Which of the following is not documented in the Physician Orders for Life-Sustaining Treatment Paradigm (POLST) form? A) Instructions for resuscitation B) Types of medical interventions desired C) Designation of durable power of attorney for health care D) Use of artificial nutrition and hydration
Answer • C) Designation of durable power of attorney for health care
Choose the correct criteria for eligibility for hospice care in a patient with dementia.Lack of meaningful verbal communication (6 or fewer words)Hospitalization for pneumonia, pyelonephritis, sepsis, or other serious complications in previous 6 moPresence of stage 3 or 4 pressure ulcersWeight loss of ≥5% in previous 6 moTotal dependence for activities of daily living A) 1,2,3,4 B) 1,3,4,5 C) 2,3,4,5 D) 1,2,3,5
Answer • Lack of meaningful verbal communication (6 or fewer words) • Hospitalization for pneumonia, pyelonephritis, sepsis, or other serious complications in previous 6 mo • Presence of stage 3 or 4 pressure ulcers 5. Total dependence for activities of daily living • D) 1,2,3,5
Appetite stimulants may increase ________ in patients undergoing palliative care. A) Enjoyment of eating B) Lean body mass C) Longevity D) A, B, and C
Answer • A) Enjoyment of eating
Choose the correct statement about the benefits of artificial hydration and nutrition (AHN). A) AHN can relieve dry mouth B) Percutaneous endoscopic gastrostomy (PEG) tubes and total parenteral nutrition increase patient comfort C) AHN may cause dyspnea from pulmonary edema D) PEG tubes help prevent pneumonia from aspiration
Answer • C) AHN may cause dyspnea from pulmonary edema
Constipation is the only side effect of treatment with opioids for which the patient does not develop tolerance. A) True B) False
Answer • A) True
Which of the following is notuseful for the treatment of nausea and vomiting induced by administration of opioids in the absence of motility and distention problems? A) Haloperidol B) Diphenhydramine C) Scopolamine D) Metoclopramide
Answer • D) Metoclopramide
Both glycopyrrolate and scopolamine cross the blood-brain barrier and may cause changes in mental status. A) True B) False
Answer • B) False
Approximately ________ of patients at end of life suffer from cough. A) 10% B) 25% C) 40% D) 60%
Answer • C) 40%
Unlike ________ for treatment of opioid induced constipation, ________ does not cause opioid withdrawal and reversal of analgesia. A) Oral naloxone; methylnaltrexone B) Methylnaltrexone; oral naloxone
Answer • A) Oral naloxone; methylnaltrexone
Which of the following statements about methylphenidate for the treatment of depression in patients with terminal illness is(are) correct? A) It is the fastest acting antidepressant B) It is well tolerated in geriatric population C) A and B D) None of the above
Answer • C) A and B
An 80-year-old patient is on high doses of morphine to control pain and dyspnea at the end of life. Which one of the following medications is appropriate for constipation caused by opioids? A. Corticosteroids. B. Naloxone (formerly Narcan). C. Ketamine (Ketalar). D. Polyethylene glycol solution (Miralax).
Answer • D. Polyethylene glycol solution (Miralax).
A 78-year-old woman with terminal breast cancer has been vomiting. She complains of feeling anxious and fearful about her rapid decline in function. Which of the following antiemetic medications is/are most appropriate? A. Benzodiazepines. B. Cannabinoids. C. Antihistamines. D. Dexamethasone.
Answer • A. Benzodiazepines. B. Cannabinoids.
An 85-year-old man with severe pneumonia is rapidly declining and is not responding to antibiotics. Which of the following actions can help prevent delirium? A. Keeping familiar persons at the bedside. B. Limiting medication changes. C. Limiting unnecessary catheterization. D. Using wrist restraints.
Answer • A. Keeping familiar persons at the bedside. B. Limiting medication changes. C. Limiting unnecessary catheterization.
