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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2866_Библиотеки_им_академика_М_И_Перельмана.pdf
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T. N. Goring and I. L. Nelson
• Patient, family, or physician uncertainty re: prognosis or
goals of care.
• Patient or family requests for futile care.
• DNR order conflicts.
• Use of artificial nutrition in seriously ill patients.
• Limited social support and a serious illness (e.g., homeless,
chronic mental illness).
• Patient or family psychological or spiritual distress.
Starting theConversation/Important
Documents
Patients with whom you want to discuss advanced care planning need to want to discuss it too—the first step in starting
the conversation is to assess your patient’s willingness to have
it. Visits arranged for the purpose of advanced care planning
are covered by Medicare. Your goal in these conversations is
to guide your patient in deciding what their goals of care are.
For example, do they want to avoid going to the hospital,
even if this means forgoing aggressive treatment that might
be life prolonging? How much discomfort are they willing to
tolerate? How involved do they want their families to be?
Are there things they want to accomplish or events (graduations, weddings) they want to attend before they die? If they
are from another country, do they want to spend the last part
of their life there?
Each conversation will be different because, at heart, you
are asking about your patient’s most deeply held beliefs
about the meaning of life and death, their role in their community, and the role of spirituality in their lives. When your
patient is from another country, cultural differences will
exist—talk of death, for example, may be unacceptable; when
they are African American, they may have a lack of trust in
the medical system that will influence their decisions about
code status [5]. Cultural competency, the umbrella term for
Chapter 5. Care at the End of Life: Palliative…
125
these different ways of looking at care, is a huge subject and
well beyond the scope of this chapter. However, if you try to
understand your patient’s perspective on their illness, and
explore what is important to them now and what their hopes
are for the future, you can work together to formulate goals
of care.
Here are some initial considerations:
• Avoid medical terminology.
• Listen more than talk. Allow periods of silence.
• Respond to cues.
• Understand that patients almost always know how sick
they are and that talking about it may be a relief.
• Make medical recommendations—remember, it’s the fam-
ily/patient’s job to define their goals and your job to
describe how their goals can be achieved.
• Make sure your patient knows that you will continue to
care for them, no matter their decisions.
A useful structure for these conversations is the SPIKES
protocol, which was developed by oncologist Robert Buckman
in the late 1990s [6]. While its original intent was to help
oncologists deliver bad news to their patients, it is equally
applicable to conversations introducing palliative or hospice
care. SPIKES is an acronym:
S for setting: It should be quiet, calm, and comfortable.
Important family members, friends, and possibly clergy
should be invited.
P for perception: What does your patient think about their
health?
I for invitation: Ask your patient how much they want to
know about their disease and its probable course.
K for knowledge: Give you patient warning that you are
going to bring up some tough issues.
E for empathy: Respond to your patient’s reaction.
S for strategy: End every conversation with a plan for the
future, even if it’s a plan for another conversation.
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T. N. Goring and I. L. Nelson
There are a number of legal and medical documents used
in advanced care planning. The two most important are as
follows:
• Health care proxy (HCP)—a form signed by the patient
that names an alternate decision-maker if they are ren-
dered incapable.
• MOLST (Medical Orders for Life-Sustaining Treatment)
Form—a more specific set of medical orders, signed by a
physician, detailing code status and level of medical
interventions.
Both of these documents can help your patient to think
more specifically about their goals. For example, the MOLST
form addresses artificially administered nutrition, use of antibiotics, and future hospitalizations. And assigning an HCP
will lead your patient to discuss what kind of care they want
in the future with their HCP.
It’s important not to focus too much on DNR/DNI (do not
resuscitate/do not intubate) orders. Some patients might have
firm opinions from the outset; some may not. DNR and DNI
are a small part of advanced care planning.
Patients should keep copies of both these documents with
them, especially when transitioning between different sites of
care.
Management ofCommon Symptoms
inPalliative Care
Almost all symptoms can be controlled in any setting with
medications, with or without minimally invasive options. You
will be using medications you are familiar with, but sometimes in different ways and at different doses. While it is
important to arrive at a diagnosis, the main thrust of treatment is comfort: diagnostic tests should be used judiciously,
and medications should be titrated to achieve comfort.
Chapter 5. Care at the End of Life: Palliative…
127
Shortness ofBreath
Determine whether or not the patient requires an inpatient
evaluation. Assess resting respiratory rate, pulse oximetry,
and auscultate lungs for adventitious sounds. Shortness of
breath (SOB) in a patient receiving palliative care should be
evaluated as in any patient with SOB.
Once you’ve identified the underlying cause, discuss treatment options with your patient or their surrogate. Many episodes of SOB can be relieved with measures such as low-dose
opioids, supplemental oxygen, antibiotics, diuretics, steroids,
and treatment of anxiety. All these interventions can be
administered at home, with hospice support. If more aggressive measures are required—i.e., fluid drainage—determine if
these are in alignment with your patient’s goals of care.
