Read this book during my Palliative Care elective
"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".
Hospice can be added on top of palliative care if the end of life is near, and focuses exclusively on caring, not curing.
2. Pain Management
Define what is causing the pain as precisely as possible.
Identify other limitations such as
- Renal insufficiency: (use methadone or fentanyl). Avoid morphine and codeine.
- Hepatic insufficiency: requires more caution with fentanyl, hydromorphone, oxycodone, and methadone. Avoid morphine.
- Cost: methadone is the most efficient.
Opioid Caveats:
- Respiratory depression is almost always preceded by sedation.
- Constipation should be anticipated and treated prophylactically.
- Nausea normally resolves after a few days.
- Sedation is common in the beginning just like nausea.
- Myoclonus means time to try another opioid or add a benzo.
- Delirium must be analyzed carefully as the cause is usually multifactorial.
- Urinary retention
- Addiction
- Pseudoaddiction is iatrogenic syndrome that mimics addiction behaviors due to inadequately treated pain.
- Physical dependence is a physiologic withdrawal syndrome.
- Tolerance is a state of adaptation.
Treated most effectively with opioids. Second line is anxiolytics such as benzodiazepines. Corticosteroids can also be used to reduce airway inflammation and edema.
Respiratory secretions can be treated with atropine eye drops, scopalamine patch, glycopyrrolate IV or SC.
4. GI symptoms
The most important thing I learned from this chapter is that feeding tubes do not reduce aspiration events. That seems to go against what most doctors assume.
Also learned that IV fluids rarely reverse the circulatory shutdown at the end stages of illness and can potentially cause fluid overload, particularly as renal function worsens.
The anti-nausea drugs used in palliative care are quite effective.
Haloperidol for nausea caused by metabolites (liver failure, renal failure, tumor products)
Dexamethasone for raised ICP.
Meclizine for vestibular disease (H1 blocker, acts at CTZ?)
Octreotide especially if co-exists with bowel obstruction.
4D. Bowel obstruction causes pain, nausea, and vomiting. In palliative care we go straight for the symptoms.
Pain treated with Glycopyrrolate is antimuscarinic, Hyoscyamine is another antimuscarinic. Celiac plexus block is last resort.
4E Constipation.
Increase fluid and fiber (psyllium, methylcellulose) intake.
Stool softeners = detergent laxitives = docusate sodium
Stimulants = Senna and Bisacodyl
Osmotic agents (8) = glycerin, sorbitol, lactulose, polyethylene glycol, milk of magnesia, magnesium citrate, sodium phosphate.
Enemas (5) = warm water, saline, mineral oil, milk and molasses, soap suds.
Prune juice,
Metoclopramide
Methylnaltrexone is mu opioid receptor antagonist
Lubiprostone is chloride channel activator
5. Delirium, Depression and Anxiety, Fatigue, and Spirituality
Delirium = Encephalopathy = an acquired syndrome of disordered consciousness and cognition that develops over a short period of time and fluctuates during the course of the day. Can have different levels of psychomotor activity. Polypharmacy in up to 60% of hospitalized patients. Second most common cause is metabolite build up. Third is infection. Then a bunch of other less common causes.
First treat the underlying cause if possible. Treat symptoms with haldol or other antipsychotic. Benzos can cause paradoxical agitation. Ritalin can be used for hypoactive delirium.
It seems important to differentiate
loss of hope,
loss of meaning,
loss of value,
loss of relationship.
For each of these feelings, acknowledge, explore, legitimize, empathize.
How to take a spiritual history: SPIRIT
- Spiritual belief system
- Personal spirituality
- Integration in a spiritual community
- Ritualized practices and restrictions
- Implications for medical care
- Terminal events planning
Dignity Therapy is "a therapeutic intervention aimed at alleviating suffering and depression and helping patients find and reshape meaning and dignity".
- Most important accomplishments and what do you feel most proud of?
- Words or instruction for your family to help them prepare for the future?
- Any particular things you still need to say to your loved ones?
Six steps to establishing patient centered goals
- Prepare and plan by identifying stakeholders and have pre-meeting huddle to align agenda with those concerned.
- Find out what the patient and family know and how much they want to know.
- Review what the medical teams know and fire a warning shot. Discuss prognosis and benefits and burdens of treatment options. Pause frequently to check for understanding.
- Respond empathetically after you have delivered the news. Listen more than talk.
- Identify and resolve conflicts. Use "I wish" statements.
- Elicit values and preferences in order to establish patient-centered goals. Be prepared to make a recommendation. Summarize the meeting, establish plan, follow-up.
7. Last-Resort Options
Proportionate Palliative Sedation
"If rapid sedation to unconsciousness is felt to be the best approach because of the patient's unique clinical circumstances, then it is critical to have experts in palliative care and ethics involved before initiation to ensure all other approaches have been fully considered and the circumstances warrant the intervention.
Ventilator Withdrawl
Requests for "hastened death"
8. Care during the last hours of life
