MAKE THE DAYS COUNT: THE WHO, WHAT, WHERE,

WHEN AND WHY OF PALLIATIVE CARE

Rebecca Mueller PA-C, MSc

Ontario, Canada

Rebecca.mueller@my.rfums.org

rlmwriting@gmail.com

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!