If intubation is on the table, tell your patient how likely it
is that they will be successfully extubated. Assure them that
you can keep them comfortable without intubation if that is
their choice. Document your conversation and make sure
their surrogate is aware.
In the actively dying patient, focus on comfort. Consider a
cooling fan for air hunger. Oxygen via nasal cannula is the standard of care, but face masks can also be used. High-flow nasal
cannula (HFNC) oxygen often cannot be administered at home,
and the patient would have to be admitted to a facility—hospital
or inpatient hospice for O2 via this modality—if that is in keeping with the patient’s goals. Opiates to treat tachypnea should be
given as an infusion or in standing doses; there is no dose ceiling
and the goal is to achieve a respiratory rate of 12 or less. Opioids
can be delivered orally, sublingually, subcutaneously, transdermally, intrathecally, or via an intravenous drip (Fig.5.3).
Constipation
Constipation is a very uncomfortable symptom and should be
managed aggressively. Opioid use, dehydration from poor
128
T. N. Goring and I. L. Nelson
Assess Respiratory Rate
Check Pulse Ox
Ascultate Lungs
Refer to CXR (if available)
ABG (if appropriate)
Check for potentially
reversoble causes:
Shortness of Breath
Consider O2 via NC
and titrate up to Pulse
Ox of 92%
If pt is actively dying:
Consider positioning,
fan, breathing training
Bronchospasm → Nebs
CHF → consider
BNP/Echo furosemide
Pneumonia → Abx +/-
Steroids
Pleural Effusion →
thoracentesis, PleurX
Anxiety → anxiolytics
Acute or Chronic PE →
LMWH
Lorazepam IV to suppress
respiratory drive
Morphine for air
hunger SL or vis IV drip
Chlorpromazine
PO/SQ or infusion
F . Algorithm for shortness of breath at the end of life
intake, vomiting, and limited mobility are the main factors
that place this population at high risk for constipation.
Ask about stool frequency, opioid use, and other medications. On physical exam, assess hydration status, and look for
Chapter 5. Care at the End of Life: Palliative…
signs of obstruction or fecal impaction. Determine if there is
an underlying, reversible medical cause that could be treated
and if treatment of such a condition is congruent with the
palliative goal. Non-pharmacologic lifestyle modifications
should be tried before medications—discontinue, substitute,
or adjust doses of constipating medications; increase fluid
intake; increase fiber intake; and encourage mobility anorectal testing, colonic transit testing, defecography, and surgery
which are invasive and unlikely to be beneficial in the palliative care population. Biofeedback or pelvic floor training
should be considered.
Treatment includes stool softeners, laxatives (bulk, osmotic,
stimulant), rectal suppositories, and enemas in escalating
doses and combinations. There are currently no evidencebased guidelines on the order in which to give laxatives, but
the American Gastroenterological Association provides
guidelines for initial management of constipation [7]. Know
the difference between stimulant (bisacodyl, senna) and
osmotic (polyethylene glycol, lactulose, sorbitol, milk of magnesia, magnesium citrate) laxatives as well as the form and
volume in which they are provided (pills vs. liquid). Some
patients may have difficulty swallowing pills or be intolerant
to sweet or large volume of liquids. Stimulant laxatives may
cause excessive cramping. Prescribe the form most comfortable for the patient at the lowest dose to encourage a bowel
movement (Fig.5.4).
129
Nausea/Vomiting
Nausea is an uncomfortable feeling which often precedes
vomiting. Both are protective mechanisms by which the body
expels toxins, unsavory food, etc., but they can also be triggered by emotional causes and medications. The symptoms
can originate in the CNS or the GI tract, and several mechanisms are usually involved. In the palliative care population,
nausea and vomiting are most frequently caused by
chemotherapy, opioid use (where symptoms usually resolve
over time), obstruction/constipation, increased intracranial
130
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T. N. Goring and I. L. Nelson
History and Physical
Perform Abdominal Exam
Abdominal Distention Consider
Upright KUB xray to r/o
obstruction/perforation
Consider Rectal Exam r/o impaction
Constipation
Discontinue non-essential
constipating meds
Step 1Step
Increase Dietary Fiber
Bulk-Forming Laxative
(Psyllium)
Stool Softeners (Docusate)
Gentle Laxative (MOM)
Laxative + Suppository/Enema
Polyethylene Glycol/Senna
+/- Promotility Agents
tep 3
Lactulose/Mag Citrate/
Polyethylene glycol
Chronic Opiate Use
Methylnaltrexone (SQ) if no
bowel obstruction
F . Management of constipation in palliative care
pressure caused by CNS lesions, metabolic disturbances
(renal failure, hypercalcemia), and/or anxiety.