What should the dose of the pain medication be for breakthrough pain? What % of the 24 hour dose q 1 hour?
Answer • 10 to 20%
PALLIATIVE AND END-OF-LIFE CARE • Approach to discussion: study of interaction between hope and desire for prognostic information among 55 patients with terminal disease; • 4 patterns—feelings swing between totally hopeful and completely discouraged (amount of information desired depended on stage) • scales and balance (hopeful but realistic • wanted information but not too much) • yin-yang (hope and bad news coexisted) • Redirected hope (from hope for cure to other things, eg, survive to certain date) • ask all patients how much information they want
Advance directive • Five Wishes form—includes designation of durable power of attorney (DPOA) for health care • Type of medical treatment desired • degree of comfort desired • desired treatment • level of information shared with loved ones • does not direct paramedics about wishes regarding code • Physician Orders for Life-Sustaining Treatment Paradigm (POLST) form • provides instructions for resuscitation • types of medical interventions • use of antibiotics • artificial nutrition and hydration • does not designate DPOA • living will registry—available in Washington • patient sends copy of documents to central database and receives card to carry in wallet
The Five Wishes Wishes 1 and 2 are both legal documents. Once signed, they meet the legal requirements for an advance directive in the states listed below. Wishes 3, 4 and 5 are unique to Five Wishes, in that they address matters of comfort care, spirituality, forgiveness, and final wishes. Wish 1: The Person I Want to Make Care Decisions for Me When I Can't This section is an assignment of a health care agent (also called proxy, surrogate, representative or health care power of attorney). This person makes medical decisions on your behalf if you are unable to speak for yourself. Wish 2: The Kind of Medical Treatment I Want or Don't Want This section is a living will--a definition of what life support treatment means to you, and when you would and would not want it. Wish 3: How Comfortable I Want to Be This section addresses matters of comfort care--what type of pain management you would like, personal grooming and bathing instructions, and whether you would like to know about options for hospice care, among others. Wish 4: How I Want People to Treat Me This section speaks to personal matters, such as whether you would like to be at home, whether you would like someone to pray at your bedside, among others. Wish 5: What I Want My Loved Ones to Know This section deals with matters of forgiveness, how you wish to be remembered and final wishes regarding funeral or memorial plans. Signing and Witnessing Requirements The last portion of the document contains a section for signing the document and having it witnessed. Some states require notarization, and are so indicated in the document.
Discussing palliative care with patients • Timing • at time of diagnosis of life-limiting disease • if physician expects patient’s death in next 6 to 12 mo • if patient has frequent hospital admissions • if chronic disease progresses • if patient with chronic untreatable disease presents with lifethreatening event that could allow natural death • set safe context for discussion • open with questions about patient’s goals for their experience • questions—identify stakeholders • ask about patient’s understanding of situation • sources of strength, • Hopes • Fears • past experiences with serious illness • keys to successful discussion • allowing patient and family time to speak increases patient satisfaction and helps reduce anxiety, posttraumatic stress disorder (PTSD), and depression among family members • Try to aim for 66/34 with patient family 66% of talking
Hospice eligibility for patients with dementia • criteria include • total dependency for activities of daily living (ADLs) • lack of meaningful verbal communication (6 or fewer words) • hospitalization for pneumonia, pyelonephritis, sepsis, or other serious complication in previous 6 mo • stage 3 or 4 pressure ulcers • loss of 10% of body weight in previous 6 mo • patient must have any 3
Benefits of hospice: • nurse on-call 24 hr/day • skilled hospice certified nursing assistant (CNA) • spiritual support • Comprehensive emotional and grief support, with special programs for children • hospice volunteers
