© Copyright Annals of Internal Medicine, 2012 Ann Int Med. 156 (3): ITC2-1. * For Best Viewing:...

© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.

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in the clinic

Palliative Care


How does palliative care differ from hospice? Consultative palliative care

Interdisciplinary: addresses goals of care + QOL, family support, symptom management

Includes ongoing curative or disease-directed therapies

Can begin with symptom onset from life-limiting disease

Assists with symptoms, hard conversations, family

Often provided in hospitals or an outpatient clinic setting

Hospice

Specific type of palliative care: recognizing EOL trajectory

Insurance coverage relinquished for life-prolonging treatment (prognosis must be ≤6 months)

Team-based support services in home or institution


Which patients should be considered for palliative care?

Criteria from the Center to Advance Palliative Care

No surprise if patient died within 12 months

Frequent admissions for same condition within several months

Complex, difficult symptoms or psychological need

Functional dependence for complex home support needed

Decline in functional status, weight, or ability to care for self

No history of advance care planning

Limited social support

Limited prognosis


What treatments are prohibited or allowed when patients are receiving palliative care?

No treatment restrictions

Including curative or life-prolonging treatments

Treatments that may all be within the purview of palliative medicine:

Hemodialysis

Chemotherapy

Radiation therapy

Blood transfusions

Surgical procedures


How is palliative care paid for by insurance and how does this differ from hospice?

Palliative medicine: board-certified subspecialty

Fee-for-service model similar to other subspecialties

Hospice: geographically prorated per diem pay system

Hospices receive amount (≈$150/day)

Rate must cover all medication, equipment, specialty services required for comfort and QOL

Cost often barrier for expensive interventions


What tools assist in prognostication or estimating survival in seriously ill patients?

Karnofsky Performance Score or Eastern Cooperative Oncology Group Performance Status

Prognosis: based on basic functional status assessment

Useful for: advanced cancer, HIV/AIDS

Not useful: chronic degenerative diseases (>75% U.S. deaths)

Palliative Performance Score

Helps determine: if days or weeks vs. weeks to months to live

Disease-specific prognostic tools

Mitchell Mortality Index for dementia, Seattle Heart Failure Score for heart failure

Used in collaboration with disease-specific subspecialist


Who should be part of the palliative care team?

Team may also include:

Physicians and advance practice nurses

Chaplains

Social workers

Psychiatrists

Psychologists

Dietitians

Pharmacists

Physical therapists

Occupational therapists

Music and pet therapists

Mindfulness training practitioners

Massage therapists

Child life experts

Bereavement/grief counselors


CLINICAL BOTTOM LINE: Palliative Care vs. Hospice… Palliative care

For patients with serious illness Focus on managing symptoms, QOL, delineating care goals

Hospice Special type of palliative care, reserved for final 6 months

Consult with palliative care specialist

If goals of care unclear + symptoms difficult to manage


How should pain be evaluated and managed?

Mild (1–3 on the 0–10 pain intensity scale)

Nonopioids (aspirin, acetaminophen, NSAIDs)

Moderate (pain score: 4–6)

Combination opioids + nonnarcotic pain relievers

Beware nonopioid overdose when need for opioid increases

Severe (pain score: 7–10)

Use opioids, preferably oral

+ NSAIDs, corticosteroids, antiepileptics, antidepressants

If parenteral route needed: use IV or subcutaneous

Transdermal opioid patches: useful for chronic pain


How should the side effects of opioid analgesics be managed?

Sedation: usually dissipates as tolerance develops

Constipation: try docusate + senna or bisacodyl

Pruritus: Try another opioid or nonsedating antihistamine

Nausea: usually dissipates as tolerance develops

Use antidopaminergic antiemetics

If refractory: try corticosteroids or ondansetron

Maintain constant levels: reduce dosing interval for immediate-release preparations, or try sustained-release or transdermal route


What additional measures should be considered in pain due to specific causes?

Visceral

Palliative surgery for bowel obstruction

Blockade of celiac plexus, sympathetic plexus, or splanchnic nerves if refractory to opioids

Neuropathic

Corticosteroids reduce tumor swelling and edema, may reduce obstruction pain + improve mood, energy

Peripheral neuropathy or nerve root impingement

Consider opioids, tricyclic antidepressants, venlafaxine, duloxetine, gabapentin or pregabalin

Bone metastases

Consider radiation, corticosteroids, bisphosphonates, interventional procedures


What treatments are most effective for relieving dyspnea?

Pharmacologic

Low-dose oral morphine (10-20 mg/d)

Gold standard; respiratory depression if increased too quickly

Benzodiazepines For dyspnea worsened by anxiety

Supplemental oxygen For terminally ill with hypoxemia and dyspnea

Nonpharmacologic Breathing training, gait aids, chest wall vibration, neuroelectrical

muscle stimulation

?: music therapy, relaxation, fan use, counseling, psychotherapy


How should clinicians select antiemetics in patients with nausea?

Opioid-induced: metoclopramide or prochlorperazine

Chemotherapy-induced: serotonin antagonists with corticosteroids as adjuvants if needed

Intracranial pressure: corticosteroids

Incomplete mechanical bowel obstruction: octreotide + dexamethasone + metoclopramide; for higher grade obstructions: venting gastrostomy tubes + octreotide

Reduced motility: metoclopramide

Radiation-induced: serotonin antagonists

Motion-associated: anticholinergic antihistamines

Posterior fossa lesions: anticholinergic antihistamines


How should agitation and distress be evaluated and treated?

