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MAKE THE DAYS COUNT: THE WHO, WHAT, WHERE,
WHEN AND WHY OF PALLIATIVE CARE
Rebecca Mueller PA-C, MSc
Ontario, Canada
WHAT
WHO Palliative Care definition
an approach that improves the
quality of life of patients and their
families facing the problem associated with life-threatening
illness, through the prevention and
relief of suffering by means of early
identification and impeccable
assessment and treatment of pain
and other problems, physical,
psychosocial and spiritual.
End of Life Ethics
Ethical Principles
Autonomy: independence
Beneficence: do good
Non-maleficence: don't harm
Justice: equal treatment
Palliative Care
• Live as actively as possible
• Pain and symptom relief
• Spiritual/emotional support
• Support for family
in conjunction with other therapies that are
intended to prolong life, such as chemotherapy or
radiation therapy, and includes those investigations
needed to better understand and manage distressing
clinical complications.
Hospice definition
The focus of hospice care is on comprehensive
physical, psychosocial, emotional, and spiritual care
to terminally ill persons and their families.
Goal: promote quality of life without burdensome
interventions
◦DNR is NOT required in
order to start hospice
care.
WHO/WHEN
Timeline/ When to Refer How do you know? ◦ Does hospice/palliative care start at 12 months? 6 months? When
to start?
◦ How do you predict death?
◦ Would you be surprised if the patient died in 1 yr?
◦ General indicators of decline?
◦ Specific clinical indicators related to dz?
Palliative care: Earlier is better ◦ Not only for individuals with only a few days left
◦ 151 biopsy-proven advanced non–small-cell lung cancer
◦ Randomized to receive early referral to palliative care team plus standard tx or standard tx only.
◦ Intervention grp had less depression, pain and aggressive intervention (chemo within 14 days of death), and more hospice care.
◦ Despite receiving less aggressive care, patients in the intervention group lived longer.
◦ median survival was 11.6 months, vs 8.9 months for the control group (P=.02).
◦ lifehttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183935/
Specific Disease related decline indicators ◦Cancer
◦Metastatic dz, if spend greater than 50% of day in
bed, prognosis is 3-6 months
◦COPD
◦ FEV1 <30% predicted, recurrent admissions, long
term O2, MRC grade 4-5, right sided heart failure
◦CHF
◦ Stage 3-4, SOB at rest, repeated admissions
Specific Disease related decline indicators
◦CKD
◦ Stage 4-5, no dialysis, n/v, pruritis, fluid overload, anorexia
◦ Liver Failure
◦Advanced dz, diuretic resistant ascities, hepatorenal syndrome, encephalopathy
◦Dementia
◦Unable to walk, incontinent, non verbal, uti, wt loss, aspiration pneumonia, reduced oral intake
◦ Despite all of this information, it is still very
difficult to predict death.
◦ We are often wrong.
◦ When in doubt, talk to the patient and refer to
hospice experts.
WHAT: SYMPTOM MANAGEMENT
Delirium
D drugs, drugs, drugs! dehydration!
E electrolyte, endocrine (thyroid), ETOH
L liver failure
I infection
R respiratory (hypoxia)
I increased intracranial pressure
U uremia(renal failure)
M mets
A syndrome of
symptoms
resulting in
decreased
cognitive
function.
Treat the
underlying
causes.
Delirium
◦ Brain mets: dexamethasone 16-32mg PO
◦ Reverse opioid toxicity
◦ Sun downing: psychotropic meds
◦ Careful with benzos!
◦Do not misinterpret restlessness, moaning
as pain or "vision" as delirium.
Delirium
◦ Haloperidol is gold standard: 0.5-2mg sq bid-tid. May use q1h for
an acute episode. 20mg/day max
◦ Risperidone 0.5-1mg po bid
◦ Olanzapine 2.5-15mg po od
◦ Midazolam 2.5mg-5mg sq q 1-2hours prn in conjunction with
above.
◦ Do not misinterpret restlessness, moaning as pain or "vision"
as delirium.
Dyspnea • Based on self reporting
• If pt feels sob, it should be addressed regardless
of oxygen saturation!
• If O2%sat <90%: supplement with oxygen
• Opioids can improve dyspnea
• Properly titrated opioids do not produce
respiratory depression
• In those with COPD, 5 day trial of corticosteroids
• Consider chlorpromazine or methotrimeprazine
when anxiety also present.
Nausea & Vomiting ◦ Common symptom
◦ Treat underlying cause ie bowel
obstruction, constipation, chemo,
gastroporesis etc..
◦ Peppermint/lemon candies, ice chips,small
meals, limit spicy and fatty foods, eliminate
strong odours, sit upright after eating, rinse
mouth before eating and after vomiting
with 1/2tsp salt and 1/2 tsp baking soda in 2
cups water
Nausea &Vomiting
◦ Depending on cause you may need:
◦ NGT
◦ IV fluids/ electrolyte replacement
◦ PEG tube/stents/ostomy/surgical resection
◦ NPO
Nausea and vomiting
◦ First line: metoclopramide 5-20mg po/sq/IV q6h. Titrate up as needed.
