Transcript Assessment and management of pain near the end of life

Assessment and management of pain
near the end of life
David Casarett MD MA
University of Pennsylvania
Goal:
To describe an evidence-based approach to
pain management near the end of life, with a
focus on:
» Assessment
» Defining goals for care and enpoints of pain
management
» Use of opioids
• Appropriate use of opioids
• Managing opioid-related side effects
» Beyond pain management: the role of hospice in
long term care
Audience:
Clinicians in long term care:
» Physicians
» RNs
» Advance Practice Nurses
Surveyors
Quality Improvement leaders
Case:
Mr. Palmer is an 84 year old man with
moderate dementia (MMSE=15), severe
peripheral vascular disease and coronary
artery disease.
 He currently lives in a nursing home, where
he is dependent on others for most activities
of daily living. He is able to speak in short
sentences and can participate in health care
decisions in a limited way. His daughter
discusses his care with him, but ultimately
makes all decisions for him.
Case, part 2
He suffers a fall that results in a fracture of
the left hip and is evaluated in a hospital
emergency room.
Because of his other medical conditions, high
operative risk, and poor quality of life, his
daughter decides with Mr. Palmer that he
would not want to undergo surgery and
instead would prefer to be kept comfortable.
He returns to the nursing home with a plan for
comfort care, with an emphasis on pain
management.
Outline
 Scope of the problem: pain near the end of life in nursing homes
 Assessment
» Background
» Principles of assessment
 Management
» Establishing goals of care
» Defining endpoints of pain management
» Opioids-the mainstay of pain management near the end of life
• Use of opioids
• Management of side effects
 Beyond pain management: the role of hospice in the nursing
home
Scope of the problem: pain near the
end of life in nursing homes
 Defining the “end of life”
» No established definition
» 6 month prognosis (hospice eligibility) not useful
• Arbitrary
• Difficult to determine accurately
» Instead: A resident is near the end of life if he/she has a
serious illness that is likely to result in death in the
foreseeable future
 Operationalize as: “Would I be surprised if this
resident were to die in the next year?” (Joanne Lynn)
 Mr. Palmer: Would not be surprised—peripheral
vascular disease, coronary artery disease, dementia,
recent hip fracture.
Scope of the problem: Common
serious illnesses in the nursing home
 Cancer*
 Dementia*
 Stroke*
 Peripheral Vascular Disease*
 Falls/Hip fracture*
 Congestive Heart Failure
 Chronic Obstructive Pulmonary Disease
 Cirrhosis
*Associated with pain
Prevalence of pain (all diagnoses)
Depends:
» Surveys: 30-71%
» Medication audits: 25-50%
Hospice (Pain requiring intervention)
» 25% (Casarett 2001)
What is the primary cause of pain?
Low back pain 40%
Previous fractures 14%
Neuropathy 11%
Leg cramps 9%
DJD (knee) 9%


Malignancy 3%
(Ferrell et al JAGS 1990)
What are the characteristics of pain
in the nursing home?
Intermittent
Constant
None
(Ferrell et al JAGS 1990)
Room for improvement?
Undetected in 1/3 (Sengstaken and King 1993)
Undertreated (Bernabei et al 1998)
Both (cognitively impaired) (Horgas and Tsai 1998)
Pain assessment
Adapted from AGS
Persistent Pain Guidelines
Comprehensive pain assessment:
History
1. Evaluation of Present Pain Complaint
1. Self-report
2. Provider/family reports
2. Impairments in physical and psychosocial function
3. Attitudes and beliefs/knowledge
4. Effectiveness of past pain-relieving treatments
5. Satisfaction with current pain treatment/concerns
Comprehensive pain assessment:
Objective data
1. Careful exam of site, referral sites, common pain sites
2. Observation of physical function
3. Cognitive impairment
4. Mood
5. Limited role for imaging
1. May be useful
2. Often will not change management
Special situations: Mild to moderate cognitive
impairment



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Direct query
Surrogate report only if patient cannot reliably communicate
Use terms synonymous with pain (“hurt” “sore”)
Ensure understanding of tool use
» Give time to grasp task and respond and repetition
 Ask about present pain
 Ask about and observe verbal and nonverbal pain-related behaviors and
changes in usual activities/functioning
 Use standard pain scale, if possible
» 0-10 Numeric Rating Scale
» *Verbal Descriptor/Pain Thermometer
» Faces Pain Scale
Numeric Rating Scale
0
No
pain
1
2
3
4
5
6
7
8
9
10
Worst
possible
pain
Verbal Descriptor Scales
Verbal Descriptor Scale (VDS)
___
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___
___
___
___
___
Most Intense Pain Imaginable
Very Severe Pain
Severe Pain
Moderate Pain
Mild Pain
Slight Pain
No Pain
(Herr et al., 1998)
Present Pain
Inventory (PPI)
0 = No pain
1 = Mild
2 = Discomforting
3 = Distressing
4 = Horrible
5 = Excruciating
(Melzack 1999)
Pain Thermometer
Pain as bad as it could be
Extreme pain
Severe pain
Moderate pain
Mild pain
Slight pain
No pain
(Herr and Mobily, 1993)
Advantages of verbal descriptor
scales
Data suggest that patients may be more likely
to be able complete verbal descriptor scales
(Ferrell 1995;Closs 2004)
May be less sensitive to cognitive
impairment/visual impairment
But, no “one size fits all” scale
Facial Pain Scales
Faces Pain Scale
Bieri D et al. Pain. 1990;41:139-150.