Assess reversible causes

Pain, urinary retention, or fecal impaction

Ensure symptom palliation and comfort before assuming delirium underlying cause

Nonspecific signs & symptoms (evaluate for cause) Hyperactivity or apathy and withdrawal

Moaning or grunting

Use of accessory muscle for breathing

Tachypnea, tachycardia, or diaphoresis


How should delirium be managed in seriously ill patients?

Distinguish from dementia

Identify / address reversible causes:

Psychoactive drugs (e.g., benzodiazepines)

Untreated pain

Urinary obstruction or bowel impaction

Sensory deprivation (missing eye glasses, ear wax)

Treat with haloperidol in small doses

If ineffective, try more sedating chlorpromazine

Consider nonpharmacologic methods (reorientation)


Is depression a normal part of serious illness and when should it be treated?

Transiently depressed mood is normal when facing serious, life-threatening illness

Treat if symptoms persist + meet criteria for depression

SSRIs

Psychostimulants

Mirtazapine

Tricyclic antidepressants, duloxetine, or venlafaxine

Assess suicidal ideation immediately

Refer to mental health or palliative care professional


When and how should providers approach treatment of anorexia in patients with serious illness? Educate patients and caregivers that disease processes

can cause anorexia and cachexia

Relieves guilt

Promotes acceptance of altered eating habits

Advise nutrition and hydration discussion in advance directives

Encourage caregivers to let patient participate in social aspects of meals (even if eating minimally)

Consider appetite stimulants if prognosis uncertain


Does artificial nutrition and hydration help patients to feel better or live longer?

Enteral and parenteral nutrition

Use in terminally ill patients is controversial

Can increase weight and strength

Especially when good functional status or when nutritional intake limited by aerodigestive malignancies

No evidence it prolongs life or improves QOL in final wks

Discuss nutritional preferences with patient

Before extreme weight loss and anorexia occur

Prevents emotional stress for patient & family later

Consider oral nutritional supplements


CLINICAL BOTTOM LINE: Management of Common Symptoms… Moderate to severe pain and dyspnea

Manage with opioids

Nausea Tailor treatment to putative associated neurotransmitters

Anxiety Investigate somatic and nonsomatic contributors to distress

before pharmacotherapy instituted Delirium in EOL

Common and distressing; treat with neuroleptics Depression

Persistent symptoms warrant treatment Anorexia/cachexia

Encourage oral intake over parenteral or enteral nutrition


How should clinicians approach EOL discussions? Reassure these discussions don’t imply “giving up”

Comprehensive discussions on goals of care should:

Assess patient and caregiver understanding of illness and disease-directed treatment options

Evaluate patient and caregiver appreciation of prognosis, either broadly or detailed, as appropriate

Develop strategies to treat and address current and anticipated physical changes, including declining in functional status and new or worsening symptoms

Chronicle patient and caregiver goals, fears, anxieties, hopes

Assure that patient and caregiver know what to expect in the normal course of disease


How can physicians assist with advance care planning, including advance directives?

Discuss when the patient can still express preferences

Advise patient to appoint surrogate decision-maker

Surrogate should…

Support patient's wishes for management and care

Know what to do if patient's condition deteriorates

Represent patient’s wishes when patient no longer able to

Consult clinical ethics committee

If you’re uncomfortable honoring a request to discontinue treatment for disorder unrelated to underlying cause of death


What are the differences between withholding or withdrawing life-sustaining treatments and euthanasia or assisted suicide?

Withdrawal or withholding of medical technology No moral, legal, or ethical difference between withdrawing

life-sustaining treatments and having never started them

Physician-assisted suicide Introduces external factor with primary goal of hastening

death independent of underlying disease process

Administration of lethal drug directly by clinician is illegal

3 states (OR, WA, and MT) allow physician aid in dying

Patient request should prompt a palliative care evaluation


When is palliative sedation ever acceptable?

To alleviate symptoms that can’t be managed any other way

May unintentionally hasten death due to side effects

Should be congruent with patient wish to relieve symptoms

Must follow standards of care

Document patient's or surrogate's understanding of risks

Benzodiazepines or anesthetic agents often used

Not experimental or outside physician responsibility to heal

Ethically + legally acceptable (main intent: relieve suffering)

Consult with palliative care team, anesthesia pain service


What should patients and their families know about palliative care?

Common misconceptions:

That hospice and palliative care are the same

That both focus exclusively on the needs of the imminently dying patient

That hospice care itself hastens or aims to hasten death

Clinicians should correct misconceptions and allay fears

Explain rationale for palliative care consultation

Explicitly state its goals

Allows for interventions aimed to relieve suffering


When is the best time to discuss palliative care?

Before patient becomes terminally ill

Helps introduce uncomfortable topics (death and dying)

Teaches patients the importance of such planning

Address advance directives and a durable health care power of attorney document

If clinical situation changes, inform patient + surrogate

Any alteration in condition, prognosis, or treatment options

Including comfort measures and surrogate's role in supporting patient's wishes for care decisions


CLINICAL BOTTOM LINE: Communication, Psychosocial, and Ethical Issues…

With seriously ill patients, discuss care goals early Helps set goals and helps maintain “hope” Address what to expect as the disease progresses Advanced care planning and surrogate decision-makers

If suffering intractable, palliative sedation ethically acceptable

Treatment withdrawal is acceptable if patient perceives that the treatment burden outweighs its benefits Moral equivalent of never having started the treatment

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