Interventions to manage symptoms at the end of life.

The aim of this article is to summarize the current evidence base about interventions that improve symptoms at the end of life. Moderate to severe symptoms are highly prevalent in the weeks and months before death: 1.4 million individuals have dyspnea; and 1 million have pain. Of those with pain, 300,000 want more pain relief. 700,000 may need more relief, but do not receive it because of the myth of opioid addiction; their physicians do not know how to manage the adverse effects of pain relieving therapies, or they don't know the various options that are available for pain relief. Of the 1 million Americans who die in hospitals, 324,000 had fatigue, 280,000 anorexia, 244,000 dyspnea, 232,000 xerostomia, 208,000 cough, 196,000 pain, 148,000 confusion, 148,000 depression, 140,000 nausea, 92,000 insomnia in 23, and 88,000 vomiting. This is caused in part by clinician ignorance. In a representative sample of oncologists, the most important source of information about symptom control was trial-and-error in practice. In addition, large, well-designed, well-controlled studies of patients at the end of life have not been performed. Clinical practice is guided by extrapolation of data from other populations and from anecdote. The system of care provided by hospice programs in the U.S. provides improved symptom control as compared with hospitals, home health agency, and nursing home systems. Population-based studies of prevalence are needed to gauge outcomes of the implementation of measures to relieve symptoms. Well-powered, definitive studies of both existing and new approaches in terminally ill patients with the most common symptoms are needed. The health care system interventions that are effective in hospice care must be studied so that they can be broadly applied to the care of all dying Americans.