Palliative Care Changing your practice, yourself, and the

system one patient at a time

William D Smucker MDAltenheim Nursing Home

Strongsville, OH

wsmucker@neo.rr.com

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 aconcept of care that should be given to allnursing home residents, regardless of theirstatus 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

Symptom

Dyspnea 65% 18% 19%

Pain 28% 20% 33%

Anxiety 32% 2% 19%

Depressed feelings 17% 6% 9%

Anorexia 11% 7% 14%

Walke LM Arch Intern Med 2004;164:2321-2324

Symptoms in Dying LTC Patients

62%

44%

38%

29%

28%

24%

18%

8%

0% 10% 20% 30% 40% 50% 60% 70%

Dyspnea

Pain

Noisy breathing

Delirium

Dysphagia

Fever

Myoclonus

None

Hall P, et al. JAGS 50:3;501 Mar 2002

Dying LTC Patients’ Treatments

Dyspnea Pain Noisy Breathing

23% No Tx 1% No Tx 39% No Tx

64% Oxygen 72% Opioids

(mostly PRN)

27% Scopolamine

27% Opioids 37% ASA, NSAIDs

23% suctioning

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 Dysphagia

Multi-system failure

PneumoniaPressure Ulcer

Sepsis

Dehydration Malnutrition

AspirationInadequate intake

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

• PO, SL, SC, IV, (not via aerosol)

Generally, doses and intervals are the same as for frail elders with pain• 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 tracheo-bronchial 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 VomitingNon-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)• Haloperidol 0.5-1mg PO/SL/IM Q1H PRN

• Morphine (for dyspnea, pain)

• Avoid benzodiazepines (paradoxical agitation)

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

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