Palliative care and family medicine

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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
  • 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

  • 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
  • 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

References

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