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Common causes of death : Common causes of death Heart disease Malignant neoplasm Cerebrovascular disease COPD Accidents Pneumonia Natl. Ctr. Health Statistics, CDC,1997 Application : Application Presentation Death Therapies to modify disease BereavementCare Hospice Therapies to? suffering and / or ? quality of life Palliative Care PALLIATIVE CARE : PALLIATIVE CARE Treatment of Patient and Involved Caregivers Focus on the End of Life Relieve Total Burden of Suffering Physical Suffering Psychological Suffering Spiritual Suffering Physical Suffering : Physical Suffering Symptoms Function Safety Hydration Nutrition Psychological Suffering : Psychological Suffering Emotion Cognition Mood Coping Responses Fears Spiritual Suffering : Spiritual Suffering Spirituality Meaning of life and death Religion Impact of actual and anticipated losses Practical Matters : Practical Matters Legal Financial Living Situation Caregivers Care of Dependents Domestic Needs Palliative Care: Initial Steps : Palliative Care: Initial Steps Assess patient/caregiver knowledge, understanding of disease and prognosis Establish lines of communication Develop terms that match knowledge level of the family Determine decision making structures Palliative Care : Initial Steps : Palliative Care : Initial Steps Assess Coping Strategies Physical Concerns Economic Concerns Family and Patient Concerns Social Network of Support for patient and caregivers Palliative Care: Initial Steps : Palliative Care: Initial Steps Assess spiritual and cultural beliefs Patient and family knowledge of death Prior experiences with death Role of death in family and cultural context Religious Beliefs Symptoms relieve : Symptoms relieve Pain Nausea Dyspnea Bowel and bladder Hydration Fatigue Skin care Anxiety Agitation Delirium Bereivement Symptom Control in Palliative Medicine : Symptom Control in Palliative Medicine ‘Good’ Death (Euthanos) : ‘Good’ Death (Euthanos) Symptoms controlled Acceptance At peace Completion of unfinished business Adjustment of family Before and after death ( reactions to death ) Pain : Pain PCM Codeine Morphine Adjuvants Carbamazepine or Gabapentin : neuropathic pain Steroids : for bone Metastasis GTN : for anginal pain Non-pharmacological methods of pain relief : Non-pharmacological methods of pain relief Massage – muscle tension, headaches, anxious patient Heat & cold applications – muscle spasm Distraction – periodic or procedural pain Transcutaneous Electrical Nerve Stimulation (TENs) – musculosketal problems Aromatherapy Complimentary and Alternative therapies Nerve block Symptom Relief : Symptom Relief Pain Management Acute, Subacute, Chronic Look for the Cause Assess frequently Step Approach Pain Relief : Pain Relief Neuropathic Pain TCAD, Anticonvulsants, topicals (Capsaicin) , Baclofen Inflammatory Pain Steroids, NSAIDS use cautiously, opioids Bone Metastasis Pamidronate, Calicitonin, opioids Muscle Spasms Baclofen, Benzodiazepines Persistent Pain : Persistent Pain Step I Acetaminophen up to 4 gm/day, ASA up to 4 gm/d NSAID use cautiously for persistent pain Step II Tramadol 50 mg max 8 tabs divided q 6h Oxycodone 5 mg max 12 tabs divided q 6h Morphine 5 mg no maximum dose q 4 hour Persistent Pain : Persistent Pain Step III Calculate 24 h opioid need and convert to long acting bid form Use short acting for breakthrough Barriers to maximal pain relief from doctors and patients Ethical precedent for using as much as needed to alleviate suffering Persistent Pain : Persistent Pain MSContin 15, 30, 60, 100, 200mg OxyContin 10, 20, 40, 80mg Hydromorphone 1, 2, 3, 4, 8mg Methadone 5,10,40mg Fentanyl 25, 50, 75, 100 microgram patch Management of Symptoms : Management of Symptoms Try to prevent symptoms if possible use laxatives with opioids give an anti-emetic when starting morphine review and often stop after 3-4 days give anti-emetics before and during chemotherapy encourage good mouth care, especially in dying patients sips of water, moisten mouth, anti-fungal agent Nausea and Vomiting : Nausea and Vomiting Match cause of nausea to treatment Increased ICP Dexamethasone Vestibular Antihistamines Chemoreceptor Dopamine Antagonist Gastric Irritation Feeds, stop NSAIDS Gut Motility Metaclopromide Ascites Diuretics Pain or anxiety Treat accordingly Dyspnea : Dyspnea Physical and/or psychological Morphine Oxygen Fan in Room, Fresh Air Secretions Control with anticholinergics and suctioning Address fears, anxiety, spiritual needs Relaxation, distraction, Anxiety : Anxiety Sources include: fear, pain, psychological and spiritual distress Treatment : Anxiolytics Human Contact Address fears Setting affairs into order Agitation : Agitation Target behavior and seek causes if possible Decrease external stimuli Use Music, Prayer Agitation as a form of communication As part of delirium very near end of life Haldol, Anxiolytics Delirium : Delirium Safety Orientation and Human Contact Anxiolytics, antipsycholtics Bowel and Bladder : Bowel and Bladder Combat constipation of narcotics, avoid impaction Careful skin care, positioning If diarrhea use anticholinergics Scheduled voids , disposable pads, Foley’s urine catheter? Manage odors Nutrition and Hydration : Nutrition and Hydration Sips, Chips, mouth care Anorexia/Cachexia Consider steroids, TCAD, Cannabinoids, Remeron (Mirtazepine – anti depressant ) Artificial Assistance Values Based Decisions Delays the inevitable Consider limited trial and withdrawal if no evident benefit Fatigue : Fatigue Somulence, activity intolerance and fatigue tend to increase Educate patient and caregivers not to push too hard Short visits, brief activities, frequent naps Central Stimulants? Skin Care and Pruritis : Skin Care and Pruritis Pruritis Consider xerosis, uremia, hypercalcemia, medication side effects, delirium Hygiene and positioning Lotions Cool moist compresses Antihistamines Bereavement : Bereavement Anticipatory grief Early Loss of Personhood in Dementia Individualized Support Interventions if protracted, interfering with starting to live again Reaction to death or impending death : Reaction to death or impending death Shock and denial Anger Bargaining Depression Acceptance References : References American Geriatrics Society 2002 Guidelines for Management of Persistent Pain. Galanos MA: Long Term Care in Geriatrics Palliative Care; Clinics in Family Practice Sept 2001;3(3) 683. Melvin TA: The Primary Care Physician in Palliative Care: Primary Care June 2001;28(2):239-49. Bernat JL: Ethical and Legal Issues in Palliative Care: Neuro Clin Nov 2001; 19(4):969-87. J Am Oseopath Assoc; Oct 2001 issue devoted to Palliative Care. Steel K: Annotated Bibliography of Palliative Care and End of Life Issues; J Am Ger Soc Mar 2000;48(3)325-32. You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.