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PALLIATIVE CARE Pat Borman, MD Advanced Training in Geriatrics

PALLIATIVE CARE Pat Borman, MD Advanced Training in Geriatrics. We cure seldom palliate often and comfort always 16th Century Anonymous. PALLIATIVE CARE. Treatment of Patient and Involved Caregivers Focus on the End of Life Kalos Thanatos

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PALLIATIVE CARE Pat Borman, MD Advanced Training in Geriatrics

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  1. PALLIATIVE CARE Pat Borman, MDAdvanced Training in Geriatrics We cure seldom palliate often and comfort always 16th Century Anonymous

  2. PALLIATIVE CARE Treatment of Patient and Involved Caregivers Focus on the End of Life Kalos Thanatos Relieve Total Burden of Suffering • Physical Suffering • Psychological Suffering • Spiritual Suffering

  3. Physical Suffering Symptoms Function Safety Hydration Nutrition

  4. Psychological Suffering Emotion Cognition Mood Coping Responses Fears Lost Dreams

  5. Spiritual Suffering Spirituality Meaning of life and death Religion Impact of actual and anticipated losses

  6. Practical Matters Legal Financial Living Situation Caregivers Care of Dependents Domestic Needs

  7. Palliative Care: Initial Steps Assess patient/caregiver knowledge, understanding of disease and prognosis • Establish lines of communication • Develop terms that match knowledge level of the family • Determine decision making structures

  8. Palliative Care : Initial Steps Assess Coping Strategies • Physical Concerns • Economic Concerns • Family and Patient Concerns • Social Network of Support for patient and caregivers

  9. Palliative Care: Initial Steps Assess spiritual and cultural beliefs • Patient and family knowledge of death • Prior experiences with death • Role of death in family and cultural context • Religious Beliefs • Specific Practices

  10. Symptom Relief Pain Management • Acute, Subacute, Chronic • Look for the Cause • Assess frequently • Step Approach

  11. Pain Relief Neuropathic Pain • TCAD, Anticonvulsants, topicals, Baclofen Inflammatory Pain • Steroids, NSAIDS use cautiously, opioids Bone Metastasis • Pamidronate, Calicitonin, opioids Muscle Spasms • Baclofen, Benzodiazepines

  12. Persistent Pain Step I • Acetaminophen up to 4 gm/day, • ASA up to 4 gm/d • NSAID use cautiously for persistent pain Step II • Tramadol 50 mg max 8 tabs divided q 6h • T#3 max 12 tabs divided q 4-6 h • Oxycodone 5 mg max 12 tabs divided q 6h • Morphine 5 mg no maximum dose q 4 hour

  13. Persistent Pain Step III • Calculate 24 h opioid need and convert to long acting bid form • Use short acting for breakthrough • Barriers to maximal pain relief from doctors and patients • Ethical precedent for using as much as needed to alleviate suffering

  14. Persistent Pain MSContin • 15, 30, 60, 100, 200mg OxyContin • 10, 20, 40, 80mg Hydromorphone • 1, 2, 3, 4, 8mg Methadone • 5,10,40mg Fentanyl • 25, 50, 75, 100 microgram patch

  15. Nausea and Vomiting Match cause of nausea to treatment • Increased ICP Dexamethasone • Vestibular Antihistamines • Chemoreceptor Dopamine Antagonist • Gastric Irritation Feeds, stop NSAIDS • Gut Motility Metaclopromide • Ascites Diuretics • Pain or anxiety Treat accordingly

  16. Dyspnea Physical and/or psychological • Morphine • Oxygen • Fan in Room, Fresh Air • Secretions Control with anticholinergics and suctioning • Address fears, anxiety, spiritual needs • Relaxation, distraction,

  17. Anxiety Sources include fear, pain, psychological and spiritual distress • Anxiolytics • Human Contact • Address fears • Setting affairs into order

  18. Agitation Target behavior and seek causes if possible Decrease external stimuli Use Music, Prayer Agitation as a form of communication As part of delirium very near end of life Haldol, Anxiolytics

  19. Delirium Safety Orientation and Human Contact Permission to go Anxiolytics, antipsycholtics

  20. Bowel and Bladder Combat constipation of narcotics, avoid impaction Careful skin care, positioning If diarrhea use anticholinergics Scheduled voids if strong enough, disposable pads, Foley? Manage odors with Kitty Litter, Charcol

  21. Nutrition and Hydration Sips, Chips, mouth care Anorexia/Cachexia • Consider steroids, TCAD, Megace, Cannabinoids, Remeron, Artificial Assistance • Values Based Decisions • Delays the inevitable • Consider limited trial and withdrawal if no evident benefit

  22. Fatigue Somulence, activity intolerance and fatigue tend to increase Educate patient and caregivers not to push too hard Short visits, brief activities, frequent naps Central Stimulants?

  23. Skin Care and Pruritis Pruritis • Consider xerosis, uremia, hypercalcemia, medication side effects, delirium Hygiene and positioning Lotions Cool moist compresses Antihistamines

  24. Bereavement Anticipatory grief Early Loss of Personhood in Dementia Individualized Support Interventions if protracted, interfering with starting to live again

  25. References • American Geriatrics Society 2002 Guidelines for Management of Persistent Pain. • Galanos MA: Long Term Care in Geriatrics Palliative Care; Clinics in Family Practice Sept 2001;3(3) 683. • Melvin TA: The Primary Care Physician in Palliative Care: Primary Care June 2001;28(2):239-49. • Bernat JL: Ethical and Legal Issues in Palliative Care: Neuro Clin Nov 2001; 19(4):969-87. • J Am Oseopath Assoc; Oct 2001 issue devoted to Palliative Care. • Steel K: Annotated Bibliography of Palliative Care and End of Life Issues; J Am Ger Soc Mar 2000;48(3)325-32.

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