© copyright annals of internal medicine, 2012 ann int med. 156 (3): itc2-1. * for best viewing:...
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© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
in the clinic
Palliative Care
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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)
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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
© Copyright Annals of Internal Medicine, 2012Ann Int Med. 156 (3): ITC2-1.
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