Palliative and Hospice Care of the Terminally Ill Introduction There has been an increase in life expectancy for men and women of all races to 77.6 years Leading causes of death in older patients are chronic conditions There is a functional decline over 6 to 12 months before death 1. 80% of patients will experience a decline before death 2. Diagnosis of cancer will have a steady and rapid decline 3. Diagnosis of heart failure, COPD, dementia and debility has a gradual and slower decline The approach of care to all patients in decline is palliative directed at improved quality of life 1. Effective management of pain and physical symptoms 2. Effective management of psychosocial and spiritual needs 3. Effective management of family and care providers needs Hospice was created to provide a painless, respectful death for the patient, at home with people who care about the patient 1. Philosophy to provide skilled care with an holistic approach for the dying patient 2. Physical, psychosocial and spiritual needs of the patient and caregiver/family 3. Not curative but palliative with the emphasis on relief of pain and suffering 4. Prognosis is limited and the focus of care is the quality of life for the patients and their families The priorities of palliative and hospice care 1. Treat pain and symptoms 2. Avoid inappropriate prolongation of life 3. Obtain a sense of control 4. Relieving burden 5. Strengthening relationships with loved ones Patient population 1. Most patients are 75 years or older 2. Ethnic minorities underused hospice 3. Cancer accounts for the highest proportion of disease diagnosis (47%) followed by AIDS 4. Increased percentages in heart, lung, kidney diseases, dementia and debility 5. For all patients, pain is the most important issue The approach to palliative care works best with a coordinated team effort Interdisciplinary team 1. Attending Physician 2. Nurse Practitioner 3. Social Worker 4. Registered Nurse 5. Chaplain 6. Healthcare Professionals 7. Trained Volunteers 8. Bereavement Counselors 9. Pharmacy Consultants A collaborative approach will facilitate a positive outcome in the care of the terminally ill patient and the proper control of pain.
Page 2 Challenges to Optimum Palliative Care and Use of Hospice Communication skills depend on 1. Honest, compassionate communication 2. Trained healthcare providers in the principles of palliate and hospice care 3. Sensitivity to cultural and social mores of the patient and family 4. Overcoming language barriers Lack of well-trained healthcare professionals Late referral 1. Too little too late 2. Palliative care and hospice should be an active part in the continuum of care 3. Governmental policy disallowing concurrent hospice care and life-prolonging treatment 4. Fear of government investigation because length of illness has exceeded 6 months Difficulty in determining terminal diagnosis Difficulty in determining prognosis 1. Advances in treatment of cancer and AIDS 2. Physicians predictions tend to be optimistic 3. Would you be surprised if this patient died within the next 12 months? if the anwer is no, then palliative care and hospice would be appropriate. Patient fears 1. Pain is the number one most common symptom at the end of life -The patient s greatest fear is unrelieved pain -95% of end of life pain can be relieved -Under treated pain is a primary ethical concern among healthcare professionals 2. Abandonment 3. Lack of control of situations and treatment 4. Unfinished goals or unresolved conflicts and failed interpersonal relationships 5. Life after death Physician and healthcare professional fears 1. Pain management and inadequate understanding the assessment and treatment rational -Addiction, tolerance and side effects of pain management and treatment -Criminal and civil risk of under treating pain 2. Communication of bad news to patient and family 3. Professional involvement it is easier to order a test than talk to a patient
Page 3 Assessment and Management of Symptoms Pain 1. Cause is often the disease process -May be due to treatment of disease -Heightened by anxiety, depression, fear 2. Should be assessed each visit with the patient 3. The patient s self-report of pain is the most reliable indicator of pain -Healthcare professionals underestimate pain -Family members overestimate pain Describe pain characteristics with regard to 1. Location 2. Distribution 3. Quality somatic, visceral or neuropathic 4. Intensity 5. Factors that lessen or heighten the pain 6. Acute, subacute, episodic or chronic 7. Breakthrough Physical examination of site of pain Functional assessment Management of pain depends on 1. Selection of an appropriate drug, dose, route and frequency 2. Aggressive titration of dose 3. Prevention of pain and relief of breakthrough pain 4. Coanalgesic medications 5. Prevention and management of side effects WHO three step analgesic ladder The type of analgesic agent depends on the severity of pain, and the patient determines pain. 1. STEP ONE -For pain level 1-3 on the scale of 10 -Non-opioid analgesic (ASA, NSAIDS, acetaminophen) -May or may not need an adjuvant agent 2. STEP TWO -For pain level 4-6 (moderate pain) -Low dose of opioid with or without combination of Step One non-opioid 3. STEP THREE -For pain level 7-10 (severe pain) Page 4
Assessment and Management of Symptoms (continued) Step One Drugs (dose ceiling) 1. Acetaminophen -Safest, but no anti-inflammatory effect -Causes liver dysfunction at doses >4000mg/day -Use with caution with liver or renal impairment 2. NSAIDS -Effective for inflammation and bone pain -Anti-platelet effect -GI bleeding side effect Step Two Drugs (dosage ceiling) 1. Combination of acetaminophen and an opioid 2. May be used as a co-analgesic at any step Step Three Drugs (opioids do not have a dosage ceiling) 1. Morphine -Immediate of sustained release form -Most commonly used opioid -Drug of choice for severe pain 2. Oxycodone (Oxycontin and Roxicodone) -Safe and effective as morphine for cancer pain -Less common side effects (hallucinations and delirium) 3. Hydromorphone (Dilaudid) -4X as potent as morphine -Immediate release form 4. Fentanyl (Duragesic) -Most potent 100X as potent as morphine -12 hour delay in peak blood level -Advantage in a patient who can t swallow 5. Methadone -Extreme care in titrating dose due to respiratory depression -Dosed q4-6hrs., but half-life is 24-36 hrs. 6. Propoxyphen (Darvon) should not be used in palliative care due to toxicity in high doses and lack of efficacy over acetaminophen 7. Meperidine (Demerol) should not be used because of toxicity and limited efficacy Page 5
Assessment and Treatment of Symptoms (continued) Opioids do not have a ceiling effect -The dose can be titrated until pain is relieved or side effects become unmanageable. -Start with a low dose and titrate daily -MS IR, hydromorphone and oxycodone are good intial drugs Extra or rescue doses of opioids are necessary for BREAKTHROUGH pain -Most appropriate dose is the immediate release form of the same opioid in routine use for pain control -Rescue dose should be 5-15% of the 24-hour dose given PO q one hour -If more than 3 rescue doses are needed in 24 hours, the increase the routine drug by 25-100% depending on the severity of pain Side effects of Opioids 1. Constipation 100% of patient 2. Nausea and vomiting tolerance will develop in 3-7 days 3. Allergy true allergy to opioids is rare Adjuvant Therapies: Coanalgesic Agents 1. Neuropathic pain -Tricyclic antidepressants -Corticosteriods -Anticonvulsants -Topical of local anesthetics 2. Bone pain -NSAIDS -Corticosteroids Nonpharmacologic Agents 1. Complementary/Alternative Methods -Acupuncture -Yoga 2. Body-based/Manipulative Methods 3. Application of cold and/or heat -Massage, stroking, compression, percussion and vibration -Changing a patient s position in the bed or chair -Range of motion exercises -Pillows, splints, support devices, mattresses and cushions Cognitive and Behavioral Approaches 1. Focused relaxation and breathing exercises -Provide distraction from pain 2. Progressive muscle relaxation 3. Distraction through music, art, games, meditation, prayer and visiting with friends 4. Imagery/Hypnotherapy