Principles of assessment:
mild/moderate cognitive impairment
The “best” assessment method is the one that
the patient can use
This is often, but not always, a verbal
descriptor scale
Use the same instrument/scale consistently
Use it in the same way
Special situations:
Moderate to severe cognitive impairment
Direct observation or history for evidence of pain-related
behaviors (during movement, not just at rest)
 Facial expressions of pain (grimacing)
» Less specific: slight frown, rapid blinking, sad/frightened face, any
distorted expression
 Vocalizations (crying, moaning, groaning)
» Less specific: grunting, chanting, calling out, noisy breathing, asking
for help
 Body movements (guarding)
» Less specific: rigidity, tense posture, fidgeting, increased pacing,
rocking, restricted movement, gait/mobility changes such as limping,
resistance to moving
Moderate to severe cognitive impairment
 Unusual behavior should trigger assessment of pain as a
potential cause
» Caveat: Some patients exhibit little or no pain-related behaviors
associated with severe pain
 Always consider whether basic comfort needs are being met
 “Pre-test probability” Evidence of pathology that may be
causative (e.g. infection, constipation, fracture)?
 Attempt an analgesic trial
» If in doubt, analgesic trial may be diagnostic
» Acetaminophen 500mg TID, (titrate up to 3-4G/day)
Principles of assessment:
moderate/severe cognitive impairment
 No single optimal method (no “gold standard”)
 Assessment requires several sources of information
(observations of several providers, family)
 Many “pain-related behaviors” are non-specific
 If no known cause of pain, trial of acetaminophen can
be useful
 If reason for pain, empirical treatment is appropriate
Pain management
Principles of pain management
Defining goals of care
Defining endpoints of pain management
Opioids-the mainstay of pain management
near the end of life
» Use of opioids
» Management of side effects
Beyond pain management: the role of
hospice in the nursing home
Individualized care planning:
Defining goals of care
 Highly variable goals for care:
» Comfort
» Function
» Survival
 Highly variable preferences about: specific
management choices
»
»
»
»
Site of care
Treatment preferences (e.g. DNR, transfer to hospital)
Site of death
Optimal balance of pain, sedation, and other medication side
effects
Treating pain in a resident with these
goals….
 Cure of disease
 Maintenance or
improvement in function
 Prolongation of life
Or treating pain in a resident with
these goals….
 Relief of suffering
 Quality of life
 Staying in control
 A good death
 Support for families and
loved ones
The importance of defining goals of
care
 Cure of disease
 Maintenance or
improvement in function
 Prolongation of life
 Relief of suffering
 Quality of life
 Staying in control
 A good death
 Support for families and
loved ones
Individualized care planning:
2 examples
 Mr. Palmer’s daughter accepts that there are no
further treatment options available to extend life. She
says it is most important for her father to avoid pain
or discomfort.
» Aggressive pain management
» Family support
» Hospice
 Mr. Palmer’s daughter says that he would want any
treatment that might improve his survival and
maintain the function he has left. She says he wants
aggressive treatment even if it results in discomfort.
