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Study shows benefits from palliative care

By Amos Esty

Bakitas led a study which showed that giving patients a chance to talk about end-of-life issues lifted their mood.

Marie Bakitas, D.N.Sc., has long believed that palliative care improves the lives of patients; now she has the data to prove it. Bakitas, an assistant professor at DMS, led a recent trial which found that patients with advanced cancer who were enrolled in a palliative-care program reported higher quality of life and better mood than patients not enrolled in the program.

Debate: The results were particularly timely given that they were published, in the Journal of the American Medical Association, in the midst of a national debate that had some critics of health-care reform equating end-of-life counseling with "death panels."

The goal of palliative care is to help patients and their families cope with the problems that accompany challenging diseases. Bakitas says that over the course of her time working in palliative care, she has witnessed a number of positive effects. "What palliative care does is it gently and sensitively addresses mortality," she says. "If you knew that you only had a certain period of time to live, how would you want to live it?" When people are given the opportunity to discuss such issues, she says, they are better able to make decisions consistent with their personal values.

In 1999, palliative care was just gaining recognition as a potential part of end-of-life treatment when DHMC began a small demonstration project designed to assess its benefits. The project went well, so the team working on it decided to conduct a clinical trial to quantify the improved quality of life they had observed anecdotally in patients who received palliative care.

From 2003 to 2008, they enrolled 322 patients with advanced cancer in the trial. Half received standard care, and half received palliative care. However, Bakitas notes, by the time the trial began, "standard" care at DHMC included the option of using palliative-care services. So, she says, some of the patients in the control group also got some palliative care.

Loss: All the patients in the palliative-care group received an intervention dubbed Project ENABLE (short for Educate, Nurture, Advise, Before Life Ends). It was led by advanced-practice nurses and began with four educational sessions designed to help patients identify and solve some of the problems likely to arise during the course of their treatment—such as ensuring that they got the medical attention they needed, were able to manage their symptoms, made decisions about finances and advance planning, and dealt with feelings of loss and grief.

"Palliative care . . . gently and sensitively addresses mortality."

Mood: After the four sessions, the nurses followed up with patients once a month. They measured their quality of life, mood, and symptom intensity at the start of the trial, after one month, and then every three months thereafter.

Bakitas and her collaborators found that patients in the palliative-care group reported a higher quality of life and better mood than patients in the control group. One interesting finding, she says, was that even as the intensity of patients' symptoms increased, their quality of life improved. "The things we were doing were allowing them to be able to cope with the physical symptoms."

The team had also hypothesized that the palliative interventions would lead to lower symptom intensity and less use of medical resources, but they did not find statistically significant differences in those endpoints.

Bakitas recently got word that DHMC has received funding for a follow-up trial. One question it will address is when palliative care should be offered to make it as effective as possible. Some patients will be enrolled in the palliative-care program immediately after receiving a diagnosis of advanced cancer; others will be enrolled four months after their diagnosis. The trial will also examine selected biomarkers that could indicate whether the palliative intervention gives a boost to patients' immune systems.

Bakitas hopes the findings so far will help convince providers nationwide to offer palliative care. "Probably one of the obstacles in other cancer centers is that the oncologists still have this fear of exposing their patients who have incurable cancers to that information," she says. Given the results of the Dartmouth trial, that position may become increasingly difficult to take.

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