Procedures and investigations

Considering burdens and benefits 

For palliative care patients, quality of life is a key goal. Consider the impact and likely value of treatments and investigations.

Key points

• The benefits, burdens and costs of all investigations and procedures should be carefully considered for palliative care patients. The clinical judgements can sometimes be difficult, and seeking advice from a palliative care specialist may be helpful.
  • Quality of life and wellbeing may should be assessed by looking at the patient, and considering their performance state, as well as by looking at scans and blood tests.
  • Encouraging less focus on monitoring of results (e.g. scans, blood tests, tumour markers, weight) may be psychologically helpful as disease progresses - although this is sometimes difficult for both doctors and patients.
  • Not all problems that are diagnosed will be reversible, and reversing a problem may not always make a person feel better or improve their performance state. Treatment decisions should therefore be individualised and made in the context of the patient’s goals of care.
  • When a person’s prognosis is short, the benefit of investigations and treatments becomes increasingly marginal, and risks associated with hospitalisation increase.
  • An investigation which is unlikely to lead to any change in management of the patient is probably unnecessary, nor is it usually appropriate to investigate if a patient would not wish to be treated.
  • Monitoring renal function, liver function, and albumin levels intermittently can be helpful to assist in safe prescribing.
• Abdominal paracentesis to drain ascites is a relatively simple procedure that does not usually require admission to hospital. It can provide effective short-term symptom relief in people with uncomplicated ascites.
  
• The rate of recurrence of ascites following a tap is generally an indication of disease activity.
• Frequently recurring ascites in a patient with a prognosis of months may benefit from placement of a port to allow drainage of smaller volumes more frequently at home.
  Wisconsin Fast Facts: Palliative Treatment of Malignant Ascites.
• Thoracentesis to drain pleural effusions can sometimes improve dyspnoea and other related symptoms, however it has a risk of pneumothorax or haemothorax. Ideally, the procedure should be done where x-ray and resuscitation equipment and the facility to insert a chest tube with underwater sealed drain are available.
  • The rate of reaccumulation of an effusion following a tap is generally an indication of disease activity
  • Frequently recurring pleural effusions in a patient with a prognosis of months or more may benefit from placement of a pleural catheter to allow drainage of smaller volumes more frequently at home.
    Wisconsin Fast Facts: Malignant Pleural Effusions Interventional Management
• Palliation of severe dyspnoea by non-invasive ventilation (BiPAP) is sometimes an option. It is used most commonly in end-stage chronic obstructive pulmonary disease (COPD). However the implications for dying patients need to be carefully considered.
  Wisconsin Fast Facts: Using Non-Invasive Ventilation at the End-of-Life