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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
• Constipation
• Dyspnea
• Delirium
• Nausea /
• Depression
Vomiting
• 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
Cerebral cortex
Anxiety/Memories
Motion sickness
Vestibular apparatus
Vestibular disease
Uremia
Hypercalcemia
Chemotrigger
Receptor Zone
Drugs
Gastric irritation
Intestinal distension
Gag reflex
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?
Symptom Clusters 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?
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
Main Message
• 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?
Questions?