» Surgical intervention
» Aggressive physical therapy
Curative / Life-prolonging Therapy
Course of illness
Relieve Suffering (Palliative Care
and hospice)
Challenges of defining goals of care
accurately
 Interpreting resident statements
 Multiple disciplines=multiple interpretations
» (Importance of clear documentation)
 Conflicting resident/family goals
 Uncertainty about resident decision-making capacity
 Changes in goals over time (resident and family)
 Inconsistent preferences or goals (e.g. extending life
but no transfer to acute care)
Defining goals of care: principles
Broad categories are most useful (survival,
function, comfort, others that are residentdefined)
Goals rather than treatment preferences (e.g.
resuscitation status)
Useful guides (not mutually exclusive):
» Prolonging survival
» Preserving function/independence
» Maximizing comfort
Case: Goals for care
 Mr. Palmer’s daughter accepts that there are no
further treatment options available to extend life. She
says it is most important for her father to avoid pain
or discomfort.
 This plan is communicated to other family members
and staff, and is clearly documented in the medical
record
Defining endpoints of pain
management
The optimal plan of pain management is one
that:
» Achieves an acceptable (to the patient) level of
pain relief
» Preserves an acceptable level of alertness and
function
» Offers an acceptable side effect profile
Defining endpoints of pain
management
Usually not “no pain”
Depends on:
» Goals
» Treatment preferences
» Tolerance for side effects
A note about assessing satisfaction
 Advantages:
» Simple, easy to assess
» Easy to interpret
» Often encouraged by facility leadership
 Disadvantages:
» Ceiling effect
» Poor association with pain control
» Confounded by other factors (Ward 1996, Desbiens 1996,
Casarett 2002, Gordon 1996)
•
•
•
•
Side effects
prn dosing/control
Ethnicity
Depression
Pain management near the end of
life: focus on opioids
Multiple strategies for the management of
pain near the end of life
Heat/cold
TENS units
Counseling
Spiritual support
NSAIDs/Acetaminophen
Agents for neuropathic pain (e.g. tricyclic
antidepressants, gabapentin)
Opioids
Key principles of management
 Opioids are mainstay of management
 Use of multiple pharmacological agents is often
needed to provide optimal management:
»
»
»
»
NSAIDs
Tricyclic antidepressants
Corticosteroids
Anticonvulsants
 Traditional rules discouraging polypharmacy don’t
apply in this setting: importance of individualized
management.
Why focus on opioids?
Highly effective
Underutilized
Poorly understood by providers and public
Common misconceptions
Pain management near the end of
life: the role of opioids
The mainstay of effective pain management
near the end of life
Appropriate for residents with moderate or
severe pain
» 4/10 or greater, or
» Conditions that are associated with moderatesevere pain (when resident is too cognitively
impaired to permit an accurate assessment of
severity)
Addiction and other concerns about
opioids
Addiction: a syndrome of physical and
psychological dependence
» Very rare in opioid treatment near the end of life
» Estimates of risk are <<1%
Except in very unusual circumstances (e.g.
history of drug dependence), concerns about
addiction are not appropriate in the setting of
pain management near the end of life
Increases in opioid dose often
attributed (incorrectly) to addiction
 Tolerance: Gradual decrease in sensitivity to opioid
effects (pain relief and side effects)
» Results in “dose creep”
 Disease progression
 Pseudo addiction: Increases in medication requests
(particularly prn opioids) out of proportion to pain
and/or medication hoarding, in the setting of
significant discomfort
» Often labeled as addiction/diversion
» Much more likely to be due to fear of pain/slow nursing
response to requests for prn meds/desire for more control
over pain management
» Managed by more aggressive pain management not by
reducing/controlling opioids
Using opioids: strategies for
administration
Non-invasive (oral//PEG tube/transdermal)
administration is preferred
Sustained release preferred for persistent
pain
Virtually all patients receiving sustained
release opioids should have prn opioid
available for “breakthrough” pain (typically
10% of the 24 SR dose)
Strategies for administration
 Begin with immediate release preparation
» Scheduled (cognitively impaired/severe pain)
» prn
 Can increase every 6-8 hours (faster if using IV/SC
administration)
 Titrate up in reasonable (proportional) steps (think in
terms of 20-50% increases)
 Switch to a long-acting preparation when pain control
is adequate but continue access to prn dosing
 If continued titration is needed, use prn doses to
estimate additional opioid requirements
Which opioid? Basic considerations
 Morphine: Inexpensive, widely available, and can be
administered by multiple routes and schedules
 Hydromorphone: More potent, but no SR and limited
routes of administration. Advantages in renal
insufficiency.
 Oxycodone: SR available, also concentrated PO, but
no IV. Possibly decreased risk of delirium in older
patients.
 Methadone: inexpensive, available IV and PO. T1/2
is longer than duration of effect.
