Managing symptoms in end-of-life care

Family physicians who care for terminally ill patients must manage a wide range of bothersome symptoms, including pain, fatigue, dyspnea, delirium, and constipation. According to a Cochrane for Clinicians article in the December 1st issue of AFP, constipation affects up to half of all patients receiving palliative care and nearly 9 in 10 palliative care patients who use opioid medications for pain. Unfortunately, a Cochrane review found limited evidence on the effectiveness of laxatives in these patients, as Dr. William Cayley Jr. comments:

For patients with constipation, especially those with opioid-induced constipation, there is insufficient evidence to recommend one laxative over another. The choice of laxatives should be based on past patient experience, tolerability, and adverse effects. Methylnaltrexone is a newer agent that may be useful especially for patients with opioid-induced constipation that has not responded to standard laxatives, but there is limited evidence of potential adverse effects. Therefore, judicious use preceded by a discussion with patients about known risks and benefits is warranted.

The Cochrane Library recently discussed this review in its Journal Club feature, which includes open access to the full text of the review, a podcast by the authors, discussion points, and a Powerpoint slide presentation of the review's main findings.

Additional resources for physicians and patients on advanced directives, hospice care, and ethical issues are available in the AFP By Topic collection on End-of-Life Care. A collection of previous Cochrane for Clinicians articles is also available online.