Transcript palliative care - UNT Health Science Center

End of Life Care: An Overview
Objectives

Address issues surrounding end-of-life
care and vulnerable older adults
- definition of palliative care

- logistics of end-of life-care
- surrogate decision making and advance
directives
- symptom management
ACOVE indicators and EOL care
WHAT IS PALLIATIVE CARE?

Interdisciplinary

Goal :

to prevent and alleviate suffering

assist towards the best possible quality of life

optimize function

assist with decision making for patients with serious
illness and their families.
Can be the main focus of care or offered
concurrently with all other life - prolonging
medical treatment.

END-OF-LIFE DEMOGRAPHICS

The majority of deaths occur in elderly adults

Very ill patients may spend much of their final
time at home, but…

Hospitals or nursing homes are actual location
of most deaths

There is regional/ geographic variability in
location of deaths (home vs. institution)
Adapted from Geriatrics Review Syllabus, Sixth Edition
END-OF-LIFE (EOL) IN THE U.S.
For elderly, death is typically slow and
associated with chronic disease
 Patients experience increased dependency in
their care needs
 EOL care can be complicated by family
stress, poor symptom control, and
discontinuity of care
 In this age of technology, commonly decisions
need to be made about the use of these
agents

Adapted from Geriatrics Review Syllabus, Sixth Edition
SUDDEN DEATH, UNEXPECTED
CAUSE
< 10%, MI, accident, etc.
Health Status

Time
Death
Steady Decline
Short “Terminal Phase”
SLOW DECLINE
Periodic Crises, Sudden Death
Curative / Life Prolonging
Presentation
Adapted from Institute of Medicine
Death
Sx Control /
Palliative Care
Historical trajectories of care pathways
Consider an alternative trajectory…

Inclusion of palliative concepts from time of
diagnosis

This piece of the care plan may become more
prominent as curative therapies are less
available

More gradual transitions at the end of life
Curative / Remissive Therapy
Death
Presentation
Palliative Care
Hospice
Adapted from EPEC curriculum, 1999
WHAT IS “HOSPICE”?

Location


Group


Organization that provides care for the dying patient
Approach to care


Place for the care of dying patients
Philosophy of care for the dying patient
A Medicare benefit
Adapted from Geriatrics Review Syllabus, Sixth Edition
THE HOSPICE MEDICARE
BENEFIT

For beneficiaries with an expected prognosis of
6 months or less

Exchange curative treatments for symptomatic/
palliative treatments

Can be revoked at any time

Reimbursed per diem for one of four levels of
care

Can be utilized in the home, nursing home,
inpatient hospice units
See referenced reading, AAHPM Bulletin
THE HOSPICE MEDICARE
BENEFIT

Covered Services

physician services, nursing care

medical equipment and supplies





medications related to the terminal illness designated
short-term inpatient care (symptom management &
respite)
PT or OT based on the goals
bereavement services
home-health aide services
OBSTACLES

Limited access, i.e. rural areas

Logistical support

Late referral – median duration time spent
with hospice is only 21 days (Hospice Association of
America 2006)

Difficulties in determining prognosis
PROGNOSIS
More straightforward for cancer diagnosis
 Often unpredictable for chronic disease
COPD
Alzheimer’s Disease
Heart disease
Failure to Thrive/ Debility

PROGNOSIS

In general:
Patient’s condition is life limiting, and pt/ family
are aware
Pt/ family have elected relief of sx treatment goals
rather than curative goals
Pt has either documented clinical progression of
disease or documented recent impaired nutritional
status related to the terminal process
Karnofsky Scale
DELIVERING BAD NEWS

Prepare




Plan an agenda
Ensure availability of all medical facts
Pick an appropriate setting
Minimize interruptions

What does the patient understand? What does the
patient want to know?

Deliver the news

Be straightforward, avoiding medical jargon

Provide a “warning shot”

Allow time for discussion

Create a plan and organize for follow-up
DECISION MAKING

Autonomous choices are voluntary,
adequately informed and based on
reasoning
Does the patient have the ability to
choose?
 Does the patient understand pertinent
information?
 Does the patient appreciate the clinical
situation/ choices/ consequences?
 Can the patient reason through choices?