 Fentanyl patch: Convenient, conversion difficult, poor
choice when rapid titration is needed.
Which opioid?
Overall, no evidence of one agent’s
superiority with respect to:
» Effectiveness
» Side effects
Choice based on:
» Past experience
» Clinician’s comfort/experience with an agent
» Specific features of a resident’s case (e.g. need
for rapid titration)
Choosing an opioid in the setting of
hepatic failure
 Opioid metabolism:
» Hepatic metabolism/conjugation
» Renal excretion
 Less desirable:
» Codeine (Decreased conversion to morphine and decreased
efficacy +/- increased side effects)
» Methadone (decreased Phase I metabolism)
• Liver
• Gut metabolism and elimination (p-glycoprotein) (variable bioavailability
in hepatic failure)
 Other (preferable) agents only have increased bioavailability:
»
»
»
»
Oxycodone (decreased Phase I metabolism)
Morphine (decreased Phase II conjugation)
Hydromorphone (decreased Phase II conjugation)
Fentanyl (decreased Phase I metabolism)
Choosing an opioid in the setting of
renal failure
 Minor concern: avoid agents with significant renal
clearance:
» Oxycodone
» Fentanyl (Patch/infusion)
» Methadone (>60 mg/day)
 More important:
» Avoid agents with active metabolites that are renally cleared:
•
•
•
•
Morphine
Codeine
Meperidine (never appropriate)
Oxycodone(?): Noroxycodone and oxymorphone
» And…select agents with inactive metabolites:
• Fentanyl (norfentanyl)
– No evidence of increased neuroexcitatory side effects
• Hydromorphone (hydromorphone-3 glucuronide?)
• Methadone
Summary: renal and hepatic failure
 Theoretical reasons to select certain agents
 Although some agents are (theoretically) preferable
in certain settings, no “right” or “wrong” choice
 Rules of thumb
» If it’s not broke, don’t fix it (What appears to work for a
particular patient is a “right” choice)
» Dose escalation should be more conservative in
renal/hepatic failure
» Virtually any agent can be used effectively by “starting low
and going slow”
» When renal/hepatic failure is progressive, be prepared to
reduce the opioid dose
Choosing an opioid when PO intake
is limited
 IV/SC route (morphine, hydromorphone, methadone)
 Transdermal (fentanyl)
» Poor choice for rapid titration
» Convincing evidence of ambient heat effect (Ashburn, 2002)
» Not optimal when limited sc adipose tissue
 Rectal administration
» Suppositories, liquid, or SR formulation (short term)
» Bioavailability is probably 90-100% of oral route
» First pass metabolism depends on site of absorption
 Microcapsule formulations of morphine (Kadian,
Avinza)
» Pudding/applesauce
» PEG tube
 Liquid formulations of methadone (PEG tube)
Limited PO intake: SC administration
of opioids
For most systems, SC morphine limit is 30
mg/hour
For higher dose requirements
hydromorphone is a good alternative (potent,
can be concentrated)
No need for hyaluronidase
Butterfly needle/change q 5-7 days or with
discomfort
D5W preferred diluent
Case: pain management
Mr. Palmer received IV morphine in the ER
that was titrated up to 5 mg/hour at the time
of his transfer.
This dose was maintained on transfer
(His nurse asked Mr. Palmer’s physician for a
verbal order for a laxative to prevent opioidinduced constipation. He was started on
senna and colace BID.)
Opioid-related side effects
Side effects:
»
»
»
»
»
Sedation
Nausea/emesis
Delirium/confusion/agitation
(Constipation)
Myoclonus
Opioid-induced side effects:
Overview of options
Opioid rotation
Decrease dose
Add symptomatic therapy
Change route
Opioid-related side effects: Sedation
After 4 hours in the ER, Mr. Palmer’s pain is
6/10, and by 8 hours (after transfer) it’s a 3.
He is resting comfortably, but is arousable.
6 hours later, his nurse notes that Mr. Palmer
is not arousable, and will not respond to
voice.
