Palliative care

Five Things Physicians and Patients Should Question

Released October 29, 2014


Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment.

Palliative care provides an added layer of support to patients with life-limiting disease and their families. Symptomatic patients can benefit regardless of their diagnosis, prognosis or disease treatment regimen. Studies show that integrating palliative care with disease-modifying therapies improves pain and symptom control, as well as patient quality of life and family satisfaction. Early access to palliative care has been shown to reduce aggressive therapies at the end of life, prolong life in certain patient populations, and significantly reduce hospital costs.


Don’t delay advance care planning conversations.

Advance care planning is a process, which includes choosing a surrogate or alternate decision-maker and communicating values or wishes for medical care. This helps prepare a person for in-the-moment medical decision-making, as well as guiding their surrogate or alternate decision-maker should the person lose capacity for decision-making. Advance care planning is appropriate for healthy adults and patients with their family and healthcare providers, early, recurrently, and as circumstances change. Evidence shows that advance care planning conversations improve patient and family satisfaction with care and concordance between patients’ and families’ wishes, increase the completion of advance care planning documents, reduce the likelihood of patients receiving hospital care and the number of days spent in hospital, and increase the likelihood of receiving hospice care.


Don’t use oxygen therapy to treat non-hypoxic dyspnea.

Oxygen is frequently used to relieve shortness of breath in patients with advanced illness; however, supplemental oxygen does not benefit patients who are breathless but not hypoxic. Supplemental flow of air has been found equally effective to oxygen in this context.


Don’t use stool softeners alone to prevent opioid induced constipation.

Docusate is a widely used stool softener. A review of the evidence found that docusate is no more effective than placebo in the prevention or management of constipation and suggests that the drug has very little utility when given alone for opioid-induced constipation. Compared with placebo, docusate did not increase stool frequency or soften the stool. Docusate also failed to alleviate the common symptoms of opioid-induced constipation such as difficulty passing stools, hard stools, abdominal cramping, and incomplete stool passage.


Don’t transfuse red blood cells for arbitrary hemoglobin or hematocrit thresholds in the absence of symptoms, or if no benefit was perceived from previous transfusions.

Indications for blood transfusion depend on clinical assessment and are also guided by the etiology of the anemia. No single laboratory measurement or physiologic parameter can predict the need for blood transfusion. Transfusions are associated with increased morbidity and mortality in high-risk hospitalized inpatients. Adverse events range from mild to severe, including allergic reactions, acute hemolytic reactions, anaphylaxis, transfusion related acute lung injury, transfusion associated circulatory overload, and sepsis.

How the list was created

The Canadian Society of Palliative Care Physicians (CSPCP) established its Choosing Wisely Canada Top 5 recommendations by first establishing a small group of its members to compile a short list of 10 suggestions. Recommendations were based on experience and relevance to palliative care practice in Canada. The short list was circulated to the CSPCP board members and to all relevant national and provincial palliative care bodies representing a broad range of geographical regions, practice settings, institution types and experience for feedback. Following this review, members of the CSPCP were asked to participate in an online survey and rank the 10 suggestions in order of importance and relevance. The online survey was launched at the Annual International CSPCP conference. From the feedback of the survey the top 5 suggestions were chosen and refined. The recommendations were discussed and revised with the Choosing Wisely Canada campaign team to ensure the recommendations were in keeping with the overall campaign objectives. A literature search to support the recommendations was completed with the assistance of the independent Canadian Agency for Drugs and Technologies in Health (CADTH) and Health Quality Ontario (HQO). Item 1 was adapted with permission from the Five Things Physicians and Patients Should Question in Hospice and Palliative Medicine. © 2013 American Academy of Hospice and Palliative Medicine. Item 5 was adopted with permission from the Five Things Physicians and Patients Should Question. © 2014 Canadian Society of Internal Medicine.



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