1. CARE OF DYING PATIENT Dorothy D. Sherwood, M.D. 6/11/2005

2. WEB Resources http://www.whocancerpain.wisc.edu/index.html http://www.whocancerpain.wisc.edu/index.html http://www.whocancerpain.wisc.edu/index.html http://www.whocancerpain.wisc.edu/index.html http://epec.net/EPEC/webpages/index.cfm http://epec.net/EPEC/webpages/index.cfm http://epec.net/EPEC/webpages/index.cfm http://www.hospicecare.com/ http://www.hospicecare.com/

3. Caring for the dying patient “No procedure, no medicine, and no words can thwart death, and the physician is faced with a morass of difficult emotions in the patient, family, staff, and self.” “No procedure, no medicine, and no words can thwart death, and the physician is faced with a morass of difficult emotions in the patient, family, staff, and self.”

4. Caring for the dying patient Physicians role in the final stages of illness: Physicians role in the final stages of illness: Guide patient and family through the process. Guide patient and family through the process. Prevent and treat physical, emotional, and spiritual suffering Prevent and treat physical, emotional, and spiritual suffering Assist in defining and achieving appropriate goals for the end of life. Assist in defining and achieving appropriate goals for the end of life. A focus on comfort and quality of life A focus on comfort and quality of life

5. Sharing Bad News 1. Find an appropriate setting and time 2. Be prepared 3. Ask the patient who should be present 4. Align – “What do you know?” 5. Be brief and simple – tailored 6. Be honest 7. Listen 8. Support 9. Offer next steps 10. Document

6. Advance Care Planning 1. Arranging a private setting and sufficient time 2. Determining what the patient and family know about the illness and prognosis 3. Exploring what they are hoping for and what the team can and cannot do to meet these expectations 4. Suggesting realistic goals and indicating how they can be achieved and explicitly addressing unreasonable and unrealistic expectations 5. Responding empathically to emotional reactions 6. Making plans and following through 7. Reviewing and revising plans at inflection points

7. Whole Patient Assessment Physical Assessment Physical Assessment Psychological Assessment including, evaluation of decision-making capacity Psychological Assessment including, evaluation of decision-making capacity Social Assessment Social Assessment Spiritual Assessment Spiritual Assessment

8. Physical Symptoms Pain Pain Periodicity, Location, Intensity, Modifying Factors, Effect of Treatment, Functional Impact, Impact on Patient Periodicity, Location, Intensity, Modifying Factors, Effect of Treatment, Functional Impact, Impact on Patient Interventions: WHO 3 step pharmacological approach Interventions: WHO 3 step pharmacological approach Non-opioids Non-opioids Mild opioids Mild opioids Strong opioids Strong opioids

9. Physical Assessment JUDICIOUS EVALUATION OF THE CAUSE JUDICIOUS EVALUATION OF THE CAUSE PREVENTION AND MANAGEMENT OF SECONDARY COMPLICATIONS PREVENTION AND MANAGEMENT OF SECONDARY COMPLICATIONS SYMPTOM MANAGEMENT WITH MINIMAL SIDE EFFECTS SYMPTOM MANAGEMENT WITH MINIMAL SIDE EFFECTS REGULAR PATIENT FOLLOW-UP TO ASSESS SYMPTOM INTENSITY AND TREATMENT COMPLICATIONS REGULAR PATIENT FOLLOW-UP TO ASSESS SYMPTOM INTENSITY AND TREATMENT COMPLICATIONS

10. Physical Symptoms Pain ( continued) Pain ( continued) Short acting opioids – titrate 25 to 50 % each dose until control Short acting opioids – titrate 25 to 50 % each dose until control Use adjuvants such as BZD to reduce anxiety Use adjuvants such as BZD to reduce anxiety Long acting opioids – titrate every 48 to 72 hours. Long acting opioids – titrate every 48 to 72 hours. Add bowel regiment Add bowel regiment Assess for nausea, fatigue, confusion, respiration depression Assess for nausea, fatigue, confusion, respiration depression

11. Physical Symptoms Fatigue and Weakness – Life style adjustments – education Fatigue and Weakness – Life style adjustments – education Glucocorticoids – last about 1 month Glucocorticoids – last about 1 month Dextroamphetamine – 5 to 10 mg am and noon. Dextroamphetamine – 5 to 10 mg am and noon. Dyspnea – investigate and treat reversible Dyspnea – investigate and treat reversible Does not correlate with objective measurements Does not correlate with objective measurements Opioids and BZD Opioids and BZD Scopalamine to dry secretions Scopalamine to dry secretions Oxygen Oxygen

12. Physical Symptoms Insomnia – Insomnia – BZD BZD Relieve other symptoms Relieve other symptoms

13. Physical Symptoms Nausea, vomiting, anorexia Nausea, vomiting, anorexia Antiemetic agents Antiemetic agents Antihistamine – dimenhydrinate, meclizine Antihistamine – dimenhydrinate, meclizine Anticholinergic – Scopalamine Anticholinergic – Scopalamine Antidopaminergic – prochlorperazine, droperidol Antidopaminergic – prochlorperazine, droperidol 5-HT3 Antagonists – Ondansetron, granisetron 5-HT3 Antagonists – Ondansetron, granisetron

