Download American Medical Directors Association

Palliative Care
Changing your practice, yourself, and the
system one patient at a time
William D Smucker MD
Altenheim Nursing Home
Strongsville, OH
[email protected]
Compare and Contrast

When people describe nursing homes and
nursing home care, they use words like…..

When people describe hospice care, they
use words like……
Goals

Identify nursing home residents who would
benefit from a Palliative Care Plan

Communicate prognostic pathways to
caregivers and family

Develop practical approaches to managing
symptoms
Bill’s Agenda

Good palliative care is your responsibility

Hospice is not the panacea in LTC

Think of patients and families first, enrollment
criteria second
National Consensus Project

‘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’
•
Persons living with progressive chronic conditions
(e.g., frailty, advanced heart, lung, renal or liver disease,
dementia, and neurodegenerative disorders)
www.nationalconsensusproject.org
One way or another, it’s
your responsibility
Palliative Care = Ethical Practice
“Competence is the first ethical duty of
physicians-the goals of medicine cannot be
served unless physicians posses and
exercise at least basic knowledge and skill.”
“The ability to manage pain is an ethical duty”

Beneficence
•
Providing symptom control as well as psychosocial and
spiritual support
UNIPAC 6
Who Needs a Palliative
Care Plan?
“…good end of life care cannot be
dependent upon the ability to predict
imminent demise or 6-month
mortality.”
AMDA Toolkit: Palliative Care in the Long-Term Care Setting
Site of Death
1989
1997
Home
17.3%
24.1%
Long Term
Care
18.6%
24.1%
Hospitals
64.1%
51.8%
Nearly one third of nursing home residents
die within 12 months of admission
Palliative Care
“My own notion is that palliative care is a
concept of care that should be given to all
nursing home residents, regardless of their
status as ‘terminally ill’ or not,”
“All residents need alleviation of symptoms,
pain management, psychosocial intervention,
and spiritual care…”
Jacob Dimant MD, CMD Caring for the Ages, November 2004
Symptoms of Advanced Chronic
Illness in Community Elders
COPD
CHF
Cancer
Dyspnea
65%
18%
19%
Pain
28%
20%
33%
Anxiety
32%
2%
19%
Depressed feelings
17%
6%
9%
Anorexia
11%
7%
14%
Symptom
Walke LM Arch Intern Med 2004;164:2321-2324
Symptoms in Dying LTC Patients
None
Myoclonus
Fever
8%
18%
24%
Dysphagia
28%
Delirium
29%
Noisy breathing
Pain
Dyspnea
0%
38%
44%
62%
10% 20% 30% 40% 50% 60% 70%
Hall P, et al. JAGS 50:3;501 Mar 2002
Dying LTC Patients’ Treatments
Dyspnea
Pain
23% No Tx
1% No Tx
Noisy Breathing
39% No Tx
64% Oxygen 72% Opioids 27% Scopolamine
(mostly PRN)
27% Opioids 37% ASA,
23% suctioning
NSAIDs
Hall P, et al. JAGS 50:3;501 Mar 2002
Hospice is not the
Palliative Panacea
‘You have to know what to do
until the cavalry arrives’
Typical hospice census ≤ 10%
Palliative Care and Hospice

‘Palliative care refers to whole-person care
for patients whose diseases are not
responsive to curative treatment.’

‘Hospice refers to a program that provides
coordinated comprehensive palliative care
for terminally ill patients and their families…’
American Academy of Hospice and Palliative Medicine UNIPAC One
Prognostic Pathways
“The key to caring well for people who
will die in the (relatively) near future is
to understand how they may die and
then plan appropriately”
Murray SA Br Med J 2005;330:1007-1011
Prognosis




LTC median survival 2.75 years
43% admitted with dementia survive 2 years
Systolic HF 1 year mortality
• 13% Class III, 20-52% Class IV
Unintentional weight loss, recurrent
pneumonia, non-healing or extensive
pressure ulcers, increasing functional
decline, are key prognostic signs
Prognostic Pathways
Anorexia
Functional
Inadequate intake
Dehydration
Dysphagia
Aspiration
Malnutrition
Pressure Ulcer
Multi-system failure
Pneumonia
Sepsis
Symptom Control
As sickness progresses toward
death, measures to minimize
suffering should be intensified.
Dying patients require palliative
care of an intensity that rivals even
that of curative efforts…
Eric Cassels 1989 NEJM
Common End of Life Symptoms