Anorexia • obtain history and laboratory or radiographic data (if appropriate), and perform physical examination to seek cause • if possible, treat underlying cause (eg, reflux, constipation) • appetite stimulants—options • alcohol, • Steroids • Megestrol • delta-9-tetrahydrocannabinol, • Androgens • do not increase lean body mass or longevity • may provide patients with enjoyment of eating • Artificial hydration and nutrition (AHN) • ask about patient’s goals • during nutritional deficiency • central nervous system endorphins may cause mild euphoria • intravenous (IV) fluids do not relieve dry mouth • Percutaneous endoscopic gastrostomy (PEG) tubes and total parenteral nutrition (TPN) do not prolong life • may increase suffering (eg, dyspnea from pulmonary edema or ascites • pneumonia from aspiration • discomfort from tube or IV • possible need for restraints in patients with dementia, loose stools) • appropriate for patients with malignancies of head and neck or upper gastrointestinal tract who are having definitive surgery or receiving radiation or chemotherapy • selected ambulatory patients (eg, • patients with HIV) • patients with amyotrophic lateral sclerosis (ALS) • for patients with dementia, tube feeding does not prolong survival, prevent aspiration, Improve pressure ulcers, improve function, or give comfort
Anorexia • Study results • not randomized • median survival of 59 days among 23 patients who received PEG • 60 days among 18 patients who did not • Family concerns: encourage alternative activities to show care for patient • in case of conflicting wishes, perform therapeutic trial of feeding tube for specific time (eg, 3 days) • Reassess • continue only if pre-agreed goals met
Questions and answers • Letter of condolence: difficult but appreciated by family • Questions and answers: why does POLST form have full resuscitation option? • allows patient to specify wishes for other measures, eg, AHN • also, documentation of wish for resuscitation on POLST form indicates that patient has discussed their wishes for this option • can duration of hospice exceed 6 mo? • yes; most groups follow Medicare guidelines, which require that attending physician expects patient’s death within 6 mo • patient’s condition re-evaluated at 90 days after admission and every 60 days thereafter • patient may remain in hospice as long as expectation of death within 6 mo remains after these evaluations • some insurance companies pay only for specific period • many hospices provide charity care afterwards • do gastroenterologists believe that PEG tubes prevent aspiration? • literature does not support conclusion that PEG tubes that end in stomach prevent aspiration • Tubes that terminate in jejunum may prevent aspiration
Letter of condolence • The benefit of writing a letter of condolence as twofold: to be a source of comfort to the survivors and to help clinicians achieve a sense of closure about the death of their patient. In the sidebar on the previous page, Dr Mark Geliebter, Martinez, CA, describes how he began writing letters of condolence to his patients and the value this practice has had for him. • If you decide that writing a letter of condolence is a practice you would like to begin incorporating into your medical practice, the following guidelines, adapted from Wolfson and Menkin's "Writing a condolence letter,"3 may be helpful. • Address the family member. Dear Mrs Wagner, ... • Acknowledge the loss and name the deceased. Dr Murphy and I were deeply saddened today when we learned from your hospice nurse Lois that your mother, Ruth Smith, had died. • Express your sympathy. We are thinking of you and send our heartfelt condolences. • Note special qualities of the deceased. It seems like only yesterday that Ruth talked about her love of card playing. I admired her energy and quick wit. • Note special qualities of the family member. I was deeply moved by the devotion you and your family showed during the period of Ruth's final illness. Your concern was one indication of your love for her. Although she was a fiercely independent woman, I know she appreciated your involvement and help. • End with a word or phrase of sympathy. With affection and deep sympathy, we hope that your fond memories of Ruth will give you comfort.
