Metastatic lung cancer is hard to treat. So if there were a treatment for people with the disease that had minimal side effects, could extend not just the quantity of life but also its quality, we’d expect it to be a blockbuster. There is indeed such a treatment, as described in research published in the New England Journal of Medicine in 2010, but it’s not a tablet. It’s palliative care.
To many patients and their families, palliative care can sound like the end of the road. As a doctor I am often asked, isn’t that for when things are hopeless? It’s true that palliative care does not aim to cure disease but to treat its symptoms, from pain and anxiety to constipation. Good palliative care means measuring treatments in terms of what they do for quality of life – not what they do to the cancer on a CT scan.
So the results of the research are counterintuitive: patients who received early palliative care and less aggressive treatment lived longer. Shouldn’t patients expect full-on chemo or radiotherapy to result in longer life?
Certainly there are many cancers where these kinds of treatments can be effective cures, but the US trial involved patients whose lung cancer had already spread. One group got standard oncology care, the other had some input from oncologists in addition to early palliative care.
The people in the palliative care group had less aggressive care, but lived an average of two months longer, and enjoyed sustained improvements in their mood and quality of life. The conclusion must be that some of treatments that had been routinely administered in the past were doing more harm than good. Rather than palliative care being “last ditch”, it extended life and improved its quality.
This kind of information is very powerful when trying to weigh up the pros and cons of further treatment. Despite death being our only shared destiny, there is an amazing amount of misinformation about what medicine can achieve at the end of life, especially around morphine. This is an ancient drug and a staple of end-of-life care. Yet there have been frequent media stories describing patients being left in agony when morphine hasn’t been prescribed generously enough.
Indeed, I remember being taught as a medical student more than 20 years ago that morphine should be used sparingly for pain because, as a respiratory depressant, it would slow and could even stop patients’ breathing. This was supposedly why some terminally ill people died – as a result of an overdose of opioid, rather than the cancer itself.
Patients and relatives often give concerns about addiction as a reason why they don’t want morphine, and instead struggle on with pain. In fact, it is extremely unusual for addiction to be a problem when morphine is used in cancer care. As for the claim morphine brings about an earlier death when used for pain relief it simply isn’t based in evidence. For example, one Japanese study compared the use of opioids by people in hospices and found that there was no relationship between the dose used and time of death.
An overdose of morphine will of course stop the breathing and hasten death, but in terminal care the dose is carefully monitored and increased over time. Used in this way, it asn’t been shown to cause respiratory depression. In fact, small amounts of morphine are an effective treatment for the distress of breathlessness experienced by people with severe chronic bronchitis nearing the end of their lives. Rather than adversely affecting breathing, morphine can help people feel less breathless. Indeed, even very large doses of morphine can be used if needed. That someone crying out in pain for their next dose should be denied this form of pain relief is dreadful, and needless.
Because “morphine” and “palliative” are words often associated with fear, this in turn can mean that healthcare staff – and I include myself – are afraid to mention them. In reality, the real harm is in not having these conversations. Currently,only about half of those who want to die at home actually do – and good palliative care can help more people to do so.
It may be hard to talk about, but to get our death care better we have to know the facts about what is likely to help us at the end of our lives. Palliative care is pretty good.
