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Palliative Care Changing your practice, yourself, and the system one patient at a time William D Smucker MD Altenheim Nursing Home Strongsville, OH

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Presentation on theme: "Palliative Care Changing your practice, yourself, and the system one patient at a time William D Smucker MD Altenheim Nursing Home Strongsville, OH"— Presentation transcript:

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2 Palliative Care Changing your practice, yourself, and the system one patient at a time William D Smucker MD Altenheim Nursing Home Strongsville, OH

3 Compare and Contrast When people describe nursing homes and nursing home care, they use words like….. When people describe hospice care, they use words like……

4 Goals Identify nursing home residents who would benefit from a Palliative Care Plan Communicate prognostic pathways to caregivers and family Develop practical approaches to managing symptoms

5 Bill’s Agenda Good palliative care is your responsibility Hospice is not the panacea in LTC Think of patients and families first, enrollment criteria second

6 National Consensus Project ‘The goal of palliative care is to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease or the need for other therapies’ Persons living with progressive chronic conditions (e.g., frailty, advanced heart, lung, renal or liver disease, dementia, and neurodegenerative disorders)

7 One way or another, it’s your responsibility

8 Palliative Care = Ethical Practice “Competence is the first ethical duty of physicians-the goals of medicine cannot be served unless physicians posses and exercise at least basic knowledge and skill.” “The ability to manage pain is an ethical duty” Beneficence Providing symptom control as well as psychosocial and spiritual support UNIPAC 6

9 Who Needs a Palliative Care Plan? “…good end of life care cannot be dependent upon the ability to predict imminent demise or 6-month mortality.” AMDA Toolkit: Palliative Care in the Long-Term Care Setting

10 Site of Death Home 17.3%24.1% Long Term Care 18.6%24.1% Hospitals 64.1%51.8% Nearly one third of nursing home residents die within 12 months of admission

11 Palliative Care “My own notion is that palliative care is a concept of care that should be given to all nursing home residents, regardless of their status as ‘terminally ill’ or not,” “All residents need alleviation of symptoms, pain management, psychosocial intervention, and spiritual care…” Jacob Dimant MD, CMD Caring for the Ages, November 2004

12 Symptoms of Advanced Chronic Illness in Community Elders COPDCHFCancer Symptom Dyspnea65%18%19% Pain28%20%33% Anxiety32%2%19% Depressed feelings17%6%9% Anorexia11%7%14% Walke LM Arch Intern Med 2004;164:

13 Symptoms in Dying LTC Patients Hall P, et al. JAGS 50:3;501 Mar 2002

14 Dying LTC Patients’ Treatments DyspneaPainNoisy Breathing 23% No Tx1% No Tx39% No Tx 64% Oxygen72% Opioids (mostly PRN) 27% Scopolamine 27% Opioids37% ASA, NSAIDs 23% suctioning Hall P, et al. JAGS 50:3;501 Mar 2002

15 Hospice is not the Palliative Panacea ‘You have to know what to do until the cavalry arrives’ Typical hospice census ≤ 10%

16 Palliative Care and Hospice ‘Palliative care refers to whole-person care for patients whose diseases are not responsive to curative treatment.’ ‘Hospice refers to a program that provides coordinated comprehensive palliative care for terminally ill patients and their families…’ American Academy of Hospice and Palliative Medicine UNIPAC One

17 Prognostic Pathways “The key to caring well for people who will die in the (relatively) near future is to understand how they may die and then plan appropriately” Murray SA Br Med J 2005;330:

18 Prognosis LTC median survival 2.75 years 43% admitted with dementia survive 2 years Systolic HF 1 year mortality 13% Class III, 20-52% Class IV Unintentional weight loss, recurrent pneumonia, non-healing or extensive pressure ulcers, increasing functional decline, are key prognostic signs

19 Prognostic Pathways AnorexiaFunctionalDysphagia Multi-system failure PneumoniaPressure Ulcer Sepsis DehydrationMalnutrition Aspiration Inadequate intake

20 Symptom Control As sickness progresses toward death, measures to minimize suffering should be intensified. Dying patients require palliative care of an intensity that rivals even that of curative efforts… Eric Cassels 1989 NEJM

21 Common End of Life Symptoms Dyspnea Dry mouth Nausea, vomiting Constipation Anorexia & Weight loss Non-healing wounds Fever Delirium, restlessness Anxiety Sedation Fatigue Depression

22 Assessment and Treatment Consider benefits and burdens of workup and treatment/intervention in light of: Current stage of illness; prognosis Patient’s preferences and goals of care Consider non-pharmacological interventions Often as important as meds Often work synergistically Repeat assessment process frequently Reassess efficacy, appropriateness

23 Maximize Chances of Success Try to anticipate & prevent symptoms Maximize patient and family control If you educate pts/families before symptoms occur, they will be grateful (e.g., noisy breathing, Cheyne-Stokes) Involve team members and community resources

24 Mrs. Flowers 92 yo woman with severe dementia, vision and hearing loss, severe peripheral arterial disease, diabetes and hypertension Unavoidable weight loss 108 to 83 lbs over 12 months due to dementia, dysphagia, anorexia Increasing confusion and weakness Less oral intake past few days Last bowel movement 3 days ago

25 Mrs. Flowers Prior evaluations Multidisciplinary team has evaluated her for reversible causes of decline and interventions have not been successful Goals of care Family understands her end stage condition and wants team to avoid intensive evaluations or hospital transfer. ‘Just keep her comfortable.’

