Comfort Measures: Practical Care of the Dying Cancer Patient

Transcription

1 Cleveland Clinic Palliative Medicine Grand Rounds Comfort Measures: Practical Care of the Dying Cancer Patient American Journal of Hospice & Palliative Medicine 27(7) ª The Author(s) 2010 Reprints and permission: sagepub.com/journalspermissions.nav DOI: / Susan B. LeGrand, MD, FACP, 1,2,3 and Declan Walsh, MSc, FACP, FRCP (Edin) 1,2,3,4 Abstract Most patients with advanced malignancy will die of their disease. Care of the dying is therefore a fundamental skill for the oncologist. Although protocols exist in other countries, there is no established protocol in the United States. We present a protocol for management of the dying that is clinically useful and review the existing evidence-base. Keywords cancer, dying, comfort care, management, patient, death Introduction We will all die. It is the one universal fact of our lives. Most people die from progressive illnesses like cancer. Of the approximately 2,400,000 deaths in the United States in 2006, 23% were from malignancy a total of 552,000 individuals. Sensitive competent care of the dying is a fundamental medical skill. The available evidence does not support this as the case. 1,2 This is particularly true in cancer care where death usually occurs slowly and predictably. 3 A systematic literature review of cancer patients found that over half wished to die at home. 4 The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT) in contrast found 62% of those with lung cancer and 55% of those with colon cancer died in hospital. 1 Severe dyspnea was present in 70% of persons with lung cancer, with severe pain reported in more than 40% of lung and colon cancers; 52% of family members felt the patient had inadequate emotional support and 38% felt unsupported. In a more recent study, not limited to cancer, perception of the care provided in the last 48 hours of life was determined in 1059 caregivers based on where the patient died; hospital, nursing home, hospice, or home care. 5 Again, most (69%) died in health care facilities hospitals or nursing homes 33% (519/1578) died at home. Of these, 38% had no nursing services, 13% had home care and just 49% had hospice care. Only 47% of hospital deaths were assessed as excellently managed. Half of the families felt they were not adequately educated about the dying process, and 51% reported that they wanted to speak with a physician but were unable to do so. Fifty-one percent perceived inadequate emotional support, and 19% of patients with pain and dyspnea were felt to be poorly managed. The symptoms of the dying process are similar regardless of the underlying disease. Key symptoms include (1) pain (2) dyspnea, (3) respiratory tract secretions, and (4) restlessness. 6-8 Guidelines, particularly the Liverpool Care Pathway created for the health system in the United Kingdom, have been used in an attempt to standardize management, improve quality of care, and document outcomes. 9 Protocols exist for most therapeutic interventions in cancer care and it would be deemed unacceptable practice not to use them. Yet, there may be no consistent protocol to manage the dying cancer patient. In this article, we present one approach to this issue; the protocol for care of the dying used at the Harry R. Horvitz Center for Palliative Medicine, at the Cleveland Clinic Taussig Cancer Institute. It is simple to follow, and we have found it clinically useful. 8 Case Mr M was a 52-year-old white male with stage IV colon cancer. Chemotherapy included 5-FU, oxaliplatin, and leucovorin for 5 months, followed by irinotecan and cetuximab for 2 months with progression. He was admitted for abdominal pain, nausea, anorexia, and dyspnea. After a Palliative Medicine consultation, he was discharged on oral morphine sustained release 215 mg every 12 hours and morphine sulfate immediate release 1 Section of Palliative Medicine and Supportive Oncology 2 The Harry R. Horvitz Center for Palliative Medicine 3 Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute 4 The Harry R. Horvitz Chair in Palliative Medicine Corresponding Author: Susan B. LeGrand, Cleveland Clinic, 9500 Euclid Avenue, R35, Cleveland, OH 44195, USA legrans@ccf.org 488

2 LeGrand and Walsh mg every 3 hours as needed (PRN) for pain or dyspnea. Nausea was controlled with metoclopramide 10 mg orally at meals and bedtime, with 10 mg every 6 hours PRN (Pro Re Nata). He accepted a hospice referral and was discharged to home. Two days later, he was readmitted with a rapid decline. He was lethargic, tachypneic, and delirious. His significant other, who held the Durable Power of Attorney, felt he was dying, and we agreed. We discussed initiating our comfort measures protocol. We would not check vital signs or pulse oximetry: No laboratory tests or X-rays would be done. Medication or interventions not making a direct contribution to comfort would stop. She agreed. Pastoral care services were offered and accepted. When he became unable to swallow, his pain medication was converted to a subcutaneous (SQ) infusion. Glycopyrrolate was started at 0.2 mg intravenously (IV) or SQ every 6 hours PRN for increased respiratory secretions, then scheduled around-theclock (ATC) as secretions worsened. Later, restlessness became more prominent. Chlorpromazine 25 mg IV every 6 hours PRN, and then ATC was given. Mr M died 17 days after his initial consultation. He and his family were supported through the act of dying by his Medical Oncologist and the Palliative Medicine team. Postmortem, his family reported a sense of completion and peace that facilitated their grief process. Protocol The modern clinical management of the dying person encompasses specific measures implemented solely for comfort in the last hours or days of life (Table 1). 