Lifestyle Medicine Interventions in Patients With Advanced Disease Receiving Palliative or Hospice Care

A broadened search revealed 4 main categories of lifestyle medicine research within hospice and palliative care: exercise, nutrition, stress management, and substance use.

The ongoing clinical care, advocacy, and research within the field of hospice and palliative medicine predominately focuses on the means by which to improve symptom management and quality of life for patients with serious illnesses. ¹ Lifestyle medicine interventions, if applied mindfully, have the potential to aid in improving symptom management and overall quality of life in addition to daily function for these patient populations, especially given the minimal associated risk. ² Lifestyle medicine is characterized by health and wellness modifications that most often include the promotion of a healthy diet, increased physical activity, and limitation of alcohol or tobacco use with a goal of improving overall health and quality of life. Lifestyle medicine interventions are most widely studied and accepted in the management of chronic medical conditions, often in prevention of chronic disease or as the first-line treatment. ³ Similar interventions have the potential to improve the quality of life for persons with advanced disease and more serious illness, but their effects are less well-studied, likely given that this population is particularly vulnerable.

In the article, “Lifestyle Medicine Interventions in Patients with Advanced Disease Receiving Palliative or Hospice Care,” Anandarajah et al, in this issue of American Journal of Lifestyle Medicine, ⁴ review the existing state of literature on lifestyle medicine interventions within hospice and palliative medicine, focusing on patients with advanced or end-stage disease. A broadened search revealed 4 main categories of lifestyle medicine research within hospice and palliative care: exercise, nutrition, stress management, and substance use. While many different lifestyle interventions have been considered for patients with advanced disease receiving hospice or palliative care and have been described in opinion pieces, the authors note a relative paucity of high-quality studies assessing interventions for these patient populations.

Assessment of physical activity interventions demonstrated that such modifications can be both acceptable and feasible to patients with advanced disease receiving palliative or hospice care. Positive impacts on quality of life were seen for patients with cancer and Alzheimer’s disease, and there is some evidence that physical and psychological well-being are improved by physical activity in Alzheimer’s disease as well. As for nutrition, most of the literature reviewed included consensus guidelines of patients with advanced cancer and dementia, but studies were overall limited in this regard. Stress management techniques were noted to be frequently used in these patient populations, but there is also an overall lack of evidence and studies evaluating these interventions. Assessment of substance abuse interventions are similarly lacking. Thus, there is a large gap in research of patients with serious illness receiving hospice or palliative care, especially within the categories of nutrition, stress management, and substance abuse. Review of the existing state of literature additionally demonstrated the overall complexity of implementing lifestyle interventions in this vulnerable population, highlighting the importance of an individually tailored approach for each patient. Particular attention should be paid to the importance of goals of care conversations and the point at which individual patients are along their illness trajectory. ⁴

Lifestyle medicine as related to the concepts of physical fitness and physical ability can initially feel counter to the ideas of comfort and quality of life that characterize the focus of patients with serious illness receiving hospice or palliative medicine services. This is highlighted in this review article with the authors noting several perceived barriers to physical activity, shaped by the perceptions and attitudes of patients toward the interventions, but also likely by patients feeling an overall lack of guidance on how to pursue physical activity amid their disease experience.^4,5 It is indeed novel to attach ideas of wellness to patients living with serious illnesses. As is demonstrated by this review, optimizing patients’ physical and functional abilities can often be key to maximizing quality of life as this allows patients to continue to engage in everyday activities that they value and to maintain a sense of normalcy and self-efficacy. This emphasis is especially important in advanced disease, promoting the hospice and palliative medicine philosophy of living as well as possible for as long as possible.

For many patients, quality of life is defined by independence in general, but especially from a physical and occupational functioning standpoint. Maintaining ability to perform activities of daily living, such as toileting, bathing, and dressing, can be crucial to affirming independence, and lifestyle medicine can serve as a vehicle for patients to maintain self-efficacy in the face of debilitating illness. In this review, a majority of the physical activity intervention studies focused on the population of patients with advanced cancer and did show improvements in quality of life amid different cancer types. The effects on fatigue were mixed, but some improvements were noted in overall mental and physical functioning. ⁴

Engaging in exercise programs or physical and occupational therapy is essential to maintaining functional levels. This not only aids in maintaining independence but may also help prevent further complications that worsen symptomatic experience and quality of life, such as contracture development, decreased joint integrity, and skin breakdown. ⁶ Symptoms of pain and fatigue could potentially be minimized by teaching patients to carry out activities of daily living with modified maneuvers that emphasize energy conservation principles and proper body mechanics. Physical activity and improvements in functional mobility also assist in increasing strength and confidence to prevent future falls as well as decreasing risk for pressure injuries, further reducing risk of progressive debility. ⁷

The authors might consider, in addition to recommending expansion of research on specific physical activity interventions, including occupational therapy–focused interventions as these are crucial to mitigating symptoms and improving quality of life for patients with advanced disease. Such interventions merit more research as assisting patients so that they may participate in their identified valuable community and leisure activities would likely have an effect on overall quality of life. A patient with chronic obstructive pulmonary disease who learns compensatory strategies so that their energy is not wasted during performance of basic care tasks would instead have energy and stamina to engage in tasks that bring them joy, leading to an enhanced quality of life. An Alzheimer’s patient who participates in positioning exercises would be less likely to develop pressure injuries and contractures, improving symptom experience.

Highlighting these aspects of lifestyle medicine should additionally drive policy change, encouraging hospice agencies in general to include restorative physical and occupational therapy as covered by the hospice benefit. Restoring function, preserving independence, and maintaining dignity are often primary goals for patients and, undoubtedly, can affect improving overall quality of life. A stroke patient who has completed rehabilitative care should be able to continue with restorative therapy interventions after electing hospice benefit as this allows ongoing assistance with mobility, positioning, and maintaining independence.

While an emphasis on physical fitness and ability can be viewed as integral to improving symptom control and maintaining quality of life, its promotion should be tempered with advancement of disease, as focusing on fitness and ability may lead to patients feeling personally responsible for their disease progression.^8,9 Furthermore, financial constraints associated with the current hospice reimbursement mechanism must be recognized as a barrier. As noted by the authors, promotion of lifestyle modifications must consider patient and family goals within the wider context of the disease process. Otherwise, patients are at risk of faulting themselves for not engaging vigorously in lifestyle modifications, rather than recognizing that their overall weakening and advancement toward end of life is instead due to disease progression. ⁴

Overall, the authors do an outstanding job summarizing the current state of literature for consideration of lifestyle interventions in the hospice and palliative care population. Although evidence remains limited given the challenges elucidated in studying this vulnerable population, there are compelling reasons to invest more resources into both research of and advocacy for lifestyle interventions, particularly restorative therapies aimed at maintaining independence and dignity in the seriously ill population.