Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Palliative

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Palliative Care - Key Features

1. In all patients with terminal illnesses (e.g., end-stage congestive heart failure or renal disease), use the principles of palliative care to address symptoms (i.e.., do not limit the use of palliative care to cancer patients).

- Guidelines for end-of-life care have been published by the American College of Physicians. They recommend regular patient assessment and treatment for pain, dyspnea, and depression, and obtaining advanced directives from patients with serious illness.
- 6 major components of attributes of a "good death":

(1) adequate pain & symptom management;
(2) patient participation in decision making;
(3) greater preparation for the end of life;
(4) a feeling of meaningfulness at the end of life;
(5) the ability to contribute to the well-being of others;
(6) and affirming the patient as a unique and whole person.

- 5 basic principles of palliative care:

(1) respecting the goals, preferences, and choices of the dying person;
(2) caring for the person's medical, emotional, social, and spiritual needs;
(3) supporting the needs of family members;
(4) helping with access to needed medical healthcare; and
(5) providing excellent care at the end of life.


2. In patients requiring palliative care, provide support through self, other related disciplines, or community agencies, depending on patient needs (i.e.., use a team approach when necessary).

-Communication is critical for ongoing patient and family support. It is important that physicians ask about how caregivers are doing, and about psychological distress and the need for support.
-Families usually suffer emotionally, spiritually, and financially since they care for the patient. Asking & providing information on financial aid or access to social workers can be instrumental in easing these concerns.
-Families and caregivers often need outside help, respite care, or assistance with making arrangements for the body after death. Hospice, social workers, and home health aides can offer great assistance to patients & families in addressing these needs.

3. In patients approaching the end of life:
a) Identify the individual issues important to the patient, including physical issues (e.g., dyspnea, pain, constipation, nausea), emotional issues, social issues (e.g., guardianship, wills, finances), and spiritual issues.
b) Attempt to address the issues identified as important to the patient.

Table: Assessment should include the following (From BMJ Clinical Practice)

History of illness Review the patient's disease course, including the primary illness and pertinent secondary diagnoses. Summarize the previous treatments and patient's response.
Physical symptoms Physical assessment is best organized by symptoms and functional activities, rather than by organ system. The physical examination can be used to confirm findings from the history. Occasionally, diagnostic tests are helpful if they change the care plan and are in line with the patient's goals of care.
Psychological symptoms Inquire re mood/affect, emotions, fears, cognitive state, coping mechanisms, unresolved issues.
Decision-making capacity Evaluate global and decision-specific capacity. Begin advance-care planning discussions.
Social assessment Evaluate the family, community, financial, and environmental circumstances that are affecting the patient.
Spiritual assessment Inquire about personal meaning and value of the patient's life and illness, faith, religious denomination, and desired pastor services.
Practical needs Determine caregiver, dependent, domestic, and residential needs, and how these will change as the patient's illness progresses.
Death planning Determine caregiver, dependent, domestic, and residential needs, and how these will change as the patient's illness progresses.


Table: Options for the Management of Common Problems at the End of Life. (From Essential Evidence, 2011 December)

Problem Prevalence Nonpharmacologic Options Pharmacologic Options
Pain 35%-96% Massage, positioning, transcutaneous electrical nerve stimulation, physical therapy, chiropractic therapy, acupuncture, hypnosis, spiritual practices, prayer Nonopioids (eg, acetaminophen 4 g/d, ibuprofen 1600 mg/d), advanced to mild opioids (eg, codeine 30 mg every 4 hours or hydrocodone 5 mg every 4 hours), or stronger opioids (eg, morphine 5-10 mg every 4 hours), as needed; calcitonin; antidepressants; anticonvulsants; nerve blocks; radiotherapy; radiofrequency ablation
Constipation 15%-90% Increasing fiber and fluids; increasing activity Stool softeners (eg, sodium docusate 300-600 mg/d oral); stimulant laxatives (eg, prune juice 1/2-1 glass/d, senna 2-4 tablet/d, bisacodyl 5-15 mg/d orally or per rectum); osmotic laxatives (eg, lactulose 15-30 mL every 4 to 8 hours, magnesium hydroxide 15-30 mL/d)
Dyspnea > 60% Pulmonary rehabilitation Opioids (eg, codeine 30 mg every 4 hours, morphine 5-10 mg every 4 hours); anxiolytics (eg, lorazepam 0.5-2 mg oral/sublingual/IV, diazepam 5-10 mg oral/IV)
Fatigue 40%-75% Decreasing or increasing activity; discontinuing or changing medications; reducing sleep disturbances; acupuncture Glucocorticoids (eg, dexamethasone 2- 4 mg per day); stimulants (eg, dextroamphetamine 5-10 mg oral up 20 mg); modafinil 100-200 mg up to 400 mg/day
Depression 5%-26% Counseling; exercise; music therapy Antidepressants (eg, fluoxetine 10 mg/d and increase as needed); psychostimulants (eg, dextroamphetamine or methylphenidate 2.5-5 mg twice daily) if rapid onset of action needed
Delirium 20%-30% Gentle reassurance; reorientation; safety precautions; aide presence; reducing medications Neuroleptic (eg, haloperidol 0.5-5 mg oral/subcutaneous/IM/IV q1-4h, risperidone 1-3 mg every 12 hours); anxiolytic (eg, lorazepam 0.5-2 mg oral/IM/IV); anesthetic (propofol 0.3-2 mg/hour continuous infusion)
Anorexia/cachexia 70% Eating with family members; taste of food helpful Progestogens for cancer patients (eg, megestrol acetate 400-800 mg); corticosteroids (eg, dexamethasone up to 4 mg/day)
Dehydration 62% Offer ice chips and small amounts of fluid as tolerated; lubricate lips Hypodermoclysis (subcutaneous infusion of fluids)
Nausea and vomiting (late stage) 13%-68% High protein meals with ginger; acupuncture point stimulation wristband Metoclopramide 20 mg or 0.5 mg/kg orally; scopolamine patch every 72 hours; promethazine 25 mg oral or rectal every 4-6 hours or 12.5-25 mg IV/IM every 4-6 hours; diphenhydramine 25-50 mg oral/IM/IV every 4-6 hours; 5-HT3 blockers (eg, ondansetron 8 mg or 0.15 mg/kg IV once, prechemotherapy & 16-24 mg orally once, prechemotherapy);