Doctors and Sympathy CardsBy Mark Geliebter, MD • As soon as the Code Blue ends in the emergency department all of the housestaff scatter. During my training, I was always struck by how quickly the doctors would leave the scene as soon as the patient was pronounced dead. There was no lingering--as if no one wanted to stay in the room with the dead person. The strategy seemed to be to create physical distance from any associated feelings of failure as a doctor. There was no ritual to follow at the end of an unsuccessful resuscitation effort. There was never any discussion about the ritual of death. We would spend weeks and weeks discussing the Krebs molecular "life cycle" in medical school. However, discussions about the natural cycle of life and death were rare. After practicing internal medicine for many years at Martinez, CA, I was struck by my own lack of closure when my patients died. I too would not hover at the bedside when a patient of mine had died. I would not routinely connect with family members after a death. Many years ago, I became involved in physician wellness efforts at my facility and regionally. I realized that exploring our own relationship with death and dying was a key element in physician well-being. • One of the outcomes of that exploration was the decision to start a new practice for myself in 1995. I began to list the name of every patient of mine who died. I generally would include a diagnosis, medical record number, date and place of death. I started a folder labeled "Death and Dying." I also began to send a sympathy card to each family (I later found these cards available as a KP stock item!). • Initially, I began with brief statements of sympathy. More recently, I've been writing more personal comments, especially when I've had a longer relationship with the person or their family. I frequently mention that I felt privileged to have been their physician. I also try to call the families that I feel connected to. I have received frequent positive feedback from families for my personal note or call. They are most appreciative of my thoughtful acknowledgments. • This has created a ritual practice for myself at the time of a patient's death. It also gives me a way to remember my patients. When I review my list, I can usually remember something about them, their faces, their personalities, or some ethical or medical issues that may have been challenging. Even after many years, the list elicits those memories. I would have totally forgotten many patients that had died if it weren't for my list. At times, it reminds me of memorial plaques on some synagogue or other walls that list names of members or their families who have died. Sending the sympathy card and making the follow-up phone calls have become part of my own sense of responsibility as a physician. It helps obviate the need to run out of the room after an unsuccessful Code Blue, as I did when a medical student. Integrating the reality of death; embracing it as a natural process; developing coping strategies; not labeling death as failure; finding rituals; doing outreach during and after the dying process are all part of our role as physicians. All of these insights and rituals will add to our own personal wisdom of dealing with the inevitability of our patients' and our own deaths.
Example Condolence Letter • Below is an example of a condolence letter using the seven components above: • Dear_____________,1. Acknowledge the loss, refer to deceased by name.I was deeply saddened to hear about the death of _____________. • 2. Express your sympathy.I know how difficult this must be for you. You are in my thoughts and prayers. • 3. Note special qualities of the deceased.____________was such a kind, gentle soul. She would do anything to help someone in need. • 4. Include your favorite memory.I remember one time_________________. • 5. Remind the bereaved of their personal strengths and qualities.I know how much you will miss_______________. I encourage you to draw on your strength and the strength of your family. You could use your special talent of scrapbooking to make a lasting memory book of _________________. • 6. Offer specific help.I can come over on Tuesday evenings to help you make your scrapbook. I have some lovely pictures of _______________ I’d love to share. • 7. End the letter with a thoughtful closing.May God bless you and your family during this time and always, • Sign your name_____________________ • Keep in mind that this is only an example. Write from your heart and whatever elements you include will be the right ones. • The next page includes information on writing a shorter version of the condolence letter: The Condolence Note.
Condolence note • You may decide to write a shorter version of a condolence letter on note card or on a small piece of stationary tucked inside a commercial card. If I am close enough to the deceased to have photos of them, I especially like to print one of my favorite photos on a card. That can be done from your computer or from a picture program in your local photo developing shop. • When writing a condolence note, pick just a few elements from the example on the first page of this article. Using components #1, 2, 3, and 7 is a good guide. • Acknowledge the loss and refer to the deceased by name. • Express your sympathy. • Note any special qualities of the deceased that come to mind. • End the letter with a thoughtful word, a hope, a wish, or expression of sympathy e.g. "You are in my thoughts" or “Wishing you God’s peace.” Closing such as "Sincerely," "love," or "fondly," aren’t quite as personal. • Remember that this is just a guide. You can use any of the components of a condolence letter in your note or none at all. The most important thing is to write from your heart
A letter by Abraham Lincoln • Archival communications abound with outstanding examples of fine letters of condolence. A letter by Abraham Lincoln to a girl whose father had died in the Civil War showed several of the qualities outlined above8:It is with deep grief that I learn of the death of your kind and brave Father; and especially that it is affecting your young heart beyond what is common in such cases. In this sad world of ours, sorrow comes to all; and, to the young it comes with bitterest agony, because it takes them unawares. The older have learned ever to expect it. • Note that Lincoln uses the word death directly and describes her father as kind and brave. Years later, one can only imagine how this woman might cherish such kind and comforting words from our sixteenth President.
