Non-cancer diseases that can be life-limiting and how they respond to palliative care

Dr Arun Ghoshal, MD, MRes

Palliative medicine physician

Traditionally, palliative care services have focused on patients with incurable cancer. In its 2004 guidance document Improving Supportive and Palliative Care for Adults with Cancer the National Institute for Clinical Excellence (NICE) emphasizes the importance not only of optimal symptom control but also of psychological, social, and spiritual support for patients and their families. Many physicians believe that access to palliative care should be based on need rather than diagnosis. Interestingly, many patients with non-malignant diseases face a lot of suffering and thus qualify as well. However, this is not yet common practice. Part of the reason is a lack of research or services that have developed for advanced cancer over the years.

Disease-Specific Indicators suggesting that referral to specialist palliative care services may help the physician or patient or family/caregivers. NOTE: general palliative care measures should be provided for symptoms and concerns irrespective of severity.

Renal Disease

Not suitable for, able or willing to undergo dialysis or transplant and at least one of

• Patient wishes to stop dialysis or clinical team deem further dialysis to be futile
• Uncontrolled symptoms (severe nausea, pruritus, restlessness, altered consciousness)
• Intractable fluid overload
• Rapid deterioration anticipated by the renal team

Liver Disease

• Ascites despite maximum diuretics; spontaneous peritonitis
• Jaundice; Hepatorenal syndrome
• PTT > 5seconds above control
• Encephalopathy
• Recurrent variceal bleeding if further intervention inappropriate
• Being considered for organ transplantation

Pulmonary Disease

At least one of

• shortness of breath on little exertion (Modified Medical Research Council grade 3 or 4)
• documented progressive disease
• symptomatic right heart failure
• cachexia
• being considered for organ transplantation

Cardiac Disease

At least one of

• advanced heart failure (New York Heart Association Grade 3/4)
• two or more admissions to the hospital within the last 12 months with symptoms of heart failure
• physical or psychological symptoms despite optimal tolerated therapy
• symptomatic arrhythmias resistant to treatment
• physical damage (e.g., stroke) following resuscitation for cardiac arrest
• cardiopulmonary resuscitation in the event of a cardiac arrest is futile or unwanted by the patient
• Poor quality of life
• being considered for organ transplantation
  

Neurological Disease

Significant progressive decline in function and at least one of

• Inability to walk
• Dependence on assistance with activities of daily living
• Barely intelligible speech; difficulty in communication
• Cachexia; difficulty eating and drinking and declines feeding tube
• Significant dyspnoea and/or requires oxygen at rest and declines assisted ventilation
  

Stroke

• Persistent vegetative state
• Severe dysphagia
• Post-stroke dementia
• Poor nutritional status

Other situations

• Multiple co-morbidities
• Patient medically unfit for surgery for the life-threatening disease
• Failure to respond to Intensive Care and death inevitable