Embarrassingly, I didn’t know about this until I heard it at a RACP conference last week.
EVOLVE is a physician led initiative to ensure the highest quality patient care through the identification and reduction of low-value practices and interventions. Many specialties have created their own lists.
ANZSPM, the Australian and New Zealand Society for Palliative Medicine, have nominated 5 interventions which they recommend against in palliative care.
“The Australian and New Zealand Society of Palliative Medicine and the Australasian Chapter of Palliative Medicine (ANZSPM / AChPM) has reviewed the evidence and consulted with its expert members to develop the following recommendations to support best patient care and reduce the use of unnecessary or ineffective practices within a given clinical context.
- Do not delay discussion of and referral to palliative care for a patient with serious illness just because they are pursuing disease-directed treatment.
- Do not delay conversations around prognosis, wishes, values and end of life planning (including advance care planning) in patients with advanced disease
- Do not use oxygen therapy to treat non-hypoxic dyspnoea in the absence of anxiety or routinely use oxygen therapy at the end of life
- Do not use percutaneous feeding tubes in patients with advanced dementia; instead use oral assisted feeding
- To avoid adverse medication interactions in cases of poly-pharmacy, do not prescribe medication without conducting a drug regimen review”
Well nothing to disagree with there (not sure about using oxygen in non hypoxic dyspnoea being fine if there is anxiety? Maybe it is just shorthand for “you don’t need oxygen, and it’s better to use education and treat the anxiety, but sometimes you can’t get round it, and the oxygen helps the person even though it shouldn’t, and really, just go ahead if it makes the person feel better. ” Mmm, their statement is definitely more concise.
I might sub in “First do no harm; cancer treatment with chemotherapy or immunotherapy in a patient with poor performance status can do more harm than good.”
Thoughts? Did they miss anything? What is in your top 5?
I think the list should better reflect the change in physician objective when a patient enters palliative care. Quality of life trumps quantity of life. So i support the suggestion in the Palliverse post that
In the same vein ( ! ), the #1 on the list in Internal Medicine should be here in Palliative Care:
Avoid medication-related harm in older patients (>65 years) receiving five
or more regularly used medicines by performing a complete medication
review and deprescribing where appropriate 1Studies show that the risk of medication-related harm rises once the number of regularly
prescribed medicines exceeds five; this risk increases exponentially as the number reaches
eight or more. Medicines that deserve particular attention are benzodiazepines and other
sedative-hypnotics, anti-psychotics, hypoglycaemic agents, antithrombotic agents,
anti-hypertensives, and anti-anginal agents.
Trying to achieve aggressive treatment targets, such as BP <130/80 or HbA1c <7 per cent, in
frail older patients with multiple co-morbidities confers little benefit and a higher risk of harm.
Discontinuation should be considered where past indications for specific medicines are no
longer valid, the risk of harm outweighs the benefits within a patient’s remaining life span,
or medicines are associated with past toxicity or non-adherence.
More philosophically, I quibble about a list of things to not do. To “ensure the highest quality patient care” there are many high value palliative actions which rank ahead of a list of practices to be stopped. So I think the list unintentionally results in a distraction from higher objectives.
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Thanks for your comment Glen, I agree! I think we are not taught enough about medication related harms, especially in older people.
True also, the comment about it being a list of things NOT to do.
I support : “First do no harm; cancer treatment with chemotherapy or immunotherapy in a patient with poor performance status can do more harm than good.”
But the entry into palliative care is a time marked by a change in health care philosophy. Quality of life is the new goal and there is explicit acceptance that quantity of life is finite and of greatly reduced priority. It is a time for education of family members and the customisation of care to the patient’s wishes.
There are clear new positive goals at the forefront of the minds of all involved. So producing a list of top five things NOT to do is a bit like making a list of the top five things a bride should frown about. However accurate the list (Groom arrives in lycra, tornado hits, no bubbly etc) brides are not rushing to read it.
Ok, so now the “Don’t” list can be set aside once we use it to help guide the “Do” list.
The Geriatric Medicine List also has some overlap, eg “Do not prescribe medication without conducting a drug regimen review”. It also warns against antipsychotics in dementia, benzodiazepines, antibiotics for axymptomatic bacteriuria, and physical restraint use for delirium