Opioid-induced sedation: background
 Prevalence: up to 60% of patients, highest in initial
days of therapy/changes in dose or route
 Differential diagnosis (extensive workup is often
undesirable):
» Sleep deprivation
» Delayed effects of opioid
» Other:
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•
•
•
Internal bleeding/hypotension
Hepatic encephalopathy
Pulmonary embolus
Sepsis
The therapeutic window
Somnolence
Pain control
Time    


The therapeutic window
Somnolence
Pain control
Time    
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Opioid-induced sedation: (acute)
management
General strategies:
» Assess respiratory status/airway
» Reassure family/staff
» Assess monitoring/nursing capacity
Specific strategies:
» Decrease dose
» Wait…
» Avoid naloxone (but bedside availability, 0.4 mg
with 10 ml water, can offer psychological value)
Opioid-induced sedation: (subacute)
management
Choice of route? (No good data to support
independent route effect)
Opioid rotation. Limited data (Most
retrospective data)
Methylphenidate
» Poor database of studies enrolling carefully
selected patients (Wilwerding et al 1995; Bruera
1987)
» Evidence of some specific effectiveness but more
global improvement in well-being
Sedation algorithm
 Acute, no respiratory depression
» If titrating up, change to maintenance dose, monitor
» If already at maintenance dose, continue, wait >6 hours
• At steady state
• Reduced sleep deficit
• Family/staff reassurance
» Still sedated, consider decreased dose
 Subacute
» Identify temporal relationships and opioid/pain mismatch
» Assess nocturnal sleep, consider hypnotic
» Assess pain control
• Inadequateopioid rotation
• Adequatemethylphenidate, 2.5 mg BID (AM and noon)10
mg and 5 mg
Sedation: Outcome
Mr. Palmer’s opioids were not increased
further and he slept for 7 hours without
breakthrough dosing.
On awaking, his pain was well-controlled but
required frequent breakthrough doses. Those
doses were incorporated into his IV infusion
over the next 24 hours and the infusion rate
was increased with no further sedation.
Opioid-related side effects: Nausea
As you are titrating morphine gradually
against pain, Mr. Palmer develops severe
nausea with repeated vomiting.
There is no associated abdominal pain,
constipation, or melena. Bowel sounds are
somewhat diminished but there is no
evidence of distention.
Opioid-induced nausea: background
 Occurs in up to 1/3 of patients
 Usually within first week of therapy
 Typically dose-independent
 Mechanisms of opioid-induced nausea:
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»
»
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Chemoreceptors in CNS
Impaired GI motility
Vestibular stimulation
Conditioning/anticipatory nausea
 Importance of ruling out related causes:
» Disease-specific symptoms
» Constipation or bowel obstruction
» Opioid-induced vertigo (<5%)
Opioid-induced nausea: management
Limited data, not helpful to extrapolate from
other common nausea syndromes (e.g.
chemotherapy)
Dose reduction unlikely to be effective
Interventions:
» Switch route (oralSC); limited data (McDonald
1991; Drexel 1989)
» Opioid rotation; better data (de Stoutz 1995)
» Symptomatic treatment…
Symptomatic treatment options
 Haloperidol, prochorperazine (Dopamine antagonism
in CTZ; Haloperidol has stronger dopamine effects)
 Metoclopramide (Peripheral pro-motility effects, antidopamine effects at higher doses, e.g. >10 mg q 6
hours)
 Scopolamine patch (purely anticholinergic effects)
 Also:
»
»
»
»
Ondansetron (Sussman 1999)
Lorazepam
Benadryl
Dexamethasone (Wang 1999)
• Decreased BBB permeability?
• GABA depletion and inhibition of the CTZ?
Nausea algorithm
 Early, aggressive treatment with metoclopramide:
» In outpatients: prescription for 8 doses with opioid
prescription
» Inpatients: Prophylactic or prn order
 Effective, no emesiscontinue and taper
 Ineffectivecontinue and add haloperidol
» Effectivecontinue
• Taper haloperidol
• Then taper metoclopramide
» Ineffectivecontinue
• Rotate opioids
• Consider switch in route
Outcome: Nausea
Metoclopramide prn was not effective and
was increased to a scheduled dose with
some relief.
Simultaneous treatment with metoclopramide
(10 mg QID) and haloperidol (0.5 mg/6 hours)
was completely effective. Haloperidol was
discontinued after 36 hours and
metoclopramide was discontinued after 3
days with no recurrence of nausea.
Opioid-related side effects: opioidinduced delirium
Mr. Palmer’s pain was well-controlled at a
new steady dose of morphine, but he
becomes agitated later that night. He is
yelling, trying to pull himself out of bed, and
seems to be experiencing visual
hallucinations.
Opioid-induced delirium: background
Long differential diagnosis list: electrolyte
abnormalities, physiological causes,
“terminal” delirium.
