Palliative care and family medicine: Difference between revisions
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== | ==Hospice== | ||
=== | ===Overview=== | ||
* Hospice is a philosophy that addresses the physical, psychological, social, and spiritual aspects of death and dying | * 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 | ** Patients elect to pursue palliative rather than curative treatment | ||
| Line 67: | Line 67: | ||
===Gastrointestinal symptoms=== | ===Gastrointestinal symptoms=== | ||
====Nausea, vomiting, and bowel obstruction==== | |||
* Conservative therapy includes NPO status, nasogastric suction, antiemetics, [[octreotide]], and [[dexamethasone]] | * Conservative therapy includes NPO status, nasogastric suction, antiemetics, [[octreotide]], and [[dexamethasone]] | ||
** [[Haloperidol]] is low cost and may be as efficacious as [[ondansetron]] | ** [[Haloperidol]] is low cost and may be as efficacious as [[ondansetron]] | ||
| Line 73: | Line 73: | ||
** Octreotide decreases intraluminal intestinal fluid | ** Octreotide decreases intraluminal intestinal fluid | ||
** Dexamethasone decreases obstruction due to edema | ** Dexamethasone decreases obstruction due to edema | ||
====Constipation==== | |||
* Constipation occurs in nearly half of palliative care patients | |||
** The incidence increases to almost 90% when palliative care patients are treated with opioids | |||
* A 2011 Cochrane review showed no significant difference between various laxatives with regard to stool frequency for the treatment of constipation in palliative care patients | |||
* This same review demonstrated that [[methylnaltrexone]] increases stool frequency at 4 hours (OR = 7.0, 95% CI, 3.8 - 12.6) and 24 hours (OR 5.4, 95% CI 3.1 - 9.4) in palliative care patients with constipation | |||
** Patients treated with methylnaltrexone reported increased rates of flatulence and dizziness, but the agent's side effect profile is not currently well known | |||
===Pain=== | ===Pain=== | ||
| Line 130: | Line 141: | ||
* Clary PL, Lawson P. [http://www.aafp.org/afp/2009/0615/p1059.html| Pharmacologic Pearls for End-of-Life Care]. ''Am Fam Physician''. 2009;79(12):1059-1065. | * Clary PL, Lawson P. [http://www.aafp.org/afp/2009/0615/p1059.html| Pharmacologic Pearls for End-of-Life Care]. ''Am Fam Physician''. 2009;79(12):1059-1065. | ||
* Jones CB, Goodman ML, Drake R, Tookman A. [http://summaries.cochrane.org/CD003448/laxatives-or-methylnaltrexone-for-the-management-of-constipation-in-palliative-care-patients| Laxatives or methylnaltrexone for the management of constipation in palliative care patients. ''Cochrane Database Syst Rev.'' 2011;(1):CD003448. | |||
[[Category: Family medicine]] | [[Category: Family medicine]] | ||
Revision as of 20:07, 27 May 2012
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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
Tools for determining patient prognosis
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
Nausea, vomiting, and bowel obstruction
- 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
Constipation
- Constipation occurs in nearly half of palliative care patients
- The incidence increases to almost 90% when palliative care patients are treated with opioids
- A 2011 Cochrane review showed no significant difference between various laxatives with regard to stool frequency for the treatment of constipation in palliative care patients
- This same review demonstrated that methylnaltrexone increases stool frequency at 4 hours (OR = 7.0, 95% CI, 3.8 - 12.6) and 24 hours (OR 5.4, 95% CI 3.1 - 9.4) in palliative care patients with constipation
- Patients treated with methylnaltrexone reported increased rates of flatulence and dizziness, but the agent's side effect profile is not currently well known
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.
- Jones CB, Goodman ML, Drake R, Tookman A. [http://summaries.cochrane.org/CD003448/laxatives-or-methylnaltrexone-for-the-management-of-constipation-in-palliative-care-patients%7C Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011;(1):CD003448.