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PALLIATIVE CARE 101 DO

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PALLIATIVE CARE 101 DO S, DON TS AND CONSULTS James Hallenbeck, MD ... (opioids) for chronic pain Special concern re combo drugs Vicodin, ... – PowerPoint PPT presentation

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Title: PALLIATIVE CARE 101 DO


1
PALLIATIVE CARE 101DOS, DONTS AND CONSULTS
  • James Hallenbeck, MD
  • Director, Palliative Care Services
  • VA Palo Alto

2
Agenda
  • Palliative and Hospice Care definitions
  • Palliative Care in the VA
  • Dos and Donts of Palliative Care
  • Palliative Care Consults

3
Hospice and Palliative Care not the same thing
  • Hospice overtly focused on care for the dying
  • A place, an organization, a philosophy
  • Palliative Care
  • Definition Care focused on the misery of
    illness

4
Annual Veteran Deaths
A small percentage of veterans die as inpatients
in VA facilities
5
Palliative Care at VA Palo Alto HCS
  • 1979 Menlo Park Hospice opens (one of the first
    publicly funded hospice in the country)
  • 1994 1999
  • Expansion from 7 to 25 beds
  • 1999 Moved to 2C, began non-vet admits
  • 2000 Palliative Care fellowship and consult
    service started
  • 2002 Palliative Medicine Clinic started

6
10
  • DONT forget the bowels, when prescribing opioids
  • DO use promotility agents such as senna
    proactively
  • DSS, stool softeners usually inadequate

7
9
  • DONT use the O2 sat meter to evaluate dyspnea
  • DO ask if patients are short of breath and treat
    accordingly

8
8
  • DONT use Phenergan and Compazine interchangeably
  • These agents opposites in action Phenergan
    antihistimine/anticholinergic, Compazine
    antidopaminergic
  • DO use Compazine as suppository of choice in
    opioid related nausea

9
7
  • DONT prescribe opioids (or any drug with
    potentially serious side-effects) with wide dose
    ranges such as 2-10 mg morphine q 20 minutes
  • DO check to see that any drug is safe across the
    dose range you prescribe

10
6
  • DONT prescribe Ativan (lorazepam) as a sole
    agent for nausea
  • Ativan only helpful if anticipatory nausea or
    anxiety associated with nausea
  • DO try to figure out why the patient is
    nauseated, what receptors are involved and treat
    accordingly

11
5
  • DONT just think about differential diagnosis
    relative to disease
  • DO consider that differential diagnosis can apply
    to symptoms. Why is a particular disease causing
    this symptom? What is the physiology of the
    symptom?

12
4
  • DONT use only short-acting agents (opioids) for
    chronic pain
  • Special concern re combo drugs Vicodin, TC 3
    and Percocet
  • DO use sustained-release or long acting opioids,
    if indicated, for chronic pain

13
3
  • DONT just tell patients what is wrong with them
  • DO elicit patients understandings of their
    illness by asking questions like, What is your
    understanding of why you are sick?

14
2
  • DONT just tell people what you are not going to
    do.
  • Nobody loves you for what you dont do
  • DO tell them what you are going to do (or how you
    will help them)
  • Especially important when discussing treatment
    withdrawal

15
1
  • DONT set out to get the DNR
  • Resuscitation status is only one of many
    difficult decisions that should incorporate
    patient and family goals
  • DO assess and document patients goals of care

16
Palliative Care Consults
  • Help with
  • Difficult decisions
  • Communication
  • Symptom management
  • Identifying appropriate venues of care for
    patients with serious, life-limiting illnesses

17
Palliative Care ConsultsWhat they are not
  • A excuse for ward teams not to talk with patients
    about difficult subjects
  • Shock troops to break through patient/family
    denial, thereby getting the DNR
  • Solely about hospice referral as a placement
    issue

18
How you can help with Palliative Care Consults
  • Be as clear as you can as to what help you would
    like
  • At least try to address patient/family goals of
    care and document prior to consult
  • If you have special concerns you would rather not
    put in the consult request in GUI, call the
    consult fellow, beeper 21656
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