Palliative Care Anna DuPen ARNP, ACHPN Palliative Care Service UWMC

Palliative care focuses on improving a patient's quality of life by managing pain and other distressing symptoms of a serious illness. Palliative care should be provided along with other medical treatments. AAHPM 2010

Hospice is palliative care for patients in their last year of life. Hospice care can be provided in patients' homes, hospice centers, hospitals, long-term care facilities or wherever a patient resides. AAHPM 2010

Physicians who specialize in hospice and palliative medicine work with other doctors and healthcare professionals, listen to patients and align their treatments with what's important to them, and help families navigate the complex healthcare system. AAHPM 2010

Palliative Care Domains Patient / Family Centered Care – Eliciting the Patient’s Story – Family Values and Priorities Shared Decision Making – The BioMedical Treatment Plan – Patient / Family Goals Pain and Symptom Management – Physical Distress – Psychological Distress – Spiritual Distress

Patient’s Likely to Need Palliative Care Cancer Heart Failure Liver Failure Pulmonary Failure Progressive Neurological Disease Renal Failure

Common Symptoms in Palliative Care Practice Pain Dyspnea Nausea / Vomiting Constipation Delirium Depression Anxiety

Pharmacologic Treatment of symptoms requires multi-tasking! What is the etiology of the symptom? How do the drugs you are using for these various symptoms interact? Is your treatment consistent with the patient’s goals of care?

General Pearls on Pain Control in Palliative Care Opioids are the mainstay for moderate to severe pain Simplest route is the best route Scheduled dosing for patients with continuous pain Breakthrough dose should be 10% of the 24 hour dose of the scheduled opioid Conversion between drugs and between routes is a “must have” skill

General Pearls on Pain Control in Palliative Care Aggressive management of opioid side effects is critical – particularly constipation Knowledge of when to use co-analgesics such as anticonvulsants, antidepressants, steroids, and NMDA antagonists is a component of advanced practice in palliative care

General Pearls on Control of Dyspnea in Palliative Care Select therapy based on etiology! COPD – bronchodilators, steroids CHF – diuretics Pleural effusion – consider thoracentesis Anxiety – anxiolytics End stage resp failure - opioids

General Pearls on Control of Nausea/Vomiting in Palliative Care Select therapy based on mechanism!

Intracranial pressure Anxiety/Memories Motion sickness Vestibular disease Uremia Hypercalcemia Drugs Gastric irritation Intestinal distension Gag reflex Cerebral cortex Vestibular apparatus Chemotrigger Receptor Zone Gastrointestinal Tract

General Pearls on Control of Constipation in Palliative Care Never write orders for opioids without writing for stool softeners +/- stimulants Patients are admitted to the hospital with painful impactions not infrequently Most patients require addition of osmotic New kid on the block is methylnaltrexone

General Pearls on Management of Delirium in Palliative Care Two types – hyperactive and hypoactive Most common cause in palliative care patients is medications, followed by progressive organ failure and infection Treatment is dependent on goals of care but generally a) minimization of delirogenic drugs and/or b) haloperidol or alternative

General Pearls on Management of Depression in Palliative Care Often missed or undertreated in acute setting Incorporate our MSW, Chaplain, Psych colleagues SSRIs or alternates are mainstay Methylphenidate or modafinil in end stage patients

General Pearls on Management of Anxiety in Palliative Care Associated with unrelieved pain or dyspnea Unstated fears – loss of control, isolation, being a burden, worry about spouse / child Incorporate our MSW, Chaplain, Psych colleagues Acute anxiety is usually treated with benzodiazepines

Symptom Clusters in the Nonverbal Patient What does severe pain look like in the nonverbal patient?

What does delirium look like in the nonverbal patient? t Symptom Clusters in the Nonverbal Patient

What does severe anxiety look like in the nonverbal patient? Symptom Clusters in the Nonverbal Patient

Difficult Symptom Issues How do these different symptoms and their treatment influence each other?

Difficult Symptom Issues What do we decide what to give and when to give it with the agitated patient?

Intractable Symptoms at End of Life When all our best efforts fail to make the dying patient comfortable – what do we do? Palliative Sedation and the Principle of Double Effect

What’s Double Effect? Allowing an unintended bad event to happen in the course of trying to do a good thing The intention of those who do the action is critical Often a highly emotional and difficult decision…double effect does not mean everything is crystal clear

Principle of Double Effect Pain or other medication may be used in a terminal illness even if it may hasten an otherwise inevitable death Four conditions must be fulfilled before the Principle of Double Effect can be invoked

Principle of Double Effect The action itself must be good or indifferent The physician/clinician intends the good effect (i.e., pain control NOT death) The good effect must not occur via the bad effect Proportionality

Pain should be treated vigorously “The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed, as either an end or a means, but only foreseen and tolerated as inevitable.” Catechism of the Catholic Church, #2279

Example Elderly person with widely metastatic cancer who has been treated for several years and has had worsening pain for weeks despite ongoing aggressive pain medication titration and is now moaning, saying pain is terrible, is moderately hypotensive, and has decreased respirations. He is on a morphine drip at 20 mg/hr What do you do?

Some choices A.Bolus with 100 mg morphine? B.Continue therapy without change? C.Administer naloxone? D.Bolus with 5 mg morphine and increase morphine drip by 15%/hr?

Some reasons A.Good effect is achieved directly by bad effect (pain control could be achieved by shooting the person, too!) B.Does not seem to meet the patient’s needs C.Could result in terrible pain, why are you doing this? D.If your intent is pain control, is probably the best option

What is the etiology of the symptom? How do the drugs you are using for these various symptoms interact? Is your treatment consistent with the patient’s goals of care? Main Message Questions?