PALLIATIVE CARE : PALLIATIVE CARE We cure seldom
palliate often
and comfort always
16th Century Anonymous
Slide 2: The active total care of patients whose disease is not responsive to curative treatment.
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.