Palliative Care

1. In all patients with terminal illnesses (e.g., end-stage congestive heart failure or renal disease), use the principles of palliative care to address symptoms (i.e.., do not limit the use of palliative care to cancer patients).

2. In patients requiring palliative care, provide support through self, other related disciplines, or community agencies, depending on patient needs (i.e.., use a team approach when necessary).

3. In patients approaching the end of life:

   1. Identify the individual issues important to the patient, including physical issues (e.g., dyspnea, pain, constipation, nausea), emotional issues, social issues (e.g., guardianship, wills, finances), and spiritual issues.

   2. Attempt to address the issues identified as important to the patient.

4. In patients with pain, manage it (e.g., adjust dosages, change analgesics) proactively through:

• • frequent reassessments.

  • monitoring of drug side effects (e.g., nausea, constipation, cognitive impairment).

5. In patients diagnosed with a terminal illness, identify and repeatedly clarify wishes about end-of-life issues (e.g., wishes for treatment of infections, intubation, dying at home)

Principles of Palliative Care

• Affirms life and regards dying as a normal process

• Neither hastens nor postpones death

• Provides relief from pain and other distressing symptoms

• Integrates the spiritual, cultural, psychosocial aspects of care

  • Ask patients about meaning of symptom/burden

• Patient, family, caregivers are treated with dignity and respect

• Patient, family, caregivers are supported in bereavement

• Offers a support system to help patients live as actively as possible until death

• Offers a support system to help patients' families cope during the patient's illness and in their own bereavement

Support

• Multidisciplinary / Team approach

  • Self

  • Family/friends

  • Other disciplines (Social worker, Nurse, Pharmacist, OT/PT, Spiritual Care, Music therapist, Psychologist, Wound care, Pet therapy, Aroma therapy)

  • Community agencies

Emergencies

Massive Hemorrhage

• Anticipation (head and neck tumors - carotid, lung, GI, hematological)

• Prepare the entourage

• Major distress order (see below)

• Cover with dark blankets/towels

• Consider tranexamic acid

See Cancer* (Spinal cord compression, SVC obstruction, hypercalcemia, pericardial tamponade, tumor lysis syndrome), Seizures, Opioid Toxicity (below)

Common Symptoms

Assess symptoms with Edmonton Symptom Assessment System (ESAS)

Dyspnea

• Position (turn, sit up, elevate head of bed)

• Air circulation (fan), oxygen PRN

• Manage cough, secretions, anxiety (relaxation therapy)

• Opioids (eg. morphine 1mg PO), benzodiazepines, bronchodilators

Pain

• Total Pain (physical, psychological, social, spiritual)

• Risk factors for difficult pain control

  • Rapid titration of opioids

  • Addiction or chemical coping

  • Psychiatric

    • Treatment: Relaxation, hypnosis

  • Incidental

  • Delirium

  • Neuropathic pain (DN4)

    • Treatment: Gabapentinoids, TCA, SNRI, opioids, cannabinoids, methadone

      • Topical lidocaine, capsaicin

• Non-Pharmacological

  • Massage / Physical therapy

  • Pet therapy

  • Acupuncture

  • Relaxation / Hypnotherapy

  • Aromatherapy / Music therapy

  • Heat/Cold

• Opioids (eg. morphine liquid or subcutaneously)

  • Opioid risk tool

  • Explain onset (eg. 30 mins), peak (eg. 1h), and duration (eg. 4h)

    • Consider breakthrough ~50% of q4h dose (or 10% of total daily dose)

  • Side effects (constipation [no tolerance], nausea, sedation, urinary retention, neurotoxicity)

    • Neurotoxicity (increased opioids, no improvement, hyperesthesia or hyperalgesia, tactile hallucinations, allodynia, myoclonus, seizures, delirium)

    • Consider rotation -25%, if toxicity -50%

  • Fentanyl patch (Fentanyl transdermal = 200:1 morphine PO)

    • Half-dose if cover skin with tegaderm underneath (do not cut)

    • 12h before onset and 12h coverage after removal

    • Consider inhaled ICS sprayed on patch for irritation

• Adjuvant: Acetaminophen, NSAIDs, steroids, bisphophonates, cannabinoids

• Interventional techniques (nerve block)

• Frequent reassessments

Constipation

• Scheduled toileting, sitting position

• Exercise/mobility

• Hydration

• Laxatives

  • Osmotic (PEG)