6-8 The goal is a peaceful death by active and medically sophisticated management of the dying process. The protocol emphasizes anticipation of common problems and proactive management with standard orders written in advance of their development. Diagnose the Dying Process This is clearly the first step, but may not be as easy at it seems. There are barriers to diagnosis of impending death (Table 2). The number of patients dying in hospitals may reflect problems in appropriate recognition of the dying patient and consequently lack of timely transfer to their preferred location. Care plans remain focused on active, but technical, management of individual problems. These interventions may themselves directly or indirectly cause or increase distress and may be medically futile given the impending death. Physical signs of impending death are listed in Table 3. Communication. In the hospital, when dying is recognized, the family should be brought together to discuss changed goals of care. A hospice nurse typically manages this in the home. This should take place in an appropriate location (ideally seated) and be documented in the medical record. The discussion with the family (and patient as appropriate) should first investigate their perception of events, as they may be well Table 1. Comfort Measures Protocol Day 1 Diagnose dying Communication with family Confirm DNR (Do Not Resuscitate) status Stop All medications not contributing to comfort All laboratory tests and X-rays Vital signs including oximetry Consider stopping hydration if present Start Morphine 1 mg every 1 hour as needed or continue any existing medication. Alternate: fentanyl for renal failure Glycopyrrolate 0.2 mg IV/SQ every 6 hours PRN. Alternate: hyoscine, hyoscyamine sulfate Chlorpromazine mg every 6 hours as needed. Alternate: lorazepam, midazolam Alternative routes for medications Insure excellent mouth care Consider urinary catheterization Daily or more if needed Reassess Frequency of PRN usage Efficacy of PRN dose Baseline comfort level Adjust Begin or increase morphine infusion if frequent PRN use and persistent baseline pain and/or dyspnea. No change if comfortable Schedule glycopyrrolate if frequent use required otherwise no change. May increase dose to 0.4 mg IV/SQ Schedule and/or increase the dose of chlorpromazine or its alternates if agitation not controlled. Note. IV ¼ intravenous; SQ ¼ subcutaneous. aware. This facilitates the subsequent conversation. If they are unaware, then a sensitive explanation that their loved one has begun to actively die should be given. Euphemisms are best avoided. Families have a need and a right to prepare for a death, including the notification of other family members, and the time to say goodbye. If resuscitation status has not been determined, this should be done immediately. Resuscitation in the setting of advanced cancer is futile care. Physicians have no ethical or legal obligation to provide futile care. 14 Since many families do not feel educated about dying, this is the time to do that. It is important to review the physical signs of dying they may witness, to include altered breathing patterns, cool extremities, and halfopen eyes. Comfort care management plans are then reviewed and implemented. Clinical Monitoring and Investigations There is no value in continuing vital sign monitoring at this time since one will not intervene in response to abnormalities. This should be specifically communicated to the family during 489

3 490 American Journal of Hospice & Palliative Medicine 27(7) Table 2. Signs of Impending Death 10,11 Bed-bound Somnolence Decreased attention span Decreasing oral intake Difficulty swallowing Visioning dead family members Patient says he is dying Disoriented to time Oliguria Confusion/restlessness Death rattle Cool/mottled extremities Eyes partially open Table 3. Barriers to the Diagnosis of Dying 10,12,13 Unrealistic expectations for improvement Lack of definitive diagnosis Fear of hastening death Unsure of skills to manage dying Poor communication skills Medicolegal concerns the meeting. Oximetry is not typically monitored as dyspnea is managed with medication. There is also no indication for further radiological or laboratory tests as they may be distressing to the patient (and family). This is not an issue in the home. Assessment. Assessment of the dying person should be no different than for those not in the last days of life. Initially, one should ensure all active symptoms are adequately controlled. The 4 major symptoms should be specifically anticipated and addressed, as well as any additional symptoms like nausea and vomiting. Emotional, psychosocial, spiritual, or religious issues should be addressed. They may be best handled by other team members such as medical social work and pastoral care. Team members can be particularly useful for emotional support. Medications. All medications should be reviewed and those not actively contributing to comfort care discontinued. Chronic comorbid illnesses are usually irrelevant. Individuals will lose the ability to swallow, so oral medications will need to be stopped. Alternate routes of administration for essential medications should be anticipated and made available. Medications for the 4 main symptoms should be readily available, even if that symptom is not present at the time of initial assessment. Efficacy should be regularly assessed, and the physician notified for adjustment of drug, dose, frequency, or administration route. The goal is excellent symptom control with the least sedation necessary to allow continued family interaction. Specific instructions should be given to nursing staff not to withhold comfort care medications with alterations in mental status or respiratory rate. The goal is patient comfort not normal physiological parameters. Pain: Pain at end of life can be controlled. 