◦ Second line: haloperidol 0.5-2.5mg po/sq q12h or domperidone 10mg po tid-qid (above 30mg daily increases risk of sudden cardiac death)
◦ Chemo/RT: ondansetron 8mg po/sq/IV q8-24h and/or oxazepam 10mg po tid or lorazepam 12-mg tid po/sl/sq/IV
◦ Brain mets: Dex 4-8mg po/sq/IV bid
◦ May use a combination of drug classes. For chronic N/V, have a regular dosing schedule
Pain
• Take a thorough hx
• Different types of pain, pain
syndromes, neuropathic,
mood
• Encourage pain diaries
Pain Non pharmacologic tx • Radiation
• Primarily used for bone mets
• Vertebroplasty
• Per cutaneous cement for malignant vertebral
collapse
• Surgery
Pain Adjuvant therapy • Tricyclics antidepressants: amitriptyline, nortriptyline,
imipramine
• Gabapentin, pregabalin
• Bisphosphonates
• Cannabinoids!!! Very useful for refractory pain,
neuropathic pain, depression, anorexia, sleep!
Pain Opioids • Start low and go slow
• Always use stool softners/laxatives (senna/lactulose)
• Give antiemetic when initiating
• Always give "breakthrough" doses
• Fentanyl, methadone, oxycodone are safest with reduced kidney function
• Give opioids around the clock
Pain Opioids • Opioid naive
• Morphine: 5mg q4h with 2.5-5mg q1h PRN
• Hydromorphone: 1mg q4h with 0.5-1mg q1h PRN
• Oxycodone: 2.5mg q4h with 1/2 tab-2.5mg q2h PRN
• Non opioid naive
• Increase long acting by 25%
• Breakthrough dose should be 10-15% of the 24 hr dose q 1-2 hr
• Acute pain crisis should be to with IV short acting only
https://opioidcalculator.practicalpainmanagement.com
Bowel Care
Constipation
• Encourage fluids
• In absence of oral intake,
body produces 1-2 oz
stool/day
• Sennacot, lactulose
• Suppositories/enemas
• Picosulfate sodium
magnesium oxide citrate
• Easier to prevent than tx!
Diarrhea
• Loperamide 2mg tab or
2mg/15ml
• 2tabs with first loose stool, 1
ran with each loose stool
after
• Max 32mg/d
• Octreotide 50-600mcg/d sq.
dosed bid-tid for refractory
diarrhea
• Consider IV fluids prn
Discussion Points
◦ IV Fluids
◦ Blood product transfusions
◦ TPN
◦ Peripheral blood tests
◦ Antibiotics
◦ Medical assisted death
◦ ~1800 since its inception
◦ Barbiturates for CNS depression (phenobarbital) and curare derivatives
(Neuromuscular junction paralysis)
Case 1
◦ Pt has had morphine 20mg PO q4h and 10mg PO q2h PRN. Pt has
had 3 breakthrough doses in the past 24 hours. Calculate a long
acting plus breakthrough dosing schedule based on the previous
24 hours of morphine use.
20mg x 6= 120mg
10mg x 3= 30mg
150mg/24 hours
150/2= 75mg bid long acting
Breakthrough dose
150 x 0.1 and 0.15= 15-22.5mg PRN
Note: no
75mg pill.
Can
combine pills
(60, 10, 5) or
use sq or pain
pump
Case 2 ◦ 78yr old male
◦ Has wife, 3 daughters
◦ High risk MDS, -11q
◦ Been on vidaza x1 yr, no
longer working
◦ Recently transformed AML
◦ Excellent performance status,
built shed
◦ Wants Transplant
• Review Dx
• What are the
treatment options
• Would you offer
transplant? Supportive
care? What are tx
goals?
• Is this active tx,
palliative, hospice care
Case 3 ◦ 67yr old woman with MM
◦ Has had transplant, 2 different chemos
◦ Relapsed again
◦ ++bone pain, fatigue, 10lb wt loss, elevated calcium, electrolytes in balance, minor new confusion but A&Ox3
◦ Terrified to lose her hair again
◦ Does not want further chemo, states "ready to die"
◦ Presents with daughter who wants more chemo
• Review Dx
• What are the
treatment options
• What tx would you
offer, what are tx
goals?
• Is this active tx,
palliative, hospice care
Case 4 ◦ 98 yr old women with dementia
◦ Lives with her daughter and 102yr old
husband
◦ Originally from India. Does not speak English.
◦ Bed bound
◦ Dysphasia. Tolerates liquids only.
◦ Mostly non verbal but angry during
bath/changes
◦ Seeing and talking to dead people at
night
◦ Family feels it is bad luck to make the
pt a DNR and discuss her death.
• Review Dx
• What are the
treatment options
• What tx would you
offer, what are tx
goals?
• Is this active tx,
palliative, hospice care
Review Discussion
Please use your
colleagues
Social Workers are
wonderful!