  • Stimulant (senna, bisacodyl)

  • Surfactant/Lubricating (docusate, glycerine suppository)

• Warm water enema

Diarrhea

• Rehydration, electrolyte correction

• Hold laxatives

• Consider psyllium, loperamide, opioid

Nausea/Vomiting

• Treat reversible causes

  • Severe pain, Cough, Infection, Hypercalcemia, Tense ascites, Raised ICP, Anxiety

  • Drug-induced or metabolic

    • Treatment: Opioid rotation, haloperidol, metoclopramide, cyclizine, hyoscine hydrobromide, ondansetron

  • Constipation / Intestinal obstruction

  • Gastritis

  • Oral candidiasis

• Non-pharmacological management

  • Cut out intolerant foods

  • Control malodour

  • Restrict intake (sips, ice chips, then gradually fluids to solids)

  • Small frequent meals

  • Cool fizzy drinks

  • Avoid lying flat after eating

  • Acupuncture/acupressure, ginger, relaxation, hypnosis, music therapy

• Pharmacological

  • Prokinetic (metoclopramide)

  • 5HT3 antagonists (ondansetron)

  • Antihistamine (dimenhydramine)

  • Anticholinergics (scopolamine)

  • Antipsychotics (Haloperidol 0.5mg SC q6-8h PRN, chlorpromazine, olanzapine)

  • Cannabinoids

Anorexia/Cachexia

• Rule out contributing causes (N/V, anxiety, pain, stool)

• Encourage favorite foods

• Small frequent meals

• Medical management:

  • Steroids (eg. dexamethasone 4mg PO BID at breakfast, and lunch), rapid onset but short-lasting (weeks)

  • Progesterone (megestrol acetate), slow-onset 2-3 weeks for effect

  • Prokinetic (metoclopramide) if early satiety

  • Mirtazapine

Asthenia/Fatigue

• Coordinate activities/help

• Change medications

• Sleep

• Medical management: Steroids. Methamphetamines (eg. methylphenidate 2.5mg PO qAM, q noon, titrate up)

Noisy respiratory secretions

• Turn head to side

• Avoid deep suctioning

• Medical management

  • Glycopyrrolate 0.2-0.4mg SC q4h PRN

  • Scopolamine if unconscious 0.4-0.6mg SC q4h PRN

    • Scopolamine patch

  • Atropine ophthalmic drops 1-3 drops SL q2-4h

Confusion/delirium

• Haloperidol 1-2mg sc q2h PRN

• Methotrimeprazine 2.5mg sc q4h PRN

• Midazolam 1mg sc q1h PRN

Other: Insomnia, Hiccups

Emotional

• Depression

  • Psychotherapy

  • Methylphenidate in short-term

  • Consider SSRI if >4w

• Anxiety

  • Hypnosis

  • Benzodiazepines (lorazepam 1mg SL/SC q6h PRN)

Social

• Guardianship

• Wills

• Finances

Spiritual

• Personal values

  • "Are spirituality or religion important in your life?"

  • "Are you at peace?"

• Relationships

• Meaning of life/death

  • "Why me?"

  • "What's after death?"

Advance Care Planning and Goals of Care

• Breaking Bad News

• Prognostication PPS

• Hopes and Fears

• Mandate

• Goals of Care

  • Treatments, resuscitation (CPR, intubation, ICU), antibiotics, PEG/NG feeding, palliative sedation

• Home vs. hospital vs. hospice

• Medical Aid in Dying

End of Life

• Prepare family for end of life

  • Progressive unresponsiveness

  • Purposeless movements, facial expressions

  • Noisy breathing

  • Possible acute events and action plan (seizure, stroke)

• Four things that matter most

  • “Please forgive me,” “I forgive you,” “Thank you,” and “I love you”

• Major distress order

  • Midazolam 5-10mg sc q10 mins PRN x3

  • Opioid 3-4 x breakthrough q30mins PRN x2

Pronouncement of Death

• Confirm and Document

  • Check ID bracelet

  • No spontaneous respiration

  • No response to tactile stimulation and pain (pressure on nailbed)

  • Absent breath sounds, heart sounds

  • Absent carotid pulse

  • Fixed pupils, non-reactive to light

  • Time of death

• Notify family if not present