Procedures 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 (eg, 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.
      Palliative Treatment of Malignant Ascites
  • Thoracocentesis 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.
      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.
    Using Non-Invasive Ventilation at the End-of-Life


Decision making in palliative care - A guide to approaching care choices

A review of how to apply key concepts in clinical decision making: quality of life, goals of care, medical futility, and burden.
Decision making in palliative care (190kb pdf)

From: Palliative Info, Canada

Palliative Care Network of Wisconsin Fast Facts - Additional resources relating to investigations and procedures

# 177 Palliative Treatment of Malignant Ascites
This Fast Fact will review treatment approaches and the important role of determining the Serum Ascites-Albumin Gradient as a diagnostic and treatment aid.

# 157 Malignant Pleural Effusions Interventional Management
This Fast Fact reviews key facts regarding effusion management.

# 084 Swallow Studies, Tube Feeding and the Death Spiral, 2nd ed
The reflex by families and doctors to provide nutrition for the patient who cannot swallow is overwhelming.

# 209 Malignant Pericardial Effusions
Malignant pericardial effusions (MPEs) are a rare complication of advanced cancer, but are associated with high morbidity and mortality. This Fast Fact discusses the diagnosis and management of MPEs.

# 230 Using Non-Invasive Ventilation at the End-of-Life
Non-invasive positive pressure ventilation (NPPV, often called 'BiPAP') is commonly used in patients with respiratory failure from COPD, congestive heart failure (CHF), and other disorders. This Fast Fact discusses medical decision making around the use of Non-Invasive Positive Pressure Ventilation (NPPV) at the end-of-life.

# 231 Practical Aspects of Using NPPV at the End-of-Life
This Fast Fact discusses practical aspects of how using NPPV can be used to palliate dyspnea in dying patients.

From: Palliative Care Network of Wisconsin Fast Facts (US)

How to - Procedural guidance on ascitic and pleural taps

From: Palliative Guidelines PLUS

Last updated 16 February 2017