If the patient does not have an IV or is no longer able to swallow, morphine sulfate liquid drops may be given sublingually and are therapeutic.
Nausea and vomiting (n/v) are common sequelae of chemo- and radiation therapies. The antiemetic used almost exclusively if there is IV access is ondansetron HCl (Zofran). An over-the-counter antiemetic that is effective for palliative care patients is dimenhydrinate (Dramamine). More recently, the cannabinoid dronabinol (Marinol) can be given in liquid form for easy swallowing or medical marijuana by inhalation to treat n/v and stimulate appetite.
Delirium as a symptom of terminal patients can be treated by benzodiazepines and sedatives by injection or orally if the patient is able to swallow.
Anxiety or restlessness is treated with an anxiolytic medication such as the benzodiazepine alprazolam (Xanax).
Dyspnea due to hypoxia or a compromised airway can be treated with a bronchodilator or expectorant.
Constipation is common and may be treated with a stool softener, laxative, suppository, or enema.
(Harding et al., 2020)

Palliative Physical Therapy

For a patient in palliative care, an important goal of physical therapy is to maximize the patient’s functional mobility independence. Special consideration is also given to the patient’s and family’s wishes with regard to their individual goals for physical therapy.

As with any patient, the therapist conducts an evaluation of the palliative care patient and determines the extent to which the patient can be physically active given postoperative pain, weakness following systemic therapies, and motivation in the face of a life-limiting diagnosis. In the patient with lung cancer, a palliative treatment plan may address management of breathlessness with breathing retraining, relaxation techniques, and the pacing of activities to ensure that the patient does not become too tired or excessively hypoxic. The plan of care, if the patient and family are in agreement, may also include assistance with mobilization abilities, practicing with gait aids such as walkers and canes, and exercises such as sit-to-stand practice (Physiopedia, 2022).

Palliative Occupational Therapy

Occupational therapists play an important role on palliative care teams by identifying life roles and activities that are meaningful to patients and addressing barriers to performing these activities. Occupational therapists working in palliative care address pain relief and symptom management, provide resources and education for patients and their families, and integrate psychological and spiritual aspects of care with the necessary medical treatments. Additionally, occupational therapists identify current and potential abilities and determine barriers to engaging in occupations, including activities of daily living, instrumental ADLs, rest and sleep, leisure, and social participation (AOTA, 2020).

Palliative Respiratory Therapy

The respiratory therapist is vital to the treatment of a patient with lung cancer throughout every aspect of their treatment and rehabilitation, including during palliative care. Oxygen and a clear airway are critical to the comfort of the patient. The RT conducts pulmonary assessments to determine and recommend the level of oxygen and treatments needed. At the end of life, when the patient goes through distinctive respiratory changes, the respiratory rate increases as the oxygen saturation decreases. The patient may experience Cheyne-Stokes breathing, with rapid respirations alternating with periods of apnea. There may be an inability to cough or independently clear their airway. Irregular breathing with a progressive slowing will occur until there is a cessation of respirations (Harding et al., 2020).

Surgical Procedures for Symptom Palliation

A stenotic airway can be splinted by tracheobronchial airway stents to relieve coughing, dyspnea, or respiratory insufficiency that may be caused by abnormal granulation tissue, lung cancer, metastatic cancers, infections, tuberculosis, lymphoma, or other inflammatory diseases. The stent is cylindrical and placed by bronchoscopy. An airway stent can prevent airway collapse and external compression, or can delay tumor growth advancing into the airway. The stent(s) can be permanent or removable. By maintaining adequate airway patency, atelectasis is prevented and the patient breathes easier (UCSDH, 2020).

For malignant tumors that remain inoperable, bronchoscopic laser interstitial thermal therapy can remove small, obstructive, bronchoscopic tumors. The process uses thermal energy that is transmitted to the cancerous tissue to remove by ablation via laser treatment. This method is safe and effective for the removal of small, peripheral endobronchial obstructions (Casal et al., 2018).