Dyspnea
Dry mouth
Nausea,
vomiting
Constipation
Anorexia &
Weight loss
Non-healing
wounds

Fever

Delirium,
restlessness

Anxiety

Sedation

Fatigue

Depression
Assessment and Treatment

Consider benefits and burdens of workup and
treatment/intervention in light of:
Current stage of illness; prognosis
Patient’s preferences and goals of care


Consider non-pharmacological interventions
•
•
Often as important as meds
Often work synergistically
Repeat assessment process frequently
•
Reassess efficacy, appropriateness
Maximize Chances of Success

Try to anticipate & prevent symptoms

Maximize patient and family control

If you educate pts/families before symptoms
occur, they will be grateful (e.g., noisy
breathing, Cheyne-Stokes)

Involve team members and community
resources
Mrs. Flowers





92 yo woman with severe dementia, vision
and hearing loss, severe peripheral arterial
disease, diabetes and hypertension
Unavoidable weight loss 108 to 83 lbs over
12 months due to dementia, dysphagia,
anorexia
Increasing confusion and weakness
Less oral intake past few days
Last bowel movement 3 days ago
Mrs. Flowers

Prior evaluations
•

Multidisciplinary team has evaluated her for reversible
causes of decline and interventions have not been
successful
Goals of care
•
Family understands her end stage condition and wants
team to avoid intensive evaluations or hospital transfer.
‘Just keep her comfortable.’
Mrs. Flowers





Appears short of breath at rest
Noisy breathing, coarse breath sounds, dry
mucus membranes
Temp of 100.5, RR 30
Sacral wound has thin slough, 1-2 cm
undermining, foul odor
On pressure-relieving mattress
•
•
Getting HTN & DM meds
Morphine (20 mg/ml) 15 mg Q 4 hrs ATC
How Would You Proceed?

History?
Assessment?
Labs?
Interventions?

Discuss working diagnoses, problem lists



Problem List







Dyspnea
Noisy breathing
Dry mouth
Malodorous
pressure ulcer
Delirium
Fever
Malnutrition






End stage state?
Infection?
Pain?
Adverse medication
effect?
Nausea?
Constipation
Dyspnea


60% of patients dying in LTC have dyspnea
Subjective sensation of uncomfortable
breathing
•
Not linked to measurements of blood gases,
respiratory rate or oxygen saturation

May limit activity and quality of life

Strongly associated with anxiety
•
•
•
Patient’s complaint may be ‘nerves, anxious’
Each may cause or exacerbate the other
Very frightening to patient and caregivers
Causes of Dyspnea








End stage state
Pneumonia
Bronchospasm
COPD
Mucus plugs
Pulmonary embolus
Pleural effusion
Deconditioning






CHF
Cardiac ischemia
Cardiac arrhythmia
Tumor invasion
Damage from
radiation/chemo
Severe anemia
Dyspnea Assessment
and Management

Approach to symptom relief may benefit
from review of PMH, meds, limited
evaluation
•
•


Physical exam, CXR
Treatment should be directed at specific pathology
when appropriate (eg. CHF, COPD)
Base assessment intensity on benefits vs
burdens
Use appropriate numerical or descriptive
scales to monitor dyspnea and chart
symptom control
Non-Pharmacologic Treatments




Find what works for this person:
•
Energy conservation, positioning, fan, open
window, relaxation techniques
Emotional support
Trial of oxygen (4-6 liters/min)
Avoid suctioning in most patients
Opioids: Dyspnea Tx of Choice


Morphine is most studied & versatile
•
Generally, doses and intervals are the same
as for frail elders with pain
•
•


PO, SL, SC, IV, (not via aerosol)
Q4H ATC with breakthrough Q30 min PRN
If already on opioids, increase dose 25-50%
For intermittent dyspnea, PRN use OK
Tips for Getting to Yes for opiates
•
Adding to optimum therapy, trial of small doses
Initial Opioid Dose: Frail Elderly




