Managing Care at End of Life:

Transcription

1 Managing Care at End of Life: Physical Suffering Pain & Dyspnea Verna Sellers, MD, MPH, AGSF Medical Director Centra PACE Lynchburg, Virginia 1

2 Speaker Disclosures: Dr. Sellers has disclosed that she has no relevant financial relationship(s).

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6 Objectives Define pain and physical suffering at End of Life (EOL) Identify participant s perspective and preferences for care: How to have the talk. Review management options for common EOL symptoms Describe etiology of treatment of dyspnea at EOL 6

7 Physical suffering Anxiety Depression Grief Anger Denial Isolation Cicely Saunders Total pain 7

8 Participant Assessments Physiological and clinical well-being Functional status Cognitive functioning Emotional/mental health status Effectiveness and safety of staff-provided and contractprovided services Centra PACE QAPI Plan

9 Nonphysical Causes of Pain Patients with terminal illnesses frequently have death related anxieties and fears and they may be reluctant to discuss their feelings. Total pain= Physical+ Emotional+ Social + Spiritual pain

10 Assess for Nonphysical Causes of Pain Use open-ended questions Look and listen Be encouraging, reassuring and Non-judgemental

11 Listen Memory problems Fear of dying Incontinence Grief mourning and depression Problems with family Anxiety

12 Specific Causes and Treatments for Dyspnea B R E A T H A I R bronchospasm Rales Effusions Airway obstruction Thick Secretions Hb low Anxiety Interpersonal Religious concerns 12

13 General Measures for Dyspnea Reduce the need for exertion Reposition to upright position Provide skin care Improve air circulation Address anxiety and provide reassurance Breathing retraining, relaxation & adaptives strategies Cpap Oxygen Opioids 13

14 Use of Opioids for Dyspnea Mild Dyspnea Hydrocodone 5mg q 4 hrs RTC and q 2 hrs PRN Acetaminophen with codeine 30 mg q 4 hrs and q 2 hours PRN Severe Dyspnea treated with opioids Oxycodone 3-10 mg q 4 hrs and PRN Morphine syrup 5-15 mg q 4 hrs and PRN Hydromorphone 1-3 mg tabs q 4 hrs & PRN 14

15 Anticipate Problems with Opioid Patient Compliance Adverse Side Effects Constipation Nausea and vomiting Treatment Sedation, drowsiness and solmnolence Confusion, hallucinations and cognitive impairment Overdose

16 Effective Stepwise Laxative Regime Docusate Senna or bisacodyl (1,2,4,6, 8) Senna + sorbitol (30,60,90,120 ml)

17 Myths About Opioids Respiratory Depression Addiction (definition) Rapid Tolerance Imminent Death Narrow Effective Dose Range Ineffective by Mouth Nausea

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19 Basic Principles of Pain Assessment and Management 1. Assess for multiple causes of pain 2. Treat each type of pain 3. Reassess continuously, 4. Especially when pain remains uncontrolled

20 Pain Assessment Scale Completed by the patient rather than the observer Adapted to the needs of the patient Simple enough to be use regularly Consistently Special Populations: culture, language, educations

21 Types of Physical Pain Cancer-related Bone and Soft Tissue Pain Neuropathic or Nerve Damage Pain Raised Intracranial Pain (ICP) Visceral Pain Noncancer-related Physical Conditions Arthritis, bladder spasms, PVD

22 Characteristics of Pain by Type Neuropathic Pain Shooting, burning, stabbing or scalding Distribution of a nerve Pain from mild touch or pressure Raised ICP Pain Generalized or posterior head pain Nausea Visceral Pain Spasms, cramping or colicky

23 Who Health Organization (WHO) Process for treating pain based on severity Three step ladder Mild Mild- moderate Moderate- severe

24 Basic Concepts of WHO For controlling pain By the mouth By the clock By the ladder For the individual With attention to detail

25 Starting Doses for Opioid Naive Adult (<60 kg) or elderly with mild pain 2-5 MG morphine equivalent every 4 hours ½ to 1 oxycodone & acetaminophen q 4 hr Adult (>60 kg) with moderate to severe pain 5-10 MG morphine equivalent q 4 hr

26 Drugs and Routes to Avoid Drugs Meperidine (Demerol) Pentazocine (Talwin) Route IM injection

27 Treatment of Pain Analgesics Non-opioid: Acetaminopen, NSAID Opioid Adjuvant Steroids, Antidepressant, antiemetics, antihistamine, anxiolytics, diuretic, GI, sedative/hypnotic, antiseizure

28 Myths About Opioids Respiratory Depression Addiction (definition) Rapid Tolerance Imminent Death Narrow Effective Dose Range Ineffective by Mouth Nausea

29 Anticipate Problems with Opioid Patient Compliance Adverse Side Effects Constipation Nausea and vomiting Treatment Sedation, drowsiness and solmnolence Confusion, hallucinations and cognitive impairment Overdose

30 Effective Stepwise Laxative Regime Docusate Senna or bisacodyl (1,2,4,6, 8) Senna + sorbitol (30,60,90,120 ml)

31 Alternative Routes of Drug Administration Sublingual Rectal (empty but moist rectum) SR morphine Naproxen or Valproic acid (enema bulb) Gelatin capsules Transdermal fentanyl Patient cannot tolerate oral When rapid dose is not needed

32 Interdisciplinary Team Treatment of total pain Support for patient and caregiver Support for team members

33 Non-pharmacologic Treatments Music, art, movies, reading =distraction Aromatherapy Massage therapy Supportive counseling Acupuncture Transepidural nerve stimulation (TENS) Meditation, relaxation, hypnosis

34 References o Plans/pace/downloads/finalreg.pdf o 34

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36 Thank you 36