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Palliative Care
MINA KIM, PHARMD
PAIN MANAGEMENT CLINICAL PHARMACIST
Palliative Care
 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.
American Academy of Hospice and Palliative Medicine
Goals of Palliative Care
 Provides relief from pain and other distressing
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symptoms
Affirms life and regards dying as a normal process –
Intends neither to hasten or postpone death
Integrates the psychological and spiritual aspects of
patient care
Offers a support system to help patients and their
family cope during the illness and in the family’s
bereavement
Uses a team approach to address the needs of
patients and their families
Team Members
 Providers (Physicians, ARNPs, PAs)
 Pharmacists
 Nurses
 Health Aides
 Social Workers
 Chaplains
 Physical/Occupational Therapists
 Music Therapists
Hospice
 Palliative care for individuals who have life-limiting or
incurable conditions in their last year of life
 Hospice care can be provided wherever a patient resides:
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Home
Inpatient hospice
Long term care facilities (SNF, nursing homes)
Hospital
 Medication focus: what is necessary to make them
comfortable (not all medications are relevant in hospice,
i.e., cholesterol medications)
Common Diseases in Palliative Care
 Cancer
 Organ Failure (Heart, Liver, Renal, Pulmonary)
 Progressive Neurological Diseases (i.e. Dementia,
Alzheimers)
 Failure to Thrive
Symptom Management
 Pain
 Dyspnea
 Constipation
 Nausea/Vomiting
 Appetite
 Delirium/Agitation
 Anxiety
Pain
 Refer to previous lecture on assessment (KEY!)
 Tylenol, NSAIDs and Opioids (standard)
 Opioids
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Best route of administration for patient (PO, IV, SC, transdermal,
PR)
Scheduled dosing for patients with continuous pain
Breakthrough dose should be 10% of the 24 hour dose of the
scheduled opioid
Know conversion between different drugs and routes
 Use adjuvant medications as indicated: i.e.,
anticonvulsants, antidepressants, steroids
 Consider nonpharmacological therapy
Dyspnea
 Difficult or labored breathing
 Incidence in terminal illness ranges from 12-74%
 Most common in lung cancer and COPD
 Tends to worsen as death approaches
 Common descriptions
 Cannot get enough air - “air hunger”
 Tightness in the chest
 Feeling a need to gasp or pant
 Feeling suffocated
Dyspnea: Treatment from Etiology
 End-of-life respiratory failure: opioids
 Morphine is the standard treatment
 Decreases patient’s perception of breathlessness, reduces
respiratory needs and oxygen consumption
 COPD or asthma: bronchodilators, steroid
 CHF leading to volume overload: diuretics
 Adjust doses according to patient response
 Signs of volume overload include: SOB, crackles in lungs,
peripheral edema
 Pleural effusion: consider thoracentesis
 Anxiety associated dyspnea: anxiolytics
Dyspnea: Treatment
 Oxygen to achieve O2 saturation > 90%
 Non-pharmacological
 Fans
 Positioning
 Breathing exercises, relaxation techniques
 Rest/conserve energy
Constipation
 2-10% of general population
 Increases with age
 Effects more than 50% of patients in a palliative care
unit or in hospice
 Frequently seen symptom at the end of life
 Undertreated by providers
Constipation: Causes
 Immobility
 Diet/hydration
 Medications
 Opioids, anticholinergics, TCAs
 Disease
 Cancer (hypercalcemia, bowel cancers, tumors invading GI
tract)
 Chronic diseases (i.e , IBS, neurologic diseases, diverticular
disease)
Constipation: Assessment
 Characteristic
 Frequency
 Physical
 Examination
 Diagnostic
 Medications
 Fluid/food intake
Constipation: Treatment
 Prevention is key!