26 Mrs. Flowers Appears short of breath at rest Noisy breathing, coarse breath sounds, dry mucus membranes Temp of 100.5, RR 30 Sacral wound has thin slough, 1-2 cm undermining, foul odor On pressure-relieving mattress Getting HTN & DM meds Morphine (20 mg/ml) 15 mg Q 4 hrs ATC

27 How Would You Proceed? History? Assessment? Labs? Interventions? Discuss working diagnoses, problem lists

28 Problem List Dyspnea Noisy breathing Dry mouth Malodorous pressure ulcer Delirium Fever Malnutrition End stage state? Infection? Pain? Adverse medication effect? Nausea? Constipation

29 Dyspnea 60% of patients dying in LTC have dyspnea Subjective sensation of uncomfortable breathing Not linked to measurements of blood gases, respiratory rate or oxygen saturation May limit activity and quality of life Strongly associated with anxiety Patient’s complaint may be ‘nerves, anxious’ Each may cause or exacerbate the other Very frightening to patient and caregivers

30 Causes of Dyspnea End stage state Pneumonia Bronchospasm COPD Mucus plugs Pulmonary embolus Pleural effusion Deconditioning CHF Cardiac ischemia Cardiac arrhythmia Tumor invasion Damage from radiation/chemo Severe anemia

31 Dyspnea Assessment and Management Approach to symptom relief may benefit from review of PMH, meds, limited evaluation Physical exam, CXR Treatment should be directed at specific pathology when appropriate (eg. CHF, COPD) Base assessment intensity on benefits vs burdens Use appropriate numerical or descriptive scales to monitor dyspnea and chart symptom control

32 Non-Pharmacologic Treatments Find what works for this person : Energy conservation, positioning, fan, open window, relaxation techniques Emotional support Trial of oxygen (4-6 liters/min) Avoid suctioning in most patients

33 Opioids: Dyspnea Tx of Choice Morphine is most studied & versatile PO, SL, SC, IV, (not via aerosol) Generally, doses and intervals are the same as for frail elders with pain Q4H ATC with breakthrough Q30 min PRN If already on opioids, increase dose 25-50% For intermittent dyspnea, PRN use OK Tips for Getting to Yes for opiates Adding to optimum therapy, trial of small doses

34 Initial Opioid Dose: Frail Elderly Morphine 2 mg PO/SL Q4H 0.1cc morphine 20mg/cc (Roxanol  ) Morphine 0.5mg SC/IM/IV Q4H Oxycodone 2mg PO/SL 0.1cc oxycodone 20mg/cc (Oxyfast  ) Hydromorphone 0.5mg PO/SL Q4H 0.5cc hydromorphone 1mg/cc (Dilaudid  ) Equivalent to 2mg Morphine ½ Percocet 5mg ½ Darvocet N 50

35 Dyspnea: Medication Options Benzodiazepines for anxiety Lorazepam PO/SL/IV mg Q4H Bronchodilators for wheezing Chlorpromazine (Thorazine  ) mg Q4-6H Steroids, diuretics, anticoagulation, erythropoietin in appropriate settings

36 Noisy Breathing What prognostic information is given by the onset of noisy breathing?

37 Death Rattle / Noisy Breathing 25-50% of dying patients 65% will expire within 48 hours Due to weak upper airway muscles plus Due to inability to control secretions Adult normal: 1.5 liters saliva, 2 liters oropharyngeal mucus/day Suctioning usually ineffective, may cause discomfort, reactive edema

38 Death Rattle / Noisy Breathing Patient experience of suffering is unlikely due to semi-comatose state Provide music to ‘mask’ noisy breathing Position on side Antimuscarinic medications Reduce production of secretions, relax tracheo- bronchial muscles Will not ‘dry’ existing secretions, so use early on before symptoms are severe

39 Antimuscarinic Medications Glycopyrrolate (Robinul  ) Does not cross blood-brain barrier, so treatment of choice in frail patients mg SC/IV/IM (0.2mg/ml) Repeat 4X/24H, typical ‘max’ dose 1.2mg/24 H 1-2 mg SL/PO (1,2mg tab; 1mg/10cc solution) Repeat 4 X/24H, typical ‘max’ dose 8 mg/24H

40 Antimuscarinic Medications Atropine 1% eye drops 1-2 drops SL/PO every 4-6 H, titrate to effect Alternatives: HyoscineHBr (Scopolamine, Levsin  ), HyoscineBuBr (Bucospan  )

41 Subcutaneous Medications Opiates Morphine, methadone Benzodiazepines Midazolam, lorazepam (short term) Antipsychotics Haloperidol Antiemetics Metoclopramide Aqua-C clysis system

