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PAlliative and Hospice Care
A Primer for the Clinician
Charlene M. Morris, PA-CStonewall, NC
2.6.15
Alicia De Troye: AAPA’s 2/14 Leadership Meeting
Definitions
• PAlliative Care is the treatment of a patient´s physical, emotional, social and spiritual needs. It seeks to improve quality of life for a person with a serious or life-threatening medical condition, and for his or her family.
http://www.cchospice.org/General_Overview.aspx
Hospice Care: designed to alleviate pain and control the symptoms of disease with expertise and compassion. In addition to physical care, hospice provides spiritual, social, and emotional support. An extension of Palliative Care
The Aging of the US
http://www.nytimes.com/interactive/2011/02/04/business/aging-population.html?_r=0 Accessed 7.8.14
From 13 to 55 million over 65!
Why We Die
• Heart disease: 597,689• Cancer: 574,743• Chronic lower respiratory diseases: 138,080• Stroke (cerebrovascular diseases): 129,476• Accidents (unintentional injuries): 120,859• Alzheimer's disease: 83,494• Diabetes: 69,071• Nephritis, nephrotic syndrome, and nephrosis:
50,476• Influenza and Pneumonia: 50,097• Intentional self-harm (suicide): 38,364
http://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
He drew a circle that shut me out-Heretic , rebel, a thing to flout.But love and I had the wit to win:We drew a circle and took him in! -- Edwin Markham
Revised, improved version
http://www.latimes.com/opinion/op-ed/la-oe-0407-silk-ring-theory-20130407-story.html accessed 7.9.14
When to recommend or refer
• Open dialogue early1. Advance directives2. Medical power of attorney3. Family and patient desires4. Address cultural and religious
concerns• Decline is obvious• Family request
Atul Gawande, MD
• Wrote Being Mortal• Discusses what we want for our
aging/ seriously ill: safety vs.• What THEY want: independence,
comfort and food
WHO gets to choose?!
A patient and friend
• Ms. Elsie• Admitting diagnosis: end-stage CAD• Died well within a week
The Process
• Call to Hospice1. Identify diagnosis2. Sign the request/co-sign for PAs3. Consider home visit or Hospice
facility
Hospice Nurses
• Angels, wonderful, loving, a blessing
• PAtient advocates and guides for clinicians
• YOUR and the patient’s escort through the process
Overall Management
– Control pain
– Improve function and quality of life
• Comfort
• Social/society/spiritual
– Avoid therapeutic toxicity when possible
– Pharmacologic and nonpharmacologic measures should be used
American College of Rheumatology Subcommittee on Osteoarthritis. Arthritis Rheum. 2000;43:1905-15.
IASP Definition of Pain
“An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such
damage”
International Association for the Study of Pain
Measure the Pain• Verbal (ask for description)• Visual Analog Scale• Observation!
Where do we go from here?
Rx Considerations
•Analgesic options, outpatient:
– Acetaminophen
– NSAIDs (COX-2)
– Tramadol
– Codeine ± acetaminophen
– Hydrocodone/oxycodone ± adjuvant
• Common concerns
– Analgesia ceiling
– GI ulcers, platelets
– CNS, GI effects
– CNS, GI effects, disorientation
– CNS, GI effects
Breakthrough Pain• Cancer as its model• Opiates and atypical opiates
– Quick onset: transmucosal fentanyl citrate (OTFC) and fentanyl buccal tablet (FBT)
– Short Acting: hydromorphone immediate release (IR)– Long acting: Tramadol ER, Oxymorphone ER, Morphine
ER • Future: Fentanyl iontophoretic transdermal
system – efficacy and side effects similar to standard intravenous
patient-controlled analgesia (IV-PCA) • Sufental trandermal patch
Schmerz. 2007 Aug 9; [Epub ahead of print] Nauck F, Eulitz N.Cancer pain management : Basic therapy and treatment of breakthrough pain.
Pharmacologic Treatment of Chronic and Breakthrough Pain CME/CE Martin E. Hale, MD, http://www.medscape.com/viewarticle/558587 Accessed 8/12/07
Bowel Program
• Senna• Colace• Miralax• Etc.
Other Rx
• Benzodiazepines• Acetaminophen• Ibuprofen/Naproxen• Recreational (street) drugs• “Dietary supplements”• Herbs, balms
Nonpharmacologic Treatment Options
• Speaking/music• Acupuncture• PT/massage/desensitization/touch• Ice/Heat• Biofeedback
Potter. Adv Stud Med. 2004;4:31-40.
– Reassurance– Listening– Holding hands– Visualization
– Patient empowerment
– Stress counseling– Behavior
modification
Death
Euthanasia and Right to Die Initiatives
• Washington and Oregon• Rx Provided after screening and
family/medical support• Interesting outcomeS!
10. Assisted Suicide (Sec. 1553)Forbids the federal government or anyone receiving federal health funds from discriminating against any health care entity that won't provide an "item or service furnished for the purpose of causing ... the death of any individual, such as by assisted suicide, euthanasia, or mercy killing."ACA provisional
statement
How comfortable are you?• Continuing care for survivors• Attending the memorial or funeral• Writing a personal note• Visiting the family
Bereavement Care
• The final component of “end of life care.” Bereavement counseling to survivors by the hospice team and other sources for up to a year after the death of their loved one.
• Rx as necessary eg: anxiety or sleep• Time
Children and Babies
GriefGrief is complex; it encompasses a wide range of emotions that can come and go in waves. You are not alone. With time, you and your family will experience new happy moments together.
http://www.sesamestreet.org/grief Accessed 7.7.14
Grieve not,
nor speak of me with tears,but laugh and talk of meas if I were beside you...I loved you so --'twas Heaven here with you.
--Isla Paschal Richardson
Forever on Thanksgiving Day the heart will find the pathway home. -- Wilbur D. Nesbit
What we do for ourselves dies with us. What we do for others and the world remains and is
immortal. - - Albert Pine
What Should We Do?
• Listen • Guide our patients and families• Gather resources• Call write and visit our legislators!
http://cqrcengage.com/ncapa/
We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.
— Albert Schweitzer, 1931