 Always prescribe constipation medications with
opioids
 Encourage fluid intake and dietary fiber
 Physical activity
 Disimpaction
Constipation: Medications
 Bulk-forming (psyllium)
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Provide bulk to the intestines to increase mass - stimulates bowel to
move
If unable to tolerate increase fluid, may lead to bowel obstruction
May not be appropriate at end of life if patient fluid intake
inadequate
2-4 tsp daily
 Lubricant (mineral oil) – 10-30 mL/day
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Overuse can cause seepage from rectum and peri-anal irritation
With chronic use, may lead to malabsorption of fat-soluble vitamins
Constipation: Medications
 Surfactant (docusate, sodium phosphate enema)
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Reduce surface tension, increase absorption of fluids and fats into
stool which soften it
Docusate 1-2 tabs PO BID
Fleet enema PRN (avoid unless severe constipation)
 Osmotic (lactulose)
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Non-absorbable sugars that exert an osmotic effect in primarily the
small
15-60 mL Q4-12 hours until BM achieved, then calculate daily
amount needed and schedule
Effectiveness is dose related, taste may be intolerable – can place in
other liquids, can cause bloating, gas, nausea
Glycerine suppositories acts as a lubricant
Constipation: Medications
 Saline (MOM, Magnesium citrate)
 Increase gastric, pancreatic, & small intestinal secretions, & motor activity
throughout the intestine
 Recommended as last resort in chronically ill patients
 MOM – 15-30 mL 1-3 x/day
 Mag citrate – 1 bottle prn
 Rule out obstruction!
 Avoid in patients with renal disease, can causing cramping/discomfort
 Stimulant (senna, bisacodyl)
 Work directly to irritate bowel & stimulate peristalsis; reduces the amount of
water & electrolytes in colon
 Bisacodyl – 5-10mg PO Qday to BID
 Senna 2 tabs at bedtime, can titrate to BID (up to 8tabs/day)
 Other: Methylnatrexone SQ shot
Nausea/Vomiting: Mechanism
 Vestibular apparatus – motion sickness, vestibular
disease (i.e. brain tumors)
 Chemoreceptor Trigger Zone – medications,
chemical imbalances (i.e. hypercalcemia)
 Cerebral cortex – increased intracranial pressure,
anxiety, stress
 Gastrointestinal – gastric irritation
Nausea/Vomiting: Assessment
 Good assessment is very important
 Precipitating/palliating
 Quality
 Temporal
 Previous treatment or therapy
Nausea/Vomiting: Nonpharmacologic
 Acupuncture
 Relaxation therapy
 Interventions if needed (stents, NG tube, etc)
 Changing food/eating patterns
 6-8 small meals a day
 Food selection
 Eat slowly
 Stay upright at least 1 hour after eating
Nausea/Vomiting: Pharmacologic
 5-HT3 receptor
 Antihistamines
antagonists
 Steroids
 Prokinetic
 Benzodiazepines
 Anticholinergic
 Butyrophenones
 Phenothiazines
 Cannabinoids
Nausea/Vomiting: Pharmacologic
 5-HT3 receptor antagonists – ondansetron,
granisetron, dolasetron
 Prokinetic – metoclopramide
 Anticholinergic – scopolamine
 Phenothiazines – prochlorperazine
Nausea/Vomiting: Pharmacologic
 Steroids – dexamethasone
 Benzodiazepines – lorazepam
 Butyrophenones - haloperidol, droperidol
 Cannabinoids – dronabinol, marijuana
Appetite
 Anorexia vs. Cachexia
 Causes
 Metabolic imbalances
 Secondary to physical symptoms (i.e. pain, dysphagia,
alcoholism)
 Medication side effects
 Physiological / Spiritual distress
Appetite: Treatment
 Medications
 Megestrol acetate (Megace)
 Metoclopramide (Reglan)
 Dexamethasone (Decadron)
 Dronabinol (Marinol)
 Non-pharmacological
 Emotional and nutritional support
 Enteral and parenteral nutrition
 Support for family
Delirium/Agitation
 Delirium – change in cognition that is relatively
acute in onset and generally reversible
 Presentation
 Disorientation
 Change in consciousness
 Distress
 Paranoia, nightmares, hallucination can often occur at end of
life
Delirium/Agitation
 Agitation – excessive restlessness accompanied by
increased mental and physical activity
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Inability to concentrate/relax
Disturbances in sleep/rest
Fluctuating levels of consciousness, cognitive dysfunction
 Often referred to as “terminal restlessness” or
“terminal agitation” at the end of life
Delirium/Agitation
 Almost half of patients experience delirium/agitation
in their last 48 hours
 Causes include (as defined by the American
Psychiatric Association DSM-IV)
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Organic: malignancies, infection, renal/hepatic failure,
metabolic abnormalities, hypoxemia
Non-organic: sensory deprivation, changes in environment,
medications, withdrawal
Delirium/Agitation: Assessment Tools
 Mini-Mental Status Exam
 Delirium rating scale
 Memorial Delirium Assessment Scale
 Confusion Assessment Method
 Neecham Confusion Scale
Delirium/Agitation: Treatment
 Is treatment necessary?