42 Mrs. Flowers Now RR 30, moist dry cough, dry mucus membranes, coarse breath sounds

43 Oral Care Basics Potent memory Assess frequently (feeding, med pass) Good way to involve family, CNAs Use whatever works Frequent sips of favorite liquids, popsicles, frozen fruit or fruit juices or tonic water, hard candies, artificial saliva Avoid alcohol mouth washes, glycerine swabs; they are drying

44 Oral Care Tips If patient is unconscious, Swab the mouth Q 1-2 H with water or NS Spray with an atomizer Water based lubricant to lips and front teeth Avoid petroleum jelly (Vaseline  ): potentially flammable if O2 in use

45 Mrs Flowers Temperature 100.5, RR 30 Plans for evaluation, treatment of fever?

46 Fever Near the End of Life Onset triggers a time of decision Best discussed in advance if possible Consider benefits and burdens of evaluation, treatment Discuss plan for curative vs. palliative treatment of infections in advance Fever responds to acetaminophen May be sign of terminal dehydration and multisystem organ failure

47 Myoclonus Up to 30% of dying LTC patients have sudden brief involuntary movements May continue during sleep, worse with stimuli Muscular ‘delirium equivalent’ Causes: progressive neurological disorders, organ failure, electrolyte disorders, hypoxia, hypercarbia, medication Treat primary cause if possible Benzodiazepines reduce signs, symptoms

48 Nausea and Vomiting Non-pharmacological Treatment Cool damp cloth to forehead, neck, wrists Bland, cool or room-temperature foods Decrease noxious stimuli, e.g., odors, noise Limit fluids with food Fresh air, fan Relaxation techniques Oral care after each emesis Acupuncture/pressure or TENS to P6

49 Opioid-induced Nausea Chemoreceptor Trigger Zone stimulation Due to rising opioid levels The most common mechanism: 28% of patients Transient (3-7 days) if dosing is steady Upper GI dysmotility (gastroparesis) Tolerance does not develop Vestibular apparatus Unusual; note spinning sensation Constipation, impaction EPERC Fast Facts

50 Nausea Treatments Prochlorperazine (Compazine  ) Potent antidopaminergic, weak antihistamine, anticholinergic agent Preferred for opioid related nausea Haloperidol Very potent anti-dopaminergic agent

51 Nausea Treatments Promethazine (Phenergan) Antihistamine with potent anticholinergic properties, very weak antidopaminergic agent Useful for vertigo and gastroenteritis due to infections and inflammation Not useful for opioid-related nausea Scopolamine A very potent, pure anticholinergic agent. EPERC Fast Facts

52 Agitation, Terminal Delirium Potent Memory Common in final hours, days of life Delirium may not clear May intensify as death approaches Try to identify contributing factors Physical exam and symptom review Medications are most common reversible cause Look for environmental triggers

53 Terminal Delirium Often requires multifactorial intervention Environmental modification(s) Psychological support Recruit family and staff Medications Neuroleptics (for delirium) Haloperidol 0.5-1mg PO/SL/IM Q1H PRN Morphine (for dyspnea, pain) Avoid benzodiazepines (paradoxical agitation)

54 Never underestimate the power of a few committed people to change the world. Indeed, it is the only thing that ever has. Margaret Mead

55 References Palliative Care in the LTC Setting Information Tool Kit. American Medical Directors Association Fast Facts Opiate conversion tool The Clinician’s Ultimate Reference (http://www.globalrph.com/narcoticonv.htm).http://www.globalrph.com/narcoticonv.htm Agarwal P Myoclonus. Curr Opin Neurol 2003; 16: Jimenez-Jimenez FJ Drug-induced myoclonus CNS Drugs 2004; 18(2): Walsh D, Strategies for pain management Supportive Cancer Therapy 2004;1: Winn PA Effective pain management in LTC. JAMDA 2004; 5(5): Winn PA, Quality palliative care in LTC JAMDA 2004; 5(3): Walke LM et al The burden of symptoms among community dwelling older persons with advanced chronic disease. Arch Intern Med 2004;164: Strumpf NE et al. Implementing palliative care in the nursing home. Annals of Long-Term Care 2004;12:35-41 Meyers FG, Linder J. Simultaneous care: disease treatment and palliative café throughout illness. J Clinical Oncology 2003;l21: Buchanan RJ, Choi MA, Wang S, Ju H. End of life care in nursing homes: residents in hospice compared to other end stage residents. J Palliat Med 2004;7: Parker-Oliver D. Hospice experience and perceptions in nursing homes. J Palliat Med 2002;5: Parker-Oliver, Porock D, Zweig S. End of life care in US nursing homes: a review of the evidence. J Am Med Dir Assoc 2005:6;S Kiely DK, Flacker JM. Common and gender specific factors associated with one-year mortality in nursing home residents. J Amer Med Dir Assoc 2002;3: Gillick MR. Rethinking the central dogma of palliative care. J Palliat Med 2005;8: Schonwetter, et al. Predictors of six-month survival among patients with dementia: an evaluation of hospice Medicare guidelines Am J Hosp Palliat Care 2003;20(2): Aqua-C Hydration System 7350 N. Ridgeway, Skokie, IL tel: fax:


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