2,7 An order for morphine 1 mg IV or SQ every 1 hour PRN for the opiate naive, in the absence of constant pain, is placed. 15 The dose should be aggressively adjusted and adequate to relieve distress. If constant pain is present (or frequent PRN doses required), then a continuous infusion of morphine 0.5 mg IV is begun. Most patients with cancer will be on opioids, and these should be continued. A PRN dose should always be available for immediate management of distress. This continuous rate can then be adjusted based on the number of PRN doses needed. Opioids should be titrated to the lowest dose required to adequately control pain without sedation. They should not be used for sedation as they may cause toxicity including myoclonus and agitation. 16,17 Individuals currently on oral medications will require an alternate route of administration at some point. The SQ route is practical and effective. Sublingual and rectal routes are alternatives in the home. Dyspnea: Opioids are efficacious for breathlessness. 18 A PRN dose of morphine 1 mg every hour should be available for the opioid naive. Baseline medications with PRN should be provided for those already on opioids. Doses should be adjusted as needed. This is one of the more common symptoms that require palliative sedation. Respiratory tract secretions: Often called death rattle, it typically occurs when swallow and cough are no longer possible. It can be helped by repositioning, and avoidance of oxygen humidification, but may require medication. Anticholinergic medications like glycopyrrolate (0.2 mg IV or SQ every 6 hours) are helpful, and should be prescribed PRN at the time of the dying diagnosis. 19 Order ATC dosing if frequently used. One to two milligrams sublingually may be given in a home setting. Alternatives include hyoscyamine sulfate mg SL (Sublingual) every 4 hours as needed or scopolamine patches/infusions. 8,19 The best drug has not been determined. 20,21 Terminal restlessness: Delirium, agitation, and restlessness are very distressing to families and caregivers. 22 The incidence varies from 25% to 88% depending on the definition and patient population. 23 The most common medications used are benzodiazepines or phenothiazines. Chlorpromazine has sedative, antiemetic, and analgesic properties and in a case series was found efficacious in the management of terminal delirium. 24 An initial dose of 12.5 mg to 25 mg IV every 6 hours PRN is given, and then if needed frequently, scheduled. Intravenous access is required. Although not given as an IV push, it can be safely infused over 15 to 30 minutes in a saline solution. A compounded concentrated solution (100 mg/ml) for sublingual use is an alternative in the home. Reassessment. Just as one would reassess the patient expected to improve, we must frequently reassess the dying. 490

4 LeGrand and Walsh 491 Titrate to comfort orders are inappropriate. Are the medications effective at current dosages? Are frequent PRN doses required? If frequent PRN doses of morphine are required then a basal rate or increase in existing basal rate is needed. For example, a patient on 2 mg/h of morphine requiring 10 bolus doses of 1 mg would get an additional 1 to 1.5 mg/h added to the basal rate. The PRN dose would not need to be changed unless it was also ineffective. If repeated doses of glycopyrrolate or chlorpromazine are required then they should be scheduled, but a PRN dose should still always be available. These gradual adjustments should be continued until the patient is comfortable. Discussion Care of the dying is a critical skill for every oncologist. Despite new medications that may prolong life in metastatic disease, nearly everyone of these patients will inevitably die. The emphasis on acute care has led to increased use of chemotherapy closer to death even though the benefit is minimal if any. 25,26 Patients and families must have time to prepare for death which can only occur when it is recognized. In this article, we have addressed the active dying phase, often defined as the last 2 to 3 days of life. Our protocol recognizes 4 main symptoms that should be proactively addressed even if not present at initiation of comfort care. Beginning a morphine infusion on everyone is inappropriate. Symptoms should be assessed just as one would in any patient and then managed individually. Each is addressed with a specific medication. Pain can be controlled in the patient with advanced cancer. 2,27 The principles are the same as in less-advanced settings. 15 Constant pain requires constant medication either by scheduled around-the-clock dosing or continuous infusions. PRN dosing must always be available. In a retrospective analysis of medication needs in the final week of life, 56% needed no change, 31% required an increase, and 13% required a decrease. 27 Dyspnea has been reported in up to 70% of dying cancer patients. 28 There have been 3 systematic reviews of the use of opioids in the management of dyspnea 18,29,30 in the terminally ill, with 2 specific to patients with cancer. 29,30 Each has shown that opioids are the medication of choice. Benzodiazepines have not shown efficacy in most trials and should not be used alone for dyspnea. 30 There may be benefit when combined with morphine. 29 Their value in anxiety related to dyspnea has not been studied. Respiratory tract secretions are reported in 44% to 56% of dying patients. 