The patient identifies the goal(s).
The plan follows the goal.
SURROGATE DECISION MAKING



May be required with both younger and older
adults
Specific surrogate may be identified via a
DPOA (durable power of attorney) for health
care
Goal of surrogate is to advocate for patient
based on what they know of patient’s wishes
- based on prior discussions, advance directives/
living wills
SOME DEFINITIONS

Durable Power of Attorney for Health Care



Living Will


Appointing someone to make medical decisions for you if
you cannot make them yourself
Does not require presence of AD or living will
Description of wishes about life sustaining medical treatments if
one is terminally ill
Advance directives




Instructions / guidance for for health care should one become
incapacitated
Can name an “agent” to make decisions for them
Wishes stated must be honored by surrogate unless court orders
otherwise
Can be revoked at any time
DECISION MAKING

If a patient cannot make their medical
decision and has not identified a surrogate
decision maker, does not have an advance
directive, or has not made their wishes
known, a surrogate may have to be identified.


Some states have an automatic order of priority for
identifying surrogates
Kansas and Missouri have no such statues
available
OTHER PALLIATIVE CARE ISSUES
Symptom management
 Cross-cultural issues
 Spiritual concerns
 Psychosocial issues

See recommended readings for further information
SYMPTOM MANAGEMENT

Multiple symptoms of concern near the end of life
- Pain
- Dyspnea
- Constipation
- Nausea
- Anxiety
- Delirium
- Fatigue
- Anorexia
PAIN

Treatment based on assessment
- severity
- nociceptive vs. neuropathic
- step-wise approach

Potential modalities
- Non-opioid
acetominophen
NSAIDs/ COX-2 –I
- Opioid
- Adjunctive
Anti-convulsants
Steroids
TCAs
And now a little about opioids…



Bind to one or more of the opiate receptors (mu,
kappa, delta)
Mu receptor is 7 transmembrance G protein
coupled receptor
- binding stabilizes the membrane so neuron doesn’t fire
Where are the mu receptors?
- periphery, dorsal root ganglia of spinal cord, periaqueductal grey of
brainstem, midbrain, gut
Opioids

“weak” opioids
- codeine
- hydrocodone
- oxycodone

“strong” opioids
- hydromorphone
- fentanyl
- morphine
Opioids

Distribution
- Hydrophilic
* morphine, oxycodone, hydromorphone
- Lipophilic
* fentanyl, methadone
Opioids


IV- morphine, hydromorphone, fentanyl
PO- morphine (LA & SA), oxycodone (LA & SA),
hydromorphone, methadone, fentanyl, hydrocodone
 Transdermal- fentanyl

Initial decisions based on
- route of administration
- need for continuous vs. intermittent dosing
- severity of pain
LA= long acting
SA= short acting
Opioids-Pharmacology




All water soluble opioids behave similarly:
Cmax is 60-90 minutes after PO dose
30 minutes after SQ or IM
6-10 minutes after IV dose
All are conjugated in liver and 90% excreted via
the kidney
With normal renal fx, all have ½ life of 3-4 hours,
reach steady state in 4-5 ½ lives
Special Notes

Morphine
- low protein binding
- dialyzes off
- active metabolite is morphine 6- glucuronide
(10%)
* accumulates in renal failure and causes
neuroexcitation
* prolonged CNS effects
Special Notes

Fentanyl
- little or no active metabolites
- Not dialyzable
- Elderly more sensitive to effects
- Unclear how TD route is affected by low subcutaneous fat

Hydromorphone
- Generally considered to have inactive metabolites
- Drug of choice with renal failure
Special Notes

Methadone
- binds mu and blocks NMDA receptors
- highly protein bound
- highly variable and prolonged half life
- Phase I metabolism and may prolong the
QT interval
- caution when changing from another
opioid to methadone
Potential opioid side effects
Nausea
 CNS depression/ sedation
 Pruritis
 Constipation
 Delirium
 Endocrine dysfunction with long term use

DYSPNEA



Subjective symptom
Pathophysiology can reflect disorder in
regulation or act of breathing
Treatment directed at underlying cause
- Most common reversible causes
bronchospasm, hypoxia, anemia
- Both non-pharmacologic and non-pharmacologic
treatments can be helpful
- Opioids used for sx relief when more directed
therapy doesn’t reverse the dypsnea
NAUSEA


