Palliative care and family medicine

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

WikiDoc Resources for Palliative care and family medicine

Articles

Most recent articles on Palliative care and family medicine

Most cited articles on Palliative care and family medicine

Review articles on Palliative care and family medicine

Articles on Palliative care and family medicine in N Eng J Med, Lancet, BMJ

Media

Powerpoint slides on Palliative care and family medicine

Images of Palliative care and family medicine

Photos of Palliative care and family medicine

Podcasts & MP3s on Palliative care and family medicine

Videos on Palliative care and family medicine

Evidence Based Medicine

Cochrane Collaboration on Palliative care and family medicine

Bandolier on Palliative care and family medicine

TRIP on Palliative care and family medicine

Clinical Trials

Ongoing Trials on Palliative care and family medicine at Clinical Trials.gov

Trial results on Palliative care and family medicine

Clinical Trials on Palliative care and family medicine at Google

Guidelines / Policies / Govt

US National Guidelines Clearinghouse on Palliative care and family medicine

NICE Guidance on Palliative care and family medicine

NHS PRODIGY Guidance

FDA on Palliative care and family medicine

CDC on Palliative care and family medicine

Books

Books on Palliative care and family medicine

News

Palliative care and family medicine in the news

Be alerted to news on Palliative care and family medicine

News trends on Palliative care and family medicine

Commentary

Blogs on Palliative care and family medicine

Definitions

Definitions of Palliative care and family medicine

Patient Resources / Community

Patient resources on Palliative care and family medicine

Discussion groups on Palliative care and family medicine

Patient Handouts on Palliative care and family medicine

Directions to Hospitals Treating Palliative care and family medicine

Risk calculators and risk factors for Palliative care and family medicine

Healthcare Provider Resources

Symptoms of Palliative care and family medicine

Causes & Risk Factors for Palliative care and family medicine

Diagnostic studies for Palliative care and family medicine

Treatment of Palliative care and family medicine

Continuing Medical Education (CME)

CME Programs on Palliative care and family medicine

International

Palliative care and family medicine en Espanol

Palliative care and family medicine en Francais

Business

Palliative care and family medicine in the Marketplace

Patents on Palliative care and family medicine

Experimental / Informatics

List of terms related to Palliative care and family medicine

## Contents

* 1 Hospice
* 1.1 Overview
* 1.2 Eligibility
* 1.3 Clarification of common misconceptions
* 1.4 Resources
* 1.4.1 General resources
* 1.4.2 Tools for determining patient prognosis
* 2 Palliative care pharmacology
* 2.1 Overview
* 2.2 Dyspnea
* 2.3 Gastrointestinal symptoms
* 2.3.1 Nausea, vomiting, and bowel obstruction
* 2.3.2 Constipation
* 2.4 Pain
* 2.4.1 Opioids
* 2.4.2 Non-opioids
* 2.5 Delirium
* 2.6 Upper respiratory secretions
* 2.7 Resources
* 2.7.1 General resources
* 3 References

## Hospice[edit | edit source]

### Overview[edit | edit source]

* 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[edit | edit source]

* 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[edit | edit source]

* 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[edit | edit source]

#### General resources[edit | edit source]

* National Hospice and Palliative Care Organization

#### Tools for determining patient prognosis[edit | edit source]

* Karnofsky Performance Scale
* Palliative Performance Scale
* Palliative Prognosis Score

## Palliative care pharmacology[edit | edit source]

### Overview[edit | edit source]

* 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[edit | edit source]

* 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[edit | edit source]

#### Nausea, vomiting, and bowel obstruction[edit | edit source]

* 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[edit | edit source]

* 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[edit | edit source]

#### Opioids[edit | edit source]

* 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[edit | edit source]

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

### Delirium[edit | edit source]

* 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[edit | edit source]

* 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[edit | edit source]

#### General resources[edit | edit source]

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

## References[edit | edit source]

* 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| Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011;(1):CD003448.