14. Physical Symptoms Nausea (continued) Nausea (continued) Prokinetic agents Prokinetic agents 5-HT4 agonist – Metoclopromide 5-HT4 agonist – Metoclopromide Others Others BZD – anticipatory nausea with chemo BZD – anticipatory nausea with chemo Glucocorticoids – chemo induced nausea Glucocorticoids – chemo induced nausea Canabinoids – chemo induced nausea Canabinoids – chemo induced nausea

15. Physical Symptoms Constipation Constipation Encourage Fluids Encourage Fluids Stimulants Stimulants Senokot – 2 to 4 Tabs per day Senokot – 2 to 4 Tabs per day Prune Juice Prune Juice Bisacodyl – 5 to 10 mg /day Bisacodyl – 5 to 10 mg /day Osmotic Osmotic Lactulose – 15 – 40 ml q 4 – 8 hours Lactulose – 15 – 40 ml q 4 – 8 hours MOM – 15-30 cc qd MOM – 15-30 cc qd Mg Citrate – 125 – 250 cc/d Mg Citrate – 125 – 250 cc/d Miralax 17 grams po qd Miralax 17 grams po qd Stool Softeners Stool Softeners Sodium docusate – 300 to 600 mg a day Sodium docusate – 300 to 600 mg a day Calcium docusate – 300 to 600 mg a day Calcium docusate – 300 to 600 mg a day

16. Physical Symptoms Others: Others: Cough Cough Swelling Swelling Itching Itching Diarrhea Diarrhea Dysphagia Dysphagia Dizziness Dizziness Loss of libido Loss of libido Fecal and urinary incontinence Fecal and urinary incontinence Neuropathy Neuropathy

17. Physical Assessment EVALUATING SUCCESS IN THE PHYSICAL DOMAIN EVALUATING SUCCESS IN THE PHYSICAL DOMAIN 1. Access: How much trouble do you have getting the medical care you need? 2. Physical: How much do you suffer from physical symptoms, such as pain, shortness of breath, fatigue, or bowel or urination problems? 3. Patient-clinician relationship: How much do you believe your physicians and nurses respect you as an individual? 4. Information: How clear is the information you receive from the health care team about what to expect regarding your illness?

18. Psychological Assessment Depression Depression Grief Grief Anxiety Anxiety Delirium Delirium Hopelessness Hopelessness Irritability Irritability Impaired concentration Impaired concentration Confusion Confusion

19. Psychological Assessment Decision Making Capacity: Decision Making Capacity: Patient autonomy, informed consent, and the right to self-determination are key principles of patient- focused, end-of-life care. Patient autonomy, informed consent, and the right to self-determination are key principles of patient- focused, end-of-life care. The physician should evaluate: The physician should evaluate: Does the patient understand what is being discussed? Does the patient understand what is being discussed? Can the patient make rational and appropriate choices based on the available options and alternatives? Can the patient make rational and appropriate choices based on the available options and alternatives? Does the patient have insight into the consequences of decisions? Does the patient have insight into the consequences of decisions?

20. Psychological Assessment Depression – “How often do you feel down, depressed?” Depression – “How often do you feel down, depressed?” Treatment Treatment Stimulants – Stimulants – Dextroamphetamine 5 to 10 mg twice daily am and noon – up to 15 mg Dextroamphetamine 5 to 10 mg twice daily am and noon – up to 15 mg Pemoline – absorbed through the buccal mucosa- 18.75 mg am and noon Pemoline – absorbed through the buccal mucosa- 18.75 mg am and noon SSRI SSRI Mirtazepine – treats anorexia, insomnia Mirtazepine – treats anorexia, insomnia Others – refer Others – refer

21. Psychological Assessment Anxiety Anxiety Alprazolam – 0.25 mg to 1 mg po tid or qid Alprazolam – 0.25 mg to 1 mg po tid or qid SSRI’s SSRI’s Delirium Delirium Atypical Neuroleptics Atypical Neuroleptics Olanzapine – 2.5 to 5 mg po qd Olanzapine – 2.5 to 5 mg po qd Risperidone – 1 – 3 mg po q 12 hours Risperidone – 1 – 3 mg po q 12 hours Anxiolytics Anxiolytics Lorazepam – 0.5 – 2 mg q 1 to 4 hours po/iv/im Lorazepam – 0.5 – 2 mg q 1 to 4 hours po/iv/im Midazolam – 1 – 5 mg continuous infusion Midazolam – 1 – 5 mg continuous infusion Anesthesia Anesthesia Propofol -.3 to 2 mg per hour continuous infusion Propofol -.3 to 2 mg per hour continuous infusion

22. Spiritual Assessment 1. What is your faith or belief? 2. Is it important in your life? 3. Are you part of a spiritual or religious community? 4. How would you like your health care provider to address these issues in your health care?

23. Spiritual Assessment 1. How much does this illness seem senseless and meaningless? 2. How much does religious belief or your spiritual life contribute to your sense of purpose? 3. Since your illness, how much do you live life with a special sense of purpose?

24. Social Assessment Financial Financial 40% report that their terminal illness has been a huge financial burden 40% report that their terminal illness has been a huge financial burden Is associated with preference of comfort care over life- prolongation Is associated with preference of comfort care over life- prolongation Increases psychological distress Increases psychological distress Consult a social worker early to assure the family of access to all the benefits available Consult a social worker early to assure the family of access to all the benefits available Relationships Assisting the patient and his/her family through the dying process Who does the patient rely on for physical needs? Emotional needs?