 Delirium vs. Agitation
 Treatment
 Correct underlying cause
 Symptomatic and supportive therapy if necessary
Delirium/Agitation: Nonpharmacological
 Environment
 Avoid excessive stimulation
 Reorient patient as needed
 Create familiar and comfortable setting
 Presence of family/friends
 Complementary therapy
 Therapeutic touch
 Spiritual support
Delirum/Agitation: Medications
 Neuroleptics
 Haldol (drug of choice)
0.5-2mg Q2-4 hours PO, IV, IM PRN
 Can prolong QT interval
 Monitor for extrapyramidal side effects
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Chlorpromazine:12.5-50mg Q4-12 hours PO, IV, IM, PR
Olanzapine: 2.5-10mg PO Q12 hours
Quetiapine: 50-100mg PO Q12 hours
 Avoid benzodiazepines in delirium – may be used for
agitation/restlessness
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Lorazepam 0.5-2mg Q1-4 hours PO, IV, IM
Anxiety
 Causes
 Poorly controlled pain
 Medical conditions causing physiological/emotional/spiritual
distress
 Interview of the patient is key
 Find physical cause and treat if possible
 Support through counseling, spiritual care, relaxation
techniques and coping skills
Anxiety: Treatment
 Benzodiazepines (most commonly used)
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Numerous agents that can be given IV/PO
Use as needed and schedule if needed
Lorazepam, alprazolam, clonazepam, diazepam
 Barbiturates
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Phenobarbital 60mg PR Q4-12 hours PRN
Use when benzodiazepines ineffective
Rapid onset and sedating
 Neuroleptics
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Useful when anxiety occurs with delirium/agitation
 Tricyclic Antidepressants
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Useful when anxiety occurs with depression
Palliative Sedation or Comfort Care
 Terminally ill patients with expected life of hours to days
 Usually takes place usually in an inpatient setting
(hospital, hospice)
 Stop all medications and procedures that are not
necessary for comfort
 Continuous drips (opioids, benzodiazepine) titrated for
comfort
Double Effect
 Medical decision that may result in both desirable and
undesirable effects: allowing an unintended bad event to
happen in the course of trying to do a good thing
 Ethically permissible if
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Action itself is good or indifferent
Agent intends the good effects
The good effect must not occur via the bad effect
 Example: giving opioids for pain in terminal cancer
but…this may also lead to respiratory depression which
may cause death sooner
Washington Death with Dignity Act
 Terminally ill, competent, adult Washington residents
 Prognosis of ≤ 6 months
 Request & self-administer lethal medication prescribed by a
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physician
2 physicians diagnose the patient and determine if the patient
has the capacity to make an informed decision
Optional referral to a psychologist/psychiatrist if concerned
about mental health affecting capacity to make decisions
Two oral and one written request
A 15-day waiting period between oral requests
Physicians, patients and others acting in good faith have
criminal and civil immunity
Main Message
Is your treatment
consistent with the
patient’s goals of care?