Palliative care and family medicine

Hospice

Overview

• Hospice is a philosophy that addresses the physical, psychological, social, and spiritual aspects of death and dying
  • Patients elect to pursue palliative rather than curative treatment

• Hospice care can be provided in any setting- patient's home, hospice home, nursing home, or hospital

• Patient's are eligible for hospice care if they have a any terminal illness with an estimated prognosis of less than six months
  • This includes non-cancer diagnoses, such as congestive heart failure, chronic obstructive pulmonary disease, failure to thrive, and dementia

• Hospice benefits cover all expenses related to the patient's terminal diagnosis that are deemed "reasonable and necessary for palliation"
  • This includes medications, skilled nursing, nursing aides, and hospital equipment, such as a hospital bed for the patient's desired location
  • Medicare pays hospice on a per diem basis that covers all medical care; this payment method often requires the attending physician to consider the cost of individual medications and treatments when multiple methods are available to treat the same symptom

• Hospice benefits provide the patient's family with bereavement support for up to one year following the death of the patient

• Patients appear to benefit most when hospice care is initiated at least two months prior to death

Eligibility

• Medicare covers hospice care for if the following four criteria are met:
  • The patient is eligible for Medicare Part A
  • The patient enrolls in a Medicare-approved hospice
  • The patient has given written consent for hospice care
  • The patient's physician and the hospice medical director certify that the patient has a terminal illness with an estimated prognosis of less than six months

Clarification of common misconceptions

• As long as a disease is running its "normal course," there is no penalty and the patient will not automatically be discharged from hospice if they survive longer than six months
  • Hospice care is initiated with two 90 day periods followed by unlimited extensions in 60 day intervals

• Patients are not required to have a do not resuscitate order

• The patient's primary care physician can and often does serve as a member of the patient's hospice care team
  • The attending physician is often the patient's primary care physician
  • The attending physician is required to write admission orders, be available by telephone, and handle the routine day-to-day medical needs of the patient

• Most private insurers offer a benefit that is modeled after the Medicare Hospice Benefit

• Patients may leave and reenter hospice care if there are unforeseen fluctuations in their disease course

• Anyone, including friend's and family members, can refer a patient to hospice; the referral does not have to come from a physician or other medical professional

• Medical problems and hospital admissions that are unrelated to the patient's terminal diagnosis generally are still covered by the patient's insurance plan while a patient pursues hospice care

Resources

General resources

• National Hospice and Palliative Care Organization

Tools for determining patient prognosis

• Karnofsky Performance Scale
• Palliative Performance Scale
• Palliative Prognosis Score

Palliative care pharmacology

Overview

• Palliative pharmacotherapy aims to relieve medical burdens while maintaining the patient's dignity and comfort

• Three main principles guide symptom management:
  • Start low and go slow
  • Treat to effect or adverse effect
  • Consider the effects of polypharmacy

Dyspnea

• Shortness of breath is sensed in the central nervous system pain
  • Persistent dyspnea after maximization of pharmacologic and non-pharmacologic respiratory therapy should be treated with opioids

Gastrointestinal symptoms

• Conservative therapy includes NPO status, nasogastric suction, antiemetics, octreotide, and dexamethasone
  • Haloperidol is low cost and may be as efficacious as ondansetron
  • Promethazine is often ineffective in palliative care
  • Octreotide decreases intraluminal intestinal fluid
  • Dexamethasone decreases obstruction due to edema

Pain

Opioids

• Basal dosing intervals for opioids should be based around peak effect, not duration of action
  • Basal dosage should be increased by 25-50% when pain is mild-moderate and 50-100% when pain is severe

• Breakthrough dosing should be ordered at 10-20% of the 24-hour morphine equivalent

• Rotate to a second opioid when the first opioid fails to control the patients pain at the highest tolerated dosage
  • Incomplete cross-tolerance can occur between opioids, so reduce dose equivalent to 50-75% when rotating opioids

• Avoid combination opioid preparations (Percocet, Roxicet, Percodan, Ibudone, etc.) due to risk of non-opioid toxicity

• Neuropathic pain, social pain, psychological pain, spiritual pain, and previous substance use are common reasons for the failure of opioids to adequately control pain

• Nausea, vomiting, sedation, and mental status changes are the most common initial adverse effects of opioids
  • These effects usually fade with continued opioid usage
  • Treat nausea with a prophylactic antiemetic for 3-5 days when initiating opioids
  • Sedation can be treated with low-dose methylphenidate

• Constipation does not abate with continued opioid usage
  • Always initiate a bowel regimen of a stimulant laxative-stool softener or stimulant laxative-osmotic laxative combination when a patient is treated with opioids
  • Continue the patient's bowel regimen even if the patient has minimal solid oral intake
  • Methylnaltrexone can be used to treat opioid induced bowel dysfunction in non-obstructed patients

• At high doses or rapidly increased dosages, opioids can cause neuroexcitation (hyperalgesia, delirium, myoclonus)

Non-opioids

• Non-steroidal anti-inflammatory agents, corticosteroids, and bisphosphonates are effective for bone pain

Delirium

• Common causes are polypharmacy, urinary retention, constipation, and infection

• Preventative measures include:
  • Having family/friends at the patient's bedside
  • Limiting changes to the patient's medications and room
  • Minimizing staff changes
  • Avoiding indwelling catheters and restraints whenever possible

Upper respiratory secretions

• Loss of the ability to clear upper respiratory secretions leads to the classic "death rattle"
• Non-pharmacologic interventions include patient positioning and gentle suction
• Pharmacologic interventions include hyoscyamine, glycopyrrolate, scopolamine, octreotide, and atropine eye drops

Resources

General resources

• End of Life/Palliative Education Resource Center
• National Cancer Institute
• New hampshire Hospice and Palliative Care Organization opioid use guidelines

References

• Weckmann, MT. The Role of the Family Physician in the Referral and Management of Hospice Hospice Patients. Am Fam Physician. 2008;77(6): 807-812.

• Clary PL, Lawson P. Pharmacologic Pearls for End-of-Life Care. Am Fam Physician. 2009;79(12):1059-1065.