Palliative Care – BC guideline 2010

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).

A palliative approach is needed for patients living with active, progressive, life-limiting illnesses who need pain and symptom management and support around practical or psychosocial issues, have care needs that would benefit from a coordinated or collaborative care approach, and/or have frequent emergency room visits.
5 Principles and Quality of Life
  1. Support, educate and tx both pt and family members
  2. address physical, psychological, social, and spiritual needs
  3. focus on symptom management and comfort measures
  4. Offer therapeutic environment and bereavement support
  5. Ensure maintenance of human dignity – respecting the goals, preferences, and choices of the dying person
6 components 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. affirming the patient as a unique and whole person.
When to initiate End-of-Life Care Discussions
  • Recent hospitalization for serious illness
  • Severe progressive medical conditions
  • Death expected within 6-12 mo
  • pt inquires about end-of-life care
Poor prognostic factors
  • progressive weight loss (especially > 10% over 6 months)
  • rapidly declining level on the Palliative Performance Scale (PPS)
  •  dyspnea & dysphagia
  • cognitive impairment
Investigations may be indicated to:
  • better understand and manage distressing clinical complications,
  • assist in determining prognosis
  • clarify appropriate goals of care, and determine whether all options have been considered before admission to hospice.

Symptom Assessment Tools

  • facilitates communication and collaboration
PPS (Palliative Performance Scale)
  • Uses functional status to predict survival in terminally ill pt.
  • Assess:
    1. Ambulation,
    2. activity and evidence of disease,
    3. self-care,
    4. intake
    5. conscious level
ESAS (Edmonton Symptom Assessment System)
  • Asks pt to rate the intensity of symptoms from 0-10
  • Track efficacy of interventions
  • Assess:
    1. Pain, SOB
    2. Tiredness, drowsiness
    3. nausea, appetite
    4. well being, other problem
    5. Depression, anxiety

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.
    • Physicians need to ask about psychological distress, the need for support and how caregivers are doing, and
  • 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.

Constipation
  • R/o obstruction, impaction, anorectal dz
  • Tx with hydration and high fibre intake + increase mobility
  • Stop unnecessary opioids &medswithanticholingergic s/e
    • Provide stool softner – docusate sodium,
    • increase peristalsis – senna,
    • alter water & electrolyte secretion – Mg hydroxide
Dry Mouth
  • Oral hygiene q2h, ice cubes, sugarless gum
  • Artificial saliva substitutes, Bethanechol,
  • Pilocarpine 1% solution as mouth rinse
Anorexia / cachexia
  • Eating with family members; taste of food helpful
  • Corticosteroids: dexamethasone up to 4mg/d po
  • Progesterone: Megestrol accetate 400-800mg po daily (Breast cancer or endometrial cancer pt)
Dysphagia
  • Frequent small feeds, ideally seated,keepheadofbed elevated for30min after eating
    • suction prn
  • Tx painful mucositis (diphenhydramine: lidocaine:Maalox in a 1:2:8 mixture)
  • Candidiasis: fluconazole
Dyspnea
  • Elevate head of bed, eliminate allergens, open window/ use fan, pulmonary rehab
  • Oxygen, bronchodilators, opioids – morphine, hydromorhpone
Death Rattle / increased Pulmonary secretions
  • Noise caused by the oscillatory movement of mucous secretions in the upper airway with inspiration and expiration
  • Oral suctioning
  • d/c unnecessary IV
  • Scopolamine sc or transdermal
Hiccups
  • Dry sugar, breathing in paper bag
  • Chlorpromazine, haloperidol, metoclopramide, baclofen, marijuana
N/V
  • Frequent small meals, avoid offensive strong odours, Tx constipation prn; high protein meals with ginger
  • Raise ICP: dexamethasone
  • Anticipatory nausea / anxiety: lorazepam
  • Vestibular dz / vertigo: dimenhydrinate
  • Drug induced, hepatic / renal failure: prochlorperazine, haloperidol
  • 5-HT3 blockers: ondansetron 8mg IV & 16-24mg po before chemotherapy
  • Anticholinergic: scopolamine patch Q72h
  • GERD: PPi or H2 antagonist
  • Gastric stasis: metoclopramide 10-20mg po daily
  • Bowel obstruction: metoclopramide, dexamethasone, octreotide
Pruritus
  • Bathing with tepid water, avoid soap, bath oils, sodium bicarbonate for jaundice
  • Antihistamines, phenothiazines, topical corticosteroids, calamine lotion
Fatigue
  • Decreasing / increasing activity; med modifications; reduce sleep disturbances
  • Glucocorticoid: dexamethasone 2-4mg po daily
  • Stimulants: dextroamphetamine 5-10mg po daily
Depression
  • Counseling; exercise, music therapy
  • SSRI: fluoxetine 10mg po daily
  • Psychostimulants: dextroamphetamine 2.5-5mg daily to bid
Delirium
  • Gentle reassurance; reorientation; safety precautions; aide presence; reducing medications
  • Neuroleptic: haloperidol 0.5-5mg po/sc/im/iv q1-4h
  • Risperidone 1-3mg q12h po
  • Anxiolytic: lorazepam 0.5-2mg po/im/iv

Table: Assessment should include the following (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.

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).

Pain
  • Hot and cold compresses, music therapy, relaxation techniques, massage, positioning
  • individualized program of physical activity to improve flexibility, strength and endurance
  • Nociceptive pain 
    • Somatic: localized to bone/skin/joint/muscle; gnawing, dull pain
    • Visceral: not well localized,crampy pain, pressure
      • Non-opioids (NSAIDs, acetaminophen)
      • weak opioids: codeine, hydrocodone, oxycodone
      • Strong opioids: morphine, hydromorphone, oxycodone, fentanyl
  • Neuropathic pain 
    • Burning, shooting, radiating pain
    • localized to dermatomal regions
      • Anticonvulsants: gabapentin, pregabalin
      • antidepressants: TCAs, SSRIs
      • Steroids: dexamethasone
  • Bony pain: non-opioids, weak opioids, bisphosphonates, radiation therapy
  • Controlled Pain: ❤ BTD each day
Titration:
  • for pt with uncontrolled pain & titrate with IR meds if >2-3 BTD
  • BTD: Break Through Dose – make it 5-10 % of total daily dose Q1h
  • Short-acting regular dose – titrate Q24h
  • Long-acting regular dose – titrate Q48h
  • Fentanyl patches – Titrate q48-72h
  • Incidental Pain – pain occurs with specific, time-limited movement
    • sufentanyl 50mcg/ml  (start with 15mcg dose) SL (not sc or IM)
Conversion:
  • IV/SC : po = 1:2
  • Morphine : Oxycodone: hydromorphone = 1:2:5
  • 10mg codeine = 1mg morphine or 2 x T3 = morphine 10mg po
Switching Opiods if
  • Lack of efficacy
  • Intolerable s/e
  • Change in the pt status
  • Practical considerations

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).

Suggested Topics for Discussion
  • Goals of care (dz vs symptom management)
    • 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
    • involved physician or nurse should proceed immediately to the home when notified, to pronounce death and assist family with further arrangements
  • Advance directives, power of attorney, public guardian and trustee
  • Tx / resuscitation options and likelihood of success
    • Full Code vs DNR status including preferences for CPR, intubation / mechanical ventilation, ICU admission / feeding tub es, artificial hydration, Abx Tx
  • Common medical interventions

References:
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Posted in 70 Palliative Care, 99 Priority Topics, FM 99 priority topics, Geri

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