19,31 There have been a series of reports on a small group of families (n ¼ 12) who heard death rattle as their loved one died. 32,33 Of the 12, 5 were distressed by the sound, while others were not. When secretions are related to infection, medications are less successful. 31 In the actively dying, IV fluids are controversial Those opposed feel burden outweighs benefit. 34 Those in favor feel it prevents delirium and myoclonus from opioid accumulation. 36 In a hospice unit that monitored dying patients, most drank less than 500 cc per day and good mouth care alleviated any symptoms of thirst. 34 A pilot study found that patients gradually decreased their intake and did not appear to suffer hunger or thirst provided they got good mouth care. 35 This study also found that families were concerned that dehydration would cause suffering and required reassurance this was not the case. 37 Legally and ethically, parenteral fluids are a medical intervention that can be stopped. The ethical situation is not that the patient is failing to drink and therefore will die, but that the patient is dying and therefore does not wish to drink. 38 Frequent mouth care is essential and family participation should be encouraged. Restlessness or delirium occurs in 25% to 85% during the active dying phase. 23,39 Although there may be some reversible causes, investigation is usually unreasonable in the last days of life. Basic needs such as the avoidance of urinary retention or fecal impaction should be anticipated. Urinary catheterization is often preferred. Assuming no readily reversible cause (including opioid toxicity 40 ), management with medication is standard. Our protocol drug has been chlorpromazine. 8,24 Benzodiazepines, lorazepam, or midazolam can be useful alternatives but can worsen delirium. 23 Sedation is not the goal in caring for the dying. One should use the least sedation possible to ensure comfort but preserve communication with the family. Palliative sedation therapy (PST) is a specific medical intervention, defined as the use of sedative medication to relieve intolerable suffering from refractory symptoms by a reduction in patient consciousness. 16 Refractory symptoms are defined as a symptom for which all possible treatment has failed, or it is estimated that no methods are available for palliation within the time frame and risk-benefit ratio that the patient can tolerate. 41 Palliative sedation therapy is not meant to expedite the dying process and need not shorten survival. 17,42 Prior to declaring a symptom refractory, consultation with a palliative medicine specialist is recommended. Palliative sedation therapy is not euthanasia as it is used proportionately to the symptoms experienced, and the intent is effective symptom control. Premature death is not the means used to obtain symptom management. 16 The means is drugdose titration only to that level of sedation required for symptom relief. Published guidelines exist. 16,41 Sedation may be temporary (for respite) or continuous. Continuous deep PST should be reserved for those hours to days from death. Consent from the patient or family is required. The family must understand that verbal communication with their loved one may be limited or cease altogether. Sedation should not be done with opioids but with phenothiazines like chlorpromazine or benzodiazepines such as lorazepam or midazolam. Midazolam is said to be the drug of choice, but this is based only on case series. 16,42,43 There have been no direct comparisons of different medications. If chlorpromazine or midazolam are ineffective or impractical, then phenobarbital or propofol may be used. 17,43 Conclusion Care of the dying is a complex clinical interplay of good communication and appropriate symptom management in an often 491

5 492 American Journal of Hospice & Palliative Medicine 27(7) rapidly changing and emotional situation. Unnecessary monitoring, procedures, and medications should be discontinued. Emotional support, education of, and availability to the family is key. An interdisciplinary team to include social work and pastoral care can be of assistance but cannot substitute for the physician. The physician s primary role is to diagnose that death is imminent, anticipate distress, and provide coordinated measures for symptom relief: (1) opioids for pain and/or dyspnea, (2) anticholinergic medications for secretions, (3) sedatives for delirium or restlessness. Each should be prescribed, even if not immediately needed, to prevent later delays in drug orders and administration. Although no single article can address all scenarios or permutations, the protocol presented here will allow a comfortable and dignified death in the majority of patients. For the more complex and when sedation is needed, palliative medicine consultation is preferred. Authors Note The Harry R. Horvitz Center is a World Health Organization Demonstration Project in Palliative Medicine and The Harry R. Horvitz Center for Palliative Medicine is an ESMO Designated Center of Integrated Oncology and Palliative Care. Declaration of Conflicting Interests The author(s) declared no conflicts of interest with respect to the authorship and/or publication of this article. Funding The author(s) received no financial support for the research and/or authorship of this article. References 1. Lynn J, Teno JM, Phillips RS, et al. Perceptions by family members of the dying experience of older and seriously ill patients. Ann Intern Med. 1997;126(2): Grond S, Zech D, Schug S, Lynch J, Lehmann KA. Validation of World Health Organization guidelines for cancer pain relief during the last days and hours of life. 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