Mechanisms of true opioid-induced delirium
» Kappa, delta receptors
» Metabolites of parent drug
» Non-specific/pathway effects (e.g. diminished
arousal, decreased orientation, altered sleep-wake
cycle)
Opioid-induced delirium: management
 Very weak evidence base for opioid-induced delirium
(only extrapolated studies)
 Non-pharmacological interventions are promising
(also extrapolated)(Inouye 1999)
 Interventions:
»
»
»
»
Reduce opioid dose(?)
Opioid rotation: best data (de Stoutz 1995)
Donepezil(?)
Second generation antipsychotics: Strong theoretical
rationale, anecdotal data, data extrapolated from other
settings.
Delirium algorithm
Inadequate pain management
» Distressing/agitated delirium opioid rotation +
symptomatic therapy (low dose haloperidol,
olanzapine, resperidone)
» Not distressing/ “quiet” delirium opioid rotation,
followed by symptomatic therapy if rotation not
effective
Adequate pain management
» Add symptomatic therapy, consider opioid rotation
if not effective
Balancing pain management and
side effects
 Confusion is an expected side effect of opioid therapy
 However, inadequate treatment of pain can produce
syndromes of confusion, including delirium (Morrison
2003)
 Therefore, confusion/delirium in the setting of opioid
management…
»
»
»
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Should not be considered as an adverse event
Should not dissuade use of opioids
Should not prompt discontinuation
Should be managed carefully
Delirium: Outcome
Mr. Palmer’s agitation responded well to 0.5
mg haloperidol PO every 4-6 hours, with
higher doses at bedtime.
Additional interventions included:
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»
»
»
Move to private room
Designated CNA (continuity)
Pictures of family
Promote normalized sleep-wake cycle through
interaction during the day
Opioid-induced side effects: general
principles of management
Assess pain management:
» Inadequate pain managementOpioid rotation
» Adequate pain management Consider
effectiveness of available symptomatic therapy:
• Reasonable data: Add symptomatic therapy
• Weak data: consider dose reduction/opioid rotation
NOTE: Effective treatment of side effects
often requires additional medications
AllConsider a change of route
Beyond pain: the total care of residents
and families near the end of life
 Mr. Palmer’s pain and side effects are adequately
managed on a stable medication regimen. However,
his interdisciplinary team identifies several additional
problems, including:
» Dry, cracked lips
» Rapid breathing that they are concerned might be due to
shortness of breath
» Frequent crying spells in one staff member who had been
very close to Mr. Palmer for the last 5 years
» The daughter’s apparently depressed mood and expressions
of guilt about “letting my father die”
Beyond pain management
Pain is only one aspect of end of life care
Residents with pain usually have other
physical symptoms
Psychological symptoms are also common
Grief and bereavement needs are common
among family, staff, and other residents
» After a residents death
» Before the resident’s death (anticipatory grief)
Pain management in the nursing
home: the role of hospice
 Program of care designed to provide comprehensive care to
patients near the end of life and their families
 Eligibility requires patients have a prognosis of 6 months or less
and that they forgo curative treatment
 Over 3100 hospice organizations serve almost 900,000 patients
annually
• The Hospice team:
Hospice physicians;
Nurses;
Home health aides;
Social workers;
Clergy or other counselors;
Trained volunteers;
Other disciplines, if needed.
• Medications related to hospice DX
• Bereavement follow up and counseling as needed for 1 year
A role for hospice in nursing homes
 Strong evidence supporting the value of hospice in
nursing homes (Miller 2001, Casarett 2001, Miller
2002, Miller 2001b, Baer 200, Teno 2004)
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»
»
»
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More services
Better pain management
Decreased restraint use
Decreased hospitalization
Better family satisfaction
A role for hospice in nursing homes
 But nursing home residents are underrepresented in
hospice
» Payment barriers
» Barriers created by institutional culture
 Lengths of stay are very short (median=26 days)
» 1/3 enroll in last week
» 10% enroll in last day
 Need for greater hospice access in nursing homes:
» Access for more residents
» Access earlier in the course of illness.
The role of hospice in the nursing
home
 Mr. Palmer’s family enrolled him in hospice, using a
community hospice agency that came to the nursing
home.
 Initial interventions included:
» Adjustments to pain medication dosing schedule to achieve
more even control
» Mouth swabs
» Oxygen and room fan to alleviate sensation of dyspnea
» Counseling for both staff and daughter
 Mr. Palmer died 2 weeks later in the nursing home,
without apparent discomfort.