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Aug ust 18, 2010

Palliative Care Extends Life, Study Finds

By DONALD G. McNEIL Jr.
In a study that sheds new light on the effects of end-of-life care, doctors hav e found that
patients with term inal lung cancer who began receiv ing palliativ e care im m ediately upon
diagnosis not only were happier, m ore m obile and in less pain as the end neared — but they
also liv ed nearly three m onths longer.

The findings, published online Wednesday by The New England Journal of Medicine,
confirm ed what palliativ 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 erhaul
passed last y ear.

“It shows that palliativ e care is the opposite of all that rhetoric about ‘death panels,’ ” said
Dr. Diane E. Meier, director of the Center to Adv ance Palliativ e Care at Mount Sinai School
of Medicine and co-author of an editorial in the journal accom pany ing the study . “It’s not
about killing Granny ; it’s about keeping Granny aliv e as long as possible — with the best
quality of life.”

In the three-y ear study , 1 51 patients with fast-growing lung cancer at Massachusetts
General, one of the nation’s top hospitals, were random ly assigned to get either oncology
treatm ent alone or oncology treatm ent with palliativ e care — pain relief and other
m easures intended to im prov e a patient’s quality of life. They were followed until the end
of 2 009 , by which tim e about 7 0 percent w ere dead.

Those getting palliativ e care from the start, the authors said, reported less depression and
happier liv es as m easured on scales for pain, nausea, m obility , w orry and other problem s.
Moreov er, ev en though substantially fewer of them opted for aggressiv e chem otherapy as
their illnesses worsened and m any m ore left orders that they not be resuscitated in a crisis,
they ty pically liv ed alm ost three m onths longer than the group getting standard care,
who liv ed a m edian of nine m onths.

Doctors and patients “traditionally see palliativ e care as som ething extended to a
hospitalized patient in the last week of life,” said Dr. Jennifer S. Tem el, an oncologist and
author of the paper. “We thought it m ade sense to start them at the tim e of diagnosis. And
we were thrilled to see such a huge im pact. It shows that palliativ e care and cancer care
aren’t m utually exclusiv e.”

Dr. Atul Gawande, a Harv ard Medical School surgeon and writer who just published a long
article in The New Yorker about hospitalized patients’ suffering before death, called the
study “am azing.”

“The field was cry ing out for a random ized trial,” he added.

Although the study could not determ ine w hy the patients liv ed longer, the authors and
other experts had sev eral theories: depression is known to shorten life, and patients w hose
pain is treated often sleep better, eat better and talk m ore with relativ es. Also, hospitals
are dangerous places for v ery sick people; they m ay get fatal blood infections, pneum onia
or bedsores, or sim ply be ov erwhelm ed by the powerful drugs and radiation attacking
their cancer.

Say ing the study was “of critical im portance,” Dr. R. Sean Morrison, president of the
Am erican Academ y of Hospice and Palliativ e Medicine, said it w as the “first concrete
ev idence of what a lot of us hav e seen in our practices — when y ou control pain and other
sy m ptom s, people not only feel better, they liv e longer.”

There is som etim es tension between m edical specialties, since surgeons and oncologists
often v iew cancer as a battle, while palliativ e care specialists are seen as “giv ing up.”

Palliativ e care ty pically begins with a long conv ersation about w hat the patient with a
term inal diagnosis w ants out of his rem aining life. It includes the options any oncologist
addresses: surgery , chem otherapy and radiation and their side effects. But it also includes
how m uch suffering a patient wishes to bear, effects on the fam ily , and legal, insurance
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 m aking m eals, dressing and bathing w hen not hospitalized.

Hospice care is intensiv e palliativ e care including hom e nursing, but insurers and
Medicare usually cov er it only if the patient abandons m edical treatm ent and two doctors
certify that death is less than six m onths away .

During the debate ov er President Obam a’s 2 009 health care bill, prov isions to hav e
Medicare and insurers pay for optional consultations with doctors on palliativ e and hospice
care led to rum ors, spread by talk-show hosts like Rush Lim baugh and Glenn Beck and by
the form er v ice-presidential candidate Sarah Palin, that the bill em powered “death
panels” that would “euthanize” elderly Am ericans.

Legislators ev entually rem ov ed the prov isions. In practice, Medicare and priv ate insu rers
do pay for som e palliativ e care, said Dr. Gail Austin Cooney , a form er president of the
palliativ e m edicine academ y . “But it’s piecem eal,” she said. “The billing is com plicated,
and for m any phy sicians that’s enough of a deterrent to not bother.”

Dr. Cooney herself had such care along with surgery and chem otherapy for ov arian
cancer in 2 008.

“I decided I wanted ev ery drop of chem otherapy they could giv e m e, and it was v ery
painful, dum ping the drugs directly into m y belly ,” she said. She needed powerful
painkillers, and also chose alternativ e-m edicine options like acupuncture and “energy
work” for nausea and fatigue.

“I’m rigid — I had m y last chem o treatm ent on Christm as Ev e because I wanted it on the
day I was due for it,” she said. “But I couldn’t hav e com pleted the program without the
psy chosocial support.”

Palliativ e care experts now want to study patients with other cancers, heart disease,
stroke, dem entia and em phy sem a. But the National Institutes of Health is under budget
pressure, and the other m ajor source of m oney for m edical research, the pharm aceutical
industry , has little incentiv e to study palliativ e care. This trial was paid for by the
Am erican Society of Clinical Oncology and priv ate philanthropy .

“Philanthropists tend to focus on curing cancer,” Dr. Tem el said. “But we can’t ignore
people who need end-of-life care.”