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.