Determining the underlying etiology of the nausea/vomiting
will help you choose the appropriate medication/intervention
that will help. Commonly used treatments in palliative care
are as follows:
• For drug effect: haloperidol, ondansetron (esp chemo
related)
• For increased intracranial pressure: dexamethasone
• In ESRD: haloperidol, dose reduced
• For anticipatory nausea: benzodiazepines
• For ileus, gastroparesis: metoclopramide
• For obstruction: octreotide, dexamethasone
• No obvious cause: metoclopramide, dexamethasone
A multimodal approach is usually indicated. Choose
agents with different mechanisms of action at the lowest
effective dose (Fig.5.5).
Chapter 5. Care at the End of Life: Palliative…
131
causes
Asses for reversible
Nausea/Vomitting
Determine etiology
Avoid polypharmacy
receptors
and target specific
(CTZ)
Opioids/Anesthetics/Chemo
Chemoreceptor Trigger Zone
GI Dysmotility/
Partial Obstruction
candidate)
obstruction
(not a surgical
Other
(3rd line)
receptors
Solitary tract
nucleus/medulla
Receptor
(2nd line)
Dopamine
(1st line)
Receptor
Serotonin
Receptor
(2nd line)
Serotonin
(1st line)
Receptor
Dopamine
Add Octreotide
SQ + Decadron
tube
Nasogastric
Lorazepam
Dexamethasone
Droperidol
Chlorpromazine
Ondansetron
Ondansetron
Droperidol
Chlorpromazine
gastrostomy
If fails, venting
Dronabinol
Promethazine
Metoclopramide
Prochlorperazine
Granisetron
Palonosetron
Granisetron
Palonosetron
Promethazine
Metoclopramide
Prochlorperazine
Vestibular/CNS Mechanical
Vertigo
Motion sickness/
Receptor
Acetylcholine
Receptor
Histamine
Scopolamine
Meclizine
Dimenhydrinate
Diphenhydramine
F . Assessment and management of nausea and vomiting in palliative care (Modified from Flake, Z.Am Fam
Physician. 2004 Mar 1;69(5):1169–1174)
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T. N. Goring and I. L. Nelson
Pain
One of the first rules of palliative care developed by Dame
Cecily Saunders is that continuous pain requires continuous
treatment. Most palliative care patients have continuous pain,
and so it is important to develop a treatment regimen that
can be delivered around the clock. While opioids are a mainstay, adjuvant medications can provide a synergistic effect
that may lessen the dose of opioids required.
Pain is divided into three broad categories. Visceral pain is
usually abdominal, poorly localized, and deep and squeezing
in nature. Somatic pain is usually incisional or musculoskeletal, well localized, and sharp in nature. Neuropathic pain
results from nerve injury caused by chemotherapy, tumor
compression, or radiation therapy and is burning or stinging
in nature. These categories are important because they will
determine which medications will be of most benefit.
However, in practice, most pain is mixed in origin.
Adjuvant medications include acetaminophen and
NSAIDS; unless there are contraindications, they should be
part of all pain regimens. For visceral pain, anti- inflammatories
like dexamethasone or prednisone are very effective. Somatic
pain responds well to NSAIDS. Neuropathic pain responds
best to tricyclic antidepressants and SNRIs and anti-epileptic
drugs such as gabapentin and topiramate.
When beginning treatment with opioids, start low and go
slow. Use oral formulations. Start with as needed (PRN) dosing
of short-acting forms, and, when an effective dose has been
established, change to long-acting formulations. Always continue PRN dosing of short-acting medications to treat breakthrough pain. And, always give medications for constipation—this
is a side effect of all opioids and requires a stimulant. When
dosing, remember that there is no ceiling dose for opioids—
medications should be titrated until relief is achieved.
Anesthesia-based interventions (nerve blocks, intrathecal
pumps, spinal stimulators) may be useful in certain regional
pain syndromes. These interventions may be appropriate for
patients with intractable side effects secondary to opioid use
and/or patients on excessive doses of opioids by allowing the
Chapter 5. Care at the End of Life: Palliative…
133
patient to reduce or eliminate opioid use. Radiation therapy
is also a useful pain treatment modality, especially in cases of
cancer-related bone pain.
The World Health Organization (WHO) has developed a
three-step ladder for cancer pain relief [8]; an algorithmic
version is presented in Fig.5.6.
Pain
Assess character, quality
duration, source,
location of pain
Nociceptive
Neuropathic
Inflammatory
Mixed category
Mild
Non-opioids
+/- adjuvant
Acetaminophen
NSAIDS
Adjuvants - (TCA,
Anxiolytics)
Non-medication pain relievers
Topical agents
Massage
Physical Therapy
Acupuncture
Document allergies
Moderate Severe
Weak Opioid
+/- adjuvant
Codeine
Oxycodone
Hydrocodone (low dose)
Morphine (low dose)
Anesthesia-based Interventions
for ongoing pain or intolerable
side effects
Nerve blocks
Intrathecal Pain Pump
Nerve stimulator
Radiation for bone pain
Strong Opioid
+/- adjuvant
Morphine
Hydromorpone
Fentanyl
Oxymorphone
Methadone
F . Management of pain in palliative care (Modified from
WHO Stepladder)