Potentially debilitating symptoms near the
end of life
Treatment based on source
- Brain chemoreceptor trigger zone, cerebral cortex,
vestibular apparatus
- GI tract obstruction, motility, mucosal irritation
www,aafp.org,
Sept.1, 2001,
Vol.64, No.5
DELIRIUM

Common near the end of life
- geriatric patients with multiple risk factors for
development


Large number of cases can be reversible
Control of delirium may be important for both
patient and family
- pharmacologic and non-pharmacologic means
ACOVE Indicators
Assessing Care of Vulnerable Elders
 Comprehensive set of quality
assessment tools for ill older adults
- Covering domains of prevention, diagnosis,

treatment, and follow up

Designed to evaluate health care at
system level rather than individual level
DECISION MAKING (ACOVE)

If a vulnerable older adult is admitted directly
to the intensive care unit (from the outpatient
setting or emergency department) and
survives 48 hours, THEN within 48 hours of
admission, the medical record should
document consideration of the patient’s
preferences for care or that these could not
be elicited or are unknown
DECISION MAKING (ACOVE)

ACOVE indicator for quality care of the
older adult:
1)
If a vulnerable older adult with dementia, coma, or
altered mental status is admitted to the hospital,
THEN within 48 hours of admission, the medical
record should contain an advance directive
indicating the patient’s surrogate decision maker
Document a discussion about who would be
surrogate decision maker or a search for a
surrogate, or
Indicate that there is no identified surrogate
2)
3)
DECISION MAKING (ACOVE)

If a vulnerable older adult carries a diagnosis of
severe dementia, is admitted to the hospital, and
survives 48 hours, THEN within 48 hours of
admission, the medical record should document
consideration of the patient’s previous preferences
for care or that these could not be elicited or are
unknown
DECISION MAKING (ACOVE)

All vulnerable older adults should have in
their outpatient charts
1) An advance directive indicating the
patient’s surrogate decision maker, or
2) Documentation of a discussion about who
would be a surrogate decision maker or a
search for a surrogate, or
3) Indication that there is no identified
surrogate
CASE 1 (1 of 3)

A 79-year-old man with a history of prostate cancer
has had worsening back pain for 3 weeks. He recalls
no recent accident or injury.

The pain limits the patient’s ability to dress and
bathe himself. He cannot get comfortable in bed and
has been sleeping in a reclining chair for the past
few nights. He took acetaminophen with codeine last
night with no relief.

Physical examination is normal except for
tenderness on palpation over the lower spine.

Bone scan demonstrates metastatic disease in the
lumbar spine and pelvis.
CASE 1 (2 of 3)
Which
of the following is the most
appropriate initial management strategy
for this patient’s pain?





(A)
(B)
(C)
(D)
(E)
Immediate-release oxycodone
Sustained-release oxycodone
Propoxyphene
Transdermal fentanyl
Acetaminophen with codeine
CASE 1 (3 of 3)
Which
of the following is the most
appropriate initial management strategy
for this patient’s pain?





(A)
(B)
(C)
(D)
(E)
Immediate-release oxycodone
Sustained-release oxycodone
Propoxyphene
Transdermal fentanyl
Acetaminophen with codeine
CASE 2 (1 of 3)

For the third time in 6 months, an 84-year-old man with
advanced dementia is admitted to the hospital for aspiration
pneumonia.

He has lost 9.5 kg (20 lb) over the past 10 months and has a
sacral pressure ulcer. He is nonverbal, unable to ambulate, and
dependent for all ADLs. His wife cares for him at home. He
does not want to go to a nursing home.