Morphine 2 mg PO/SL Q4H
•
0.1cc morphine 20mg/cc (Roxanol)
Morphine 0.5mg SC/IM/IV Q4H
Oxycodone 2mg PO/SL
•
0.1cc oxycodone 20mg/cc (Oxyfast)
Hydromorphone 0.5mg PO/SL Q4H
•
0.5cc hydromorphone 1mg/cc (Dilaudid)
Equivalent to 2mg Morphine
• ½ Percocet 5mg
• ½ Darvocet N 50
Dyspnea: Medication Options




Benzodiazepines for anxiety
•
Lorazepam PO/SL/IV 0.5-1 mg Q4H
Bronchodilators for wheezing
Chlorpromazine (Thorazine)
•
10-25 mg Q4-6H
Steroids, diuretics, anticoagulation,
erythropoietin in appropriate settings
Noisy Breathing

What prognostic information is given by the
onset of noisy breathing?
Death Rattle / Noisy Breathing

25-50% of dying patients
•
65% will expire within 48 hours

Due to weak upper airway muscles plus

Due to inability to control secretions
•
Adult normal: 1.5 liters saliva, 2 liters oropharyngeal
mucus/day

Suctioning usually ineffective, may cause
discomfort, reactive edema
Death Rattle / Noisy Breathing

Patient experience of suffering is unlikely due
to semi-comatose state
Provide music to ‘mask’ noisy breathing
Position on side

Antimuscarinic medications


•
•
Reduce production of secretions, relax tracheobronchial muscles
Will not ‘dry’ existing secretions, so use early on before
symptoms are severe
Antimuscarinic Medications

Glycopyrrolate (Robinul)
•
Does not cross blood-brain barrier, so treatment of
choice in frail patients
•
0.1-0.4 mg SC/IV/IM (0.2mg/ml)
• Repeat 4X/24H, typical ‘max’ dose 1.2mg/24 H
•
1-2 mg SL/PO (1,2mg tab; 1mg/10cc solution)
• Repeat 4 X/24H, typical ‘max’ dose 8 mg/24H
Antimuscarinic Medications


Atropine 1% eye drops
•
1-2 drops SL/PO every 4-6 H, titrate to effect
Alternatives:
•
•
HyoscineHBr (Scopolamine, Levsin),
HyoscineBuBr (Bucospan)
Subcutaneous Medications




Opiates
•
Morphine, methadone
Benzodiazepines
•
Midazolam, lorazepam
(short term)
Antipsychotics
•
Haloperidol
Antiemetics
•
Metoclopramide
Aqua-C clysis system
Mrs. Flowers

Now RR 30, moist dry cough, dry mucus
membranes, coarse breath sounds
Oral Care Basics

Potent memory

Assess frequently (feeding, med pass)

Good way to involve family, CNAs

Use whatever works
•

Frequent sips of favorite liquids, popsicles, frozen fruit or
fruit juices or tonic water, hard candies, artificial saliva
Avoid alcohol mouth washes, glycerine swabs; they
are drying
Oral Care Tips

If patient is unconscious,
•
•
•
Swab the mouth Q 1-2 H with water or NS
Spray with an atomizer
Water based lubricant to lips and front teeth
• Avoid petroleum jelly (Vaseline): potentially flammable
if O2 in use
Mrs Flowers

Temperature 100.5, RR 30

Plans for evaluation, treatment of fever?
Fever Near the End of Life

Onset triggers a time of decision
•
•
Best discussed in advance if possible
Consider benefits and burdens of evaluation, treatment

Discuss plan for curative vs. palliative treatment of
infections in advance

Fever responds to acetaminophen

May be sign of terminal dehydration and multisystem
organ failure
Myoclonus

Up to 30% of dying LTC patients have
sudden brief involuntary movements
•



May continue during sleep, worse with stimuli
Muscular ‘delirium equivalent’
•
Causes: progressive neurological disorders, organ
failure, electrolyte disorders, hypoxia, hypercarbia,
medication
Treat primary cause if possible
Benzodiazepines reduce signs, symptoms
Nausea and Vomiting
Non-pharmacological Treatment