4. In patients with pain, manage it (e.g., adjust dosages, change analgesics) proactively through:
- frequent reassessments.
- monitoring of drug side effects (e.g., nausea, constipation, cognitive impairment).

Approximately 71% to 100% of patients can achieve pain control by following the WHO ladder guidelines. The ladder starts with the use of non-opioid analgesics for mild pain --> weak opioids for moderate pain --> strong opioids for severe pain.

Table: Pain Management (from 2007 Clinical Practice Guidelines, VCH Community Palliative Care)

Evaluation If uncontrolled, r/a daily.
Titration -Consider for all pts experiencing uncontrolled pain.

-Best to titrate with IR meds when possible.

Timing of when to titrate depends on type of regular med in use: (*BTD = breakthrough doses
Short-acting Regular Dose Titrate q24h, if >2-3 BTD* used in the last 24h
Long-acting Regular dose Titrate q48h, if >2-3 BTD per day used in the last 48h
Fentanyl patches Titrate q48-72h, if >2-3 BTD per day used in the last 48-72h
Conversion Once pain is well-controlled, covert to a long acting formula Note: switching from an opioid-->methadone is complex & requires specialist consultation
Switching Reasons for switching:

- lack of efficacy
- intolerable side effects
- change in patient status
- practical considerations (pt preference, route of admin)

Equianalgesic Dose Table
Drug Oral dose Parenteral Dose Examples
Codeine 200mg n/a 2x T3's approx = morphine 10mg PO
Oxycodone 10mg n/a oxycodone 10mg po = morphine 20mg PO
Morphine 20mg 10mg morphine 10mg PO = hydromorph 2mg PO
Hydromorphone 4mg 2mg hydromorph 1mg PO = morphine 5mg PO
Fentanyl patch Use as per manufacturer's guidelines


(from pre-existing CCFP document):

Opioid Dosage adjustment Opioid Rotation
-calculate daily dose by adding regular + breakthrough doses

-adjust dose by 10-25% of daily dose (not possible at low doses)
-typical dose adjustment program, mg morphine:

- 5-10-20-30-40-50-60-80-100-120-150-180-220

- re-assess dose change efficacy q12-24hrs

-for escalating pain despite escalating dose

-for opioid neurotoxicity (delerium, myoclonus, difficult for pt to locate pain)
-Conversion: determine equianalgesic dose of the 2 opioids
Day 1: full dose old opioid, no new opioid
Day 2: lower old opioid by 1/3, add 1/3 dosc new opioid
Day 3: lower old opioid by 2/3, add 2/3 dose new opioid
Day 4: no more old opioid, add full dose new opioid


5. In patients diagnosed with a terminal illness, identify and repeatedly clarify wishes about end-of-life issues (e.g., wishes for treatment of infections, intubation, dying at home)

Table: Assessment should include the following (from Medical Care of the Dying, per pre-existing CCFP document):

Advanced Directives Home Death
- which person you want to make health care decisions for you when you can’t

- the kind of medical treatment you want/don’t want
- how comfortable you want to be
- how you want people to treat you
- what you want your loved ones to know

- clarify well ahead with pt/family, whether or not pt intends to die at home

-if home death intended: use advanced directives which clearly states DNR, and ensure both physician & pt signs
-ensure both family and any on-call physicians do not call for ambulance
-involved physician or nurse should proceed immediately to the home when notified, to pronounce death and assist family with further arrangements

Study Guide

Palliative Care

Resources

BMJ Clinical Practice
Essential Evidence, 2011 December
2007 Clinical Practice Guidelines, VCH Community Palliative Care
Medical Care of the Dying
Previous residents “CCFP Priority Topics” document