A swallow study indicates that all food consistencies are
unsafe. The hospitalist suggests tube feeding. The advanced
care plan states that the patient’s wife is his agent and that he
does not want extraordinary measures used to extend his life,
including artificial nutrition.
CASE 2 (2 of 3)
What
is the most appropriate recommendation
for this patient?
(A) Long-term placement of a feeding tube
and discharge to a skilled nursing facility
(SNF)

(B) Short-term placement of a feeding tube
and discharge to a SNF until the pressure
ulcer heals

(C) Discharge to a SNF for wound care until
the
 pressure ulcer has healed

CASE 2 (3 of 3)
What
is the most appropriate recommendation
for this patient?
(A) Long-term placement of a feeding tube
and discharge to a skilled nursing facility
(SNF)

(B) Short-term placement of a feeding tube
and discharge to a SNF until the pressure
ulcer heals

(C) Discharge to a SNF for wound care until
the
 pressure ulcer has healed

CASE 3 (1 of 3)

A 67-year-old woman with terminal metastatic ovarian cancer
presents with a 2-day history of nausea and vomiting. She has
been unable to tolerate any oral intake and has not had a bowel
movement in 4 days.

The patient is reluctant to undergo further invasive procedures
or hospitalization.

Medications are acetaminophen with codeine as needed and
docusate sodium stool softener every morning.

The patient appears uncomfortable. No fever, BP 98/60, pulse
105, tachycardia. Abdomen is markedly distended with
decreased bowel sounds, tympany on percussion, diffuse
tenderness on palpation. Rectal exam is normal.
CASE 3 (2 of 3)
In
addition to providing the patient with
morphine, which of the following is the
most appropriate management strategy?

(A) Diverting colostomy

(B) Nasogastric suctioning

(C) Octreotide

(D) Atropine

(E) Ondansetron
CASE 3 (3 of 3)
In
addition to providing the patient with
morphine, which of the following is the
most appropriate management strategy?

(A) Diverting colostomy

(B) Nasogastric suctioning

(C) Octreotide

(D) Atropine

(E) Ondansetron
SUMMARY




The goal of palliative care is to relieve suffering
and assist patients with serious illness and their
families with medical decision making
Advance directives are an important way to
facilitate this and are viewed as an important
quality indicator
Learning to communicate these issues in key
Palliative care also encompasses a wide realm of
symptom management, as well as support
surrounding psychosocial and spiritual issues
REFERENCES







AGS Panel on Persistent Pain in Older Persons, “ The Management of
Persistent Pain in Older Persons,” Journal of the American Geriatrics Society,
June 2002, Vol. 50, No.6 supplement
Finucane, Christmas, and Travis, “Tube Feeding in Patients with Advanced
Dementia: A Review of the Evidence,” JAMA, Oct. 13, 1999, Vol. 282, No. 14
Ganzini et al, “Ten Myths about Decision-Making Capacity,” Journal of the
American Medical Directors Association, May/ June 2005
Tulsky, “Beyond Advance Directives: Importance of Communications Skills at
the End of Life,” JAMA, July 20,2005, Vol. 294, No. 3
Ross and Alexander, “Management of Common Symptoms of Terminally Ill
Patients: Part I,” American Family Physician, Sept. 1, 2001, Vol. 64, No. 5
Ross and Alexander, “Management of Common Symptoms of Terminally Ill
Patients: Part II,” American Family Physician, Sept. 15, 2001, Vol. 64, No. 6
http://aspe.hhs.gov/daltcp/reports/impquesa.htm
(Click to Appendix C for prognosis guidelines)
ADDITIONAL REFERENCES




“Health Care Decision Making Web Module for
Medical Students.” Developed by Dr. Christine
Hayward, Carla Herman. University of New
Mexico School of Medicine. Funded by Donald
W. Reynolds Foundation, John A Hartford
Foundation. Web-based, self directed learning
module
EPEC Participant’s Handbook 1999
Geriatric Review Syllabus 6 teaching slides
Kinzbrunner, “The Medicare Hospice Benefit,”
AAHPM Bulletin Spring 2001,Vol. 1, No. 3
Acknowledgements

Dr. Karin Porter-Williamson, Medical Director of the
Palliative Care team at the University of Kansas
Medical Center

For GRS sixth edition teaching slides:
Co-Editors: Karen Blackstone, MD & Elizabeth L. Cobbs, MD
GRS6 Chapter Authors:
Sean Morrison, MD
Stacie T. Pinderhughes, MD & R.
GRS6 Question Writers:
Susan Charette, MD
Medical Writer:
Barbara B. Reitt, PhD, ELS (D)
Managing Editor:
Andrea N. Sherman, MS
© American Geriatrics Society