Cool damp cloth to forehead, neck, wrists
Bland, cool or room-temperature foods
Decrease noxious stimuli, e.g., odors,
noise
Limit fluids with food
Fresh air, fan
Relaxation techniques
Oral care after each emesis
Acupuncture/pressure or TENS to P6
Opioid-induced Nausea




Chemoreceptor Trigger Zone stimulation
•
•
•
Due to rising opioid levels
The most common mechanism: 28% of patients
Transient (3-7 days) if dosing is steady
Upper GI dysmotility (gastroparesis)
•
Tolerance does not develop
Vestibular apparatus
•
Unusual; note spinning sensation
Constipation, impaction
EPERC Fast Facts
Nausea Treatments

Prochlorperazine (Compazine)
•
Potent antidopaminergic, weak antihistamine,
anticholinergic agent
•

Preferred for opioid related nausea
Haloperidol
•
Very potent anti-dopaminergic agent
Nausea Treatments

Promethazine (Phenergan)
•
•
•

Antihistamine with potent anticholinergic properties,
very weak antidopaminergic agent
Useful for vertigo and gastroenteritis due to
infections and inflammation
Not useful for opioid-related nausea
Scopolamine
•
A very potent, pure anticholinergic agent.
EPERC Fast Facts
Agitation, Terminal Delirium

Potent Memory

Common in final hours, days of life

Delirium may not clear
•

May intensify as death approaches
Try to identify contributing factors
•
•
•
Physical exam and symptom review
Medications are most common reversible cause
Look for environmental triggers
Terminal Delirium




Often requires multifactorial intervention
Environmental modification(s)
Psychological support
•
Recruit family and staff
Medications
•
Neuroleptics (for delirium)
•
•
Morphine (for dyspnea, pain)
Avoid benzodiazepines (paradoxical agitation)
• Haloperidol 0.5-1mg PO/SL/IM Q1H PRN
Never underestimate the power of a few
committed people to change the world.
Indeed, it is the only thing that ever has.
Margaret Mead
References


















Palliative Care in the LTC Setting Information Tool Kit. American Medical Directors Association
Fast Facts http://www.eperc.mcw.edu/ff_index.htm
Opiate conversion tool The Clinician’s Ultimate Reference (http://www.globalrph.com/narcoticonv.htm).
Agarwal P Myoclonus. Curr Opin Neurol 2003; 16: 515-521.
Jimenez-Jimenez FJ Drug-induced myoclonus CNS Drugs 2004; 18(2): 93-104.
Walsh D, Strategies for pain management Supportive Cancer Therapy 2004;1: 157-164.
Winn PA Effective pain management in LTC. JAMDA 2004; 5(5): 342-352.
Winn PA, Quality palliative care in LTC JAMDA 2004; 5(3): 197-206.
Walke LM et al The burden of symptoms among community dwelling older persons with advanced chronic
disease. Arch Intern Med 2004;164:2321-2324.
Strumpf NE et al. Implementing palliative care in the nursing home. Annals of Long-Term Care 2004;12:35-41
Meyers FG, Linder J. Simultaneous care: disease treatment and palliative café throughout illness. J Clinical
Oncology 2003;l21:1412-1415.
Buchanan RJ, Choi MA, Wang S, Ju H. End of life care in nursing homes: residents in hospice compared to
other end stage residents. J Palliat Med 2004;7:221-232.
Parker-Oliver D. Hospice experience and perceptions in nursing homes. J Palliat Med 2002;5:713-720.
Parker-Oliver , Porock D, Zweig S. End of life care in US nursing homes: a review of the evidence. J Am Med Dir
Assoc 2005:6;S21-30.
Kiely DK, Flacker JM. Common and gender specific factors associated with one-year mortality in nursing home
residents. J Amer Med Dir Assoc 2002;3:302-309.
Gillick MR. Rethinking the central dogma of palliative care. J Palliat Med 2005;8:909-913
Schonwetter, et al. Predictors of six-month survival among patients with dementia: an evaluation of hospice
Medicare guidelines Am J Hosp Palliat Care 2003;20(2):105-113
Aqua-C Hydration System 7350 N. Ridgeway, Skokie, IL 60076 • tel: 847-674-7075 • fax: 847-674-7066
[email protected] • www.norfolkmedical.com