PALLIATIVE CARE Pat Borman, MD Advanced Training in Geriatrics

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PALLIATIVE CARE Pat Borman, MDAdvanced Training
in Geriatrics

• We cure seldom
• palliate often
• and comfort always
• 16th Century Anonymous

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PALLIATIVE CARE

• Treatment of Patient and Involved
  Caregivers
• Focus on the End of Life
• Kalos Thanatos
• Relieve Total Burden of Suffering
• Physical Suffering
• Psychological Suffering
• Spiritual Suffering

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Physical Suffering

• Symptoms
• Function
• Safety
• Hydration
• Nutrition

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Psychological Suffering

• Emotion
• Cognition
• Mood
• Coping Responses
• Fears
• Lost Dreams

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Spiritual Suffering

• Spirituality
• Meaning of life and death
• Religion
• Impact of actual and anticipated losses

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Practical Matters

• Legal
• Financial
• Living Situation
• Caregivers
• Care of Dependents
• Domestic Needs

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Palliative Care Initial Steps

• Assess patient/caregiver knowledge,
  understanding of disease and prognosis
• Establish lines of communication
• Develop terms that match knowledge level of the
  family
• Determine decision making structures

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Palliative Care Initial Steps

• Assess Coping Strategies
• Physical Concerns
• Economic Concerns
• Family and Patient Concerns
• Social Network of Support for patient and
  caregivers

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Palliative Care Initial Steps

• Assess spiritual and cultural beliefs
• Patient and family knowledge of death
• Prior experiences with death
• Role of death in family and cultural context
• Religious Beliefs
• Specific Practices

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Symptom Relief

• Pain Management
• Acute, Subacute, Chronic
• Look for the Cause
• Assess frequently
• Step Approach

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Pain Relief

• Neuropathic Pain
• TCAD, Anticonvulsants, topicals, Baclofen
• Inflammatory Pain
• Steroids, NSAIDS use cautiously, opioids
• Bone Metastasis
• Pamidronate, Calicitonin, opioids
• Muscle Spasms
• Baclofen, Benzodiazepines

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Persistent Pain

• Step I
• Acetaminophen up to 4 gm/day,
• ASA up to 4 gm/d
• NSAID use cautiously for persistent pain
• Step II
• Tramadol 50 mg max 8 tabs divided q 6h
• T3 max 12 tabs divided q 4-6 h
• Oxycodone 5 mg max 12 tabs divided q 6h
• Morphine 5 mg no maximum dose q 4 hour

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Persistent Pain

• Step III
• Calculate 24 h opioid need and convert to long
  acting bid form
• Use short acting for breakthrough
• Barriers to maximal pain relief from doctors and
  patients
• Ethical precedent for using as much as needed to
  alleviate suffering

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Persistent Pain

• MSContin
• 15, 30, 60, 100, 200mg
• OxyContin
• 10, 20, 40, 80mg
• Hydromorphone
• 1, 2, 3, 4, 8mg
• Methadone
• 5,10,40mg
• Fentanyl
• 25, 50, 75, 100 microgram patch

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Nausea and Vomiting

• Match cause of nausea to treatment
• Increased ICP Dexamethasone
• Vestibular Antihistamines
• Chemoreceptor Dopamine Antagonist
• Gastric Irritation Feeds, stop NSAIDS
• Gut Motility Metaclopromide
• Ascites Diuretics
• Pain or anxiety Treat accordingly

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Dyspnea

• Physical and/or psychological
• Morphine
• Oxygen
• Fan in Room, Fresh Air
• Secretions Control with anticholinergics and
  suctioning
• Address fears, anxiety, spiritual needs
• Relaxation, distraction,

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Anxiety

• Sources include fear, pain, psychological and
  spiritual distress
• Anxiolytics
• Human Contact
• Address fears
• Setting affairs into order

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Agitation

• Target behavior and seek causes if possible
• Decrease external stimuli
• Use Music, Prayer
• Agitation as a form of communication
• As part of delirium very near end of life
• Haldol, Anxiolytics

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Delirium

• Safety
• Orientation and Human Contact
• Permission to go
• Anxiolytics, antipsycholtics

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Bowel and Bladder

• Combat constipation of narcotics, avoid
  impaction
• Careful skin care, positioning
• If diarrhea use anticholinergics
• Scheduled voids if strong enough, disposable
  pads, Foley?
• Manage odors with Kitty Litter, Charcol

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Nutrition and Hydration

• Sips, Chips, mouth care
• Anorexia/Cachexia
• Consider steroids, TCAD, Megace, Cannabinoids,
  Remeron,
• Artificial Assistance
• Values Based Decisions
• Delays the inevitable
• Consider limited trial and withdrawal if no
  evident benefit

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Fatigue

• Somulence, activity intolerance and fatigue
  tend to increase
• Educate patient and caregivers not to push too
  hard
• Short visits, brief activities, frequent naps
• Central Stimulants?

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Skin Care and Pruritis

• Pruritis
• Consider xerosis, uremia, hypercalcemia,
  medication side effects, delirium
• Hygiene and positioning
• Lotions
• Cool moist compresses
• Antihistamines

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Bereavement

• Anticipatory grief
• Early Loss of Personhood in Dementia
• Individualized
• Support
• Interventions if protracted, interfering
  
• with starting to live again

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References

• American Geriatrics Society 2002 Guidelines for
  Management of Persistent Pain.
• Galanos MA Long Term Care in Geriatrics
  Palliative Care Clinics in Family Practice Sept
  20013(3) 683.
• Melvin TA The Primary Care Physician in
  Palliative Care Primary Care June
  200128(2)239-49.
• Bernat JL Ethical and Legal Issues in Palliative
  Care Neuro Clin Nov 2001 19(4)969-87.
• J Am Oseopath Assoc Oct 2001 issue devoted to
  Palliative Care.
• Steel K Annotated Bibliography of Palliative
  Care and End of Life Issues J Am Ger Soc Mar
  200048(3)325-32.