A Dying Art?The Doctor’s Letter of CondolenceGregory C. Kane, MD, FCCP • In their commentary on writing letters of condolence, Bedell et al5 outlined why doctors do not regularly write letters of condolence. Potential explanations included a lack of time, a loss for the appropriate expression of sympathy, a feeling that they did not know the patient well enough, lack of a specific team member responsible for writing the letter, or a sense of failure over the death. No doubt, this has been fostered by a lack of role modeling or broader discussion of such practices. • In a personal and memorable patient encounter, I sat and listened while a tearful patient cried at having received no contact from the physician who treated her husband for metastatic lung cancer for a treatment duration of 9 months. As I struggled to comprehend her sense of pain and abandonment, I considered offering as possible explanation that the physician may not have been “on call” at the time of the death and may have mistakenly believed that his partner had offered such a gesture verbally. Before I could respond, however, my patient added that her veterinarian had sent a card when the family dog died. I was speechless. • Other physicians have shared similar experiences, sometimes involving family members, friends, or mutual patients. In his convocation speech on becoming President of the American College of Chest Physicians in 2003, Dr. Richard Irwin described a vision for patient-centered care. His vision was comprehensive but also included a discussion of sympathy cards after the death of a patient. He noted, “when physicians do not acknowledge the deaths of their patients, it is perceived that physicians are silently saying that the deceased patient was not important.
Nausea and vomiting (NV) • consider possible causes • Opioids: act on chemotactic trigger zone (rich in dopaminergic receptors) and on vestibular system (may manifest after changing position) • data unclear whether NV side effects similar for all opioids • patients eventually become tolerant • constipation only side effect of opioids for which no tolerance develops • if NV mild, continue drug until tolerance develops • if NV severe, rotate to other opioids • Antiemetics haloperidol, scopolamine (anticholinergic) or promethazine (Phenergan); antihistamine diphenhydramine (Benadryl) also works well • 5HT3 antagonists (eg, ondansetron) not generally helpful for managing opioid-mediated NV • Haloperidol most potent antidopaminergic, followed by prochlorperazine • promethazine has minimal antidopaminergic properties • metoclopramide (Reglan) binds few receptors relevant to NV • useful only for problems with motility and distention
Bowel obstruction • most often associated with pelvic cancer, especially ovarian and colon • symptoms include NV and cramping abdominal pain • treatments surgical, interventional, and medical • usually possible to avoid IV and nasogastric tube • Surgical treatment: includes venting gastrostomy tubes for small bowel obstructions but not for colonic obstructions • Drug therapy: cocktail of opioids, anticholinergic agent, and somatostatin (octreotide) • opioids—help relieve pain; evidence suggests they do not increase risk for paralytic ileus • dopamine antagonist—eg, haloperidol; much lower dose (ie, 0.5 to 2 mg every 4-6 hr) of haloperidol required than for psychosis (5 to 10 mg) • spasms; agents include glycopyrrolate or scopolamine • glycopyrrolate administered IV or PO) and does not cross blood-brain barrier or cause changes in mental status • scopolamine administered by patch and crosses blood-brain barrier • consider prokinetic drugs for partial small bowel obstruction and discontinue if pain increases • octreotide—inhibits splanchnic blood flow and decreases secretions from intestinal mucosa to diminish distention • administered IV or subcutaneously • Effective dose usually <400 g/day