Transcript PALLIATIVE CARE 101 DO’S, DON’TS AND CONSULTS

PALLIATIVE CARE 101
DO’S, DON’TS AND
CONSULTS
James Hallenbeck, MD
Director, Palliative Care Services
VA Palo Alto
Agenda
Palliative and Hospice Care –definitions
 Palliative Care in the VA
 Do’s and Don’ts of Palliative Care
 Palliative Care Consults
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Hospice and Palliative Care – not
the same thing…
Hospice –overtly focused on care for the
dying
 A place, an organization, a philosophy
 Palliative Care –
 Definition: “Care focused on the misery
of illness”

Annual Veteran Deaths
A small percentage of veterans die as
inpatients in VA facilities
Palliative Care at VA Palo Alto
HCS
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1979 – Menlo Park Hospice opens (one of the first
publicly funded hospice in the country)
1994 –1999
 Expansion from 7 to 25 beds
 1999 Moved to 2C, began non-vet admits
2000 Palliative Care fellowship and consult
service started
2002 Palliative Medicine Clinic started
10
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DON’T forget the bowels, when prescribing
opioids

DO use promotility agents such as senna
proactively
 DSS, stool softeners usually inadequate
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DON’T use the O2 sat meter to evaluate
dyspnea

DO ask if patients are short of breath and
treat accordingly
8
DON’T use Phenergan and Compazine
interchangeably
 These agents opposites in action:
Phenergan antihistimine/anticholinergic,
Compazine antidopaminergic
 DO use Compazine as suppository of
choice in opioid related nausea

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DON’T prescribe opioids (or any drug with
potentially serious side-effects) with wide
dose ranges such as 2-10 mg morphine q 20
minutes

DO check to see that any drug is safe across
the dose range you prescribe
6
DON’T prescribe Ativan (lorazepam) as a
sole agent for nausea
 Ativan only helpful if anticipatory nausea
or anxiety associated with nausea
 DO try to figure out why the patient is
nauseated, what receptors are involved and
treat accordingly
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DON’T just think about differential
diagnosis relative to disease

DO consider that differential diagnosis can
apply to symptoms. Why is a particular
disease causing this symptom? What is the
physiology of the symptom?
4
DON’T use only short-acting agents
(opioids) for chronic pain
 Special concern re combo drugs –
Vicodin, T&C #3 and Percocet
 DO use sustained-release or long acting
opioids, if indicated, for chronic pain
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3
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DON’T just tell patients what is wrong with
them
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DO elicit patients’ understandings of their
illness by asking questions like, “What is
your understanding of why you are sick?’
2
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DON’T just tell people what you are not
going to do.
 Nobody loves you for what you don’t do
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DO tell them what you are going to do (or
how you will help them)
 Especially important when discussing
“treatment withdrawal”
1
DON’T set out to “get the DNR”
 Resuscitation status is only one of many
“difficult decisions” that should
incorporate patient and family goals
 DO assess and document patients’ goals of
care
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Palliative Care Consults

Help with:
 Difficult decisions
 Communication
 Symptom management
 Identifying appropriate venues of care for
patients with serious, life-limiting
illnesses
Palliative Care Consults
What they are not
A excuse for ward teams not to talk with
patients about difficult subjects
 Shock troops to break through
patient/family denial, thereby “getting” the
DNR
 Solely about hospice referral as a
“placement” issue
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How you can help with Palliative
Care Consults
Be as clear as you can as to what help you
would like
 At least try to address patient/family goals
of care and document prior to consult
 If you have special concerns you would
rather not put in the consult request in GUI,
call the consult fellow, beeper: 21656
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