PAlliative and Hospice Care

A Primer for the Clinician

Charlene M. Morris, PA-CStonewall, NC

2.6.15

Alicia De Troye: AAPA’s 2/14 Leadership Meeting

Definitions

• PAlliative Care is the treatment of a patient´s physical, emotional, social and spiritual needs. It seeks to improve quality of life for a person with a serious or life-threatening medical condition, and for his or her family.

http://www.cchospice.org/General_Overview.aspx

Hospice Care: designed to alleviate pain and control the symptoms of disease with expertise and compassion. In addition to physical care, hospice provides spiritual, social, and emotional support. An extension of Palliative Care

The Aging of the US

http://www.nytimes.com/interactive/2011/02/04/business/aging-population.html?_r=0 Accessed 7.8.14

From 13 to 55 million over 65!

Why We Die

• Heart disease: 597,689• Cancer: 574,743• Chronic lower respiratory diseases: 138,080• Stroke (cerebrovascular diseases): 129,476• Accidents (unintentional injuries): 120,859• Alzheimer's disease: 83,494• Diabetes: 69,071• Nephritis, nephrotic syndrome, and nephrosis:

50,476• Influenza and Pneumonia: 50,097• Intentional self-harm (suicide): 38,364

http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm

He drew a circle that shut me out-Heretic , rebel, a thing to flout.But love and I had the wit to win:We drew a circle and took him in! -- Edwin Markham

Revised, improved version

http://www.latimes.com/opinion/op-ed/la-oe-0407-silk-ring-theory-20130407-story.html accessed 7.9.14

When to recommend or refer

• Open dialogue early1. Advance directives2. Medical power of attorney3. Family and patient desires4. Address cultural and religious

concerns• Decline is obvious• Family request

Atul Gawande, MD

• Wrote Being Mortal• Discusses what we want for our

aging/ seriously ill: safety vs.• What THEY want: independence,

comfort and food

WHO gets to choose?!

A patient and friend

• Ms. Elsie• Admitting diagnosis: end-stage CAD• Died well within a week

The Process

• Call to Hospice1. Identify diagnosis2. Sign the request/co-sign for PAs3. Consider home visit or Hospice

facility

Hospice Nurses

• Angels, wonderful, loving, a blessing

• PAtient advocates and guides for clinicians

• YOUR and the patient’s escort through the process

Overall Management

– Control pain

– Improve function and quality of life

• Comfort

• Social/society/spiritual

– Avoid therapeutic toxicity when possible

– Pharmacologic and nonpharmacologic measures should be used

American College of Rheumatology Subcommittee on Osteoarthritis. Arthritis Rheum. 2000;43:1905-15.

IASP Definition of Pain

“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such

damage”

International Association for the Study of Pain

Measure the Pain• Verbal (ask for description)• Visual Analog Scale• Observation!

Where do we go from here?

Rx Considerations

•Analgesic options, outpatient:

– Acetaminophen

– NSAIDs (COX-2)

– Tramadol

– Codeine ± acetaminophen

– Hydrocodone/oxycodone ± adjuvant

• Common concerns

– Analgesia ceiling

– GI ulcers, platelets

– CNS, GI effects

– CNS, GI effects, disorientation

– CNS, GI effects

Breakthrough Pain• Cancer as its model• Opiates and atypical opiates

– Quick onset: transmucosal fentanyl citrate (OTFC) and fentanyl buccal tablet (FBT)

– Short Acting: hydromorphone immediate release (IR)– Long acting: Tramadol ER, Oxymorphone ER, Morphine

ER • Future: Fentanyl iontophoretic transdermal

system – efficacy and side effects similar to standard intravenous

patient-controlled analgesia (IV-PCA) • Sufental trandermal patch

Schmerz. 2007 Aug 9; [Epub ahead of print] Nauck F, Eulitz N.Cancer pain management : Basic therapy and treatment of breakthrough pain.

Pharmacologic Treatment of Chronic and Breakthrough Pain  CME/CE Martin E. Hale, MD, http://www.medscape.com/viewarticle/558587 Accessed 8/12/07

Bowel Program

• Senna• Colace• Miralax• Etc.

Other Rx

• Benzodiazepines• Acetaminophen• Ibuprofen/Naproxen• Recreational (street) drugs• “Dietary supplements”• Herbs, balms

“I Don’t Want To Be An Addict”

Fear of Opiates

Nonpharmacologic Treatment Options

• Speaking/music• Acupuncture• PT/massage/desensitization/touch• Ice/Heat• Biofeedback

Potter. Adv Stud Med. 2004;4:31-40.

– Reassurance– Listening– Holding hands– Visualization

– Patient empowerment

– Stress counseling– Behavior

modification

Death

Euthanasia and Right to Die Initiatives

• Washington and Oregon• Rx Provided after screening and

family/medical support• Interesting outcomeS!

10. Assisted Suicide (Sec. 1553)Forbids the federal government or anyone receiving federal health funds from discriminating against any health care entity that won't provide an "item or service furnished for the purpose of causing ... the death of any individual, such as by assisted suicide, euthanasia, or mercy killing."ACA provisional

statement

How comfortable are you?• Continuing care for survivors• Attending the memorial or funeral• Writing a personal note• Visiting the family

Bereavement Care 

• The final component of “end of life care.” Bereavement counseling to survivors by the hospice team and other sources for up to a year after the death of their loved one.

• Rx as necessary eg: anxiety or sleep• Time

Children and Babies

GriefGrief is complex; it encompasses a wide range of emotions that can come and go in waves. You are not alone. With time, you and your family will experience new happy moments together.

http://www.sesamestreet.org/grief Accessed 7.7.14

Grieve not,

nor speak of me with tears,but laugh and talk of meas if I were beside you...I loved you so --'twas Heaven here with you.

--Isla Paschal Richardson

Forever on Thanksgiving Day the heart will find the pathway home. -- Wilbur D. Nesbit

What we do for ourselves dies with us. What we do for others and the world remains and is

immortal.           - - Albert Pine

What Should We Do?

• Listen • Guide our patients and families• Gather resources• Call write and visit our legislators!

http://cqrcengage.com/ncapa/

We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.

— Albert Schweitzer, 1931