Definitions for the strength of evidence (high, moderate low, insufficient evidence to determine benefits or risks) and strength of recommendations (strong, weak, I - recommendation) are repeated at the end of the Major Recommendations.
Recommendation 1: In patients with serious illness at the end of life, clinicians should regularly assess patients for pain, dyspnea, and depression. (Grade: strong recommendation, moderate quality of evidence.)
Patients needing end-of-life care may present with substantial symptoms, including pain; discontinuity in care; and substantial caregiver burdens. These concerns are critically important for patients and families coping with serious chronic illnesses. Although each patient and family will require individualized assessment and care, the evidence shows that a set of general issues is shared widely among patients needing end-of-life care. These issues include pain and other symptom management, psychological well-being, care coordination, and advance care planning, and caregiver burden. The evidence was classified as moderate quality because it was mostly derived from studies of patients with cancer or cancer-predominant populations in addition to being heterogeneous.
Recommendation 2: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage pain. For patients with cancer, this includes nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates. (Grade: strong recommendation, moderate quality of evidence.)
Clinicians should use specific effective therapies for all patients with acute and chronic pain. Strong evidence supports using nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates for pain relief in patients with cancer. Bisphosphonates are effective for bone pain relief in patients with breast cancer and myeloma.
Recommendation 3: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage dyspnea, which include opioids in patients with unrelieved dyspnea and oxygen for short-term relief of hypoxemia. (Grade: strong recommendation, moderate quality of evidence.)
Opioids should be considered in patients with severe and unrelieved dyspnea, for example, in cancer and cardiopulmonary disease at the end of life. Clinicians should consider the use of oxygen for hypoxemia for advanced chronic obstructive pulmonary disease. Evidence also supports the use of beta-agonists for treating dyspnea in chronic obstructive pulmonary disease, but this use has not been studied for end-of-life care.
Recommendation 4: In patients with serious illness at the end of life, clinicians should use therapies of proven effectiveness to manage depression. For patients with cancer, this includes tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial intervention. (Grade: strong recommendation, moderate quality of evidence.)
Clinicians should assess for and manage symptoms of depression in patients with serious chronic diseases. For patients with cancer, strong evidence shows that depression should be treated with generally effective therapies, including tricyclic antidepressants, selective serotonin reuptake inhibitors, or psychosocial interventions. Because the strong evidence is derived only from the studies that included patients with cancer and not for all patients at the end of life, it is classified as moderate on average.
Recommendation 5: Clinicians should ensure that advance care planning, including completion of advance directives, occurs for all patients with serious illness. (Grade: strong recommendation, low quality of evidence.)
All care planning must address certain elements, such as surrogate decision makers, resuscitation, and emergency treatment, and should occur as early as possible in the course of serious illness before the end of life. Care planning must anticipate specific issues for each patient's clinical course, for example, the management of dementia, including tube feeding; whether to initiate or continue chemotherapy in patients with cancer; and whether to deactivate implantable cardioverter defibrillators in patients who have intractable congestive heart failure. Care plans should be reassessed when significant clinical change occurs. Moderate evidence supports the effectiveness of multicomponent interventions in increasing advance directives. Research shows that skilled facilitators and a system focusing on various key decision makers, such as patients, caregivers, and providers, as well as improving shared understanding of values are critical in the planning of care.
Strength of Evidence
This guideline grades the evidence and recommendations by using the American College of Physicians' clinical practice guidelines grading system adopted from the classification developed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) workgroup (see table below).
The American College of Physicians' Guideline Grading System
|Quality of Evidence
||Strength of Recommendation
|Benefits Clearly Outweigh Risks and Burden OR Risks and Burden Clearly Outweigh Benefits
||Benefits Finely Balanced with Risks and Burden
|Insufficient evidence to determine benefits or risks
||I - recommendation