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Integrating Palliative Care into Long-Term Care
207
• Initiate practical, nonpharmacologic interventions such as offering smaller, more
frequent meals of blander food, relaxation techniques, appropriate body positioning when eating or while being fed, and attention both during and after PEG
tube feeding.
• Prescribe pharmacologic treatment based on the major cause(s) of nausea/vomiting (refer to Table3).
Combination pharmacotherapy (based on each medication’s different antiemetic
pharmacologic mechanism and neurotransmitter system) may be necessary especially when nausea/vomiting has multiple etiologies or is refractory. Note that
dexamethasone, metoclopramide, and low dose antipsychotics also have central
antiemetic effects. Be aware of the potential side effects of serotonin receptor
antagonists such as ondansetron (headache, constipation, fatigue, xerostomia) and
of anticholinergics and antihistamines (drowsiness, fatigue, confusion, dry mouth,
constipation, urinary retention, blurred vision). Metoclopramide can cause extrapyramidal syndrome, dystonia, and tardive dyskinesia. Low dose haloperidol
(0.5–2 mg) or olanzapine (2.5–7.5 mg) may be useful in alleviating nausea/
vomiting.
Dronabinol can have an antiemetic effect though poor evidence of efcacy (start
at 2.5mg twice a day to a maximum of 20mg/day). Though FDA approved for
refractory chemo-related nausea/vomiting, practitioners may consider its off-label
use yet must be prudent when prescribed in the elderly. High cost may preclude its
use. Common adverse effects include somnolence, asthenia, paranoia, delirium,
nausea, and vomiting. Opioid-induced nausea/vomiting may require either a dose
reduction of the opioid or rotation to another opioid.
Constipation
Many patients who reside in a long-term care setting experience constipation, especially when terminally ill. Constipation can occur because of a combination of poor
uid intake, low dietary ber, impaired mobility, as well as constipating drugs such
as opioids, anticholinergics, iron, calcium preparations, and antihypertensive especially calcium channel blockers, diuretics and clonidine.
Management of Constipation Includes the Following:
• Prevention is paramount.
• Identify potentially reversible causes, including medication-induced and medical
conditions such as a rectal fecal impaction; metabolic disturbances (hypercalcemia, hypothyroidism); GI causes (always consider if intestinal obstruction could
be present); and neurologic causes (such as nerve root or spinal cord compression or, for example, visceral neuropathy that can occur in Parkinson’s disease).
• Identify life-threatening causes such as malignant bowel obstruction or narcotic
bowel syndrome.
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Table 4 Stepwise regimen to prevent and treat constipation
“The Sixth Vital Sign”
1. Begin with: Senna with/without docusate 1–2 tabs/cap qd-bid
2. Titrate up to: Senna 3–4 tabs bid
3. If needed add: Sorbitol or lactulose
or
polyethylene glycol
4. Consider, in
addition:
5. If needed: Mineral oil or soap suds enema
6. If rectal
impaction:
Glycerin rectal suppository with/without bisacodyl
rectal suppository
May need digital dis-impaction
30 cc qd-bid
17g in 8oz water
qd-bid
scheduled qd -qod
P. Winn
• Practical interventions include making toilets accessible, establishing a bowel
routine, and encouraging increased uid intake (if tolerated).
• Reduce the anticholinergic load of medications if possible.
• Establish an individualized bowel regimen according to each laxative’s mechanism of action (refer to Table4). Combination therapy is often required.
• Monitor for side effects of laxatives, which can include bloating, cramping, nausea/vomiting, and diarrhea.
• Bulk-forming laxatives are usually not recommended because they can exacerbate constipation in underhydrated and less mobile patients and often cause or
worsen bloating, nausea, or vomiting.
Foremost remember to anticipate and prevent opioid-induced constipation, and
second, as the dose of the opioid is increased, so must the laxative regimen also be
increased. Stimulant laxatives such as senna are most effective for opioid-induced
constipation. In severe constipation, consider oral lubiprostone or methylnaltrexone
sc, though expensive.
Stool softeners are considered to have poor effectiveness but can be prescribed in
some patients when initiating their bowel regimen, i.e., the “laxative ladder”
(Table4). Remember that some patients may also require a rectally administered
lubricating agent (glycerin suppository) and/or stimulant (bisacodyl) to ensure defecation in addition to oral agents. Always consider the possible presence of a rectal
fecal impaction. Note that a rectal fecal impaction can cause “paradoxical” diarrhea
or urinary retention, either of which may not be evident on patient history, symptoms, or exam. This may require urinary bladder cauterization and manual disimpaction, though PEG solution administered orally may be effective.
Delirium
Delirium is an acute confusional state that is characterized by a uctuating course
during the day/night, inattention, and disorganized thinking and speech. Delirium
can be hyperactive, hypoactive, or mixed. A good caveat is to remember that any
Integrating Palliative Care into Long-Term Care
209
acute illness or any medication, regardless of when it was started, can precipitate
delirium especially in those with advanced illness. Remember that even a gradual
dose reduction or discontinuing an opioid, benzodiazepine, or alcohol can precipitate delirium.
Management of Delirium in Patients with Advanced, Serious Illness Includes
the Following:
• Identify potential reversible causes, especially whether it may be
medication-induced.
• Discontinue nonessential medications and reduce anticholinergic load.
• Initiate practical interventions: familiarize the patient to the environment,
improve sleep and the sleep-wake cycle, reduce environmental stimuli, and optimize hearing and eyesight (i.e., hearing aids “in,” eyeglasses “on”), and adequate
hydration.
• Reduce immobility by removing/minimizing use of any physical restraints,
including a Foley catheter, if possible.
• Determine whether pain could be contributing to the delirium, and if so, treat it
appropriately.
• If delirium persists, consider as rst-line medication therapy low-dose haloperidol (no more than 2–3 mg total/day), often in divided doses. Start low and
go slow.
• Second-line medication may include a low-dose benzodiazepine, usually lorazepam 0.5–1mg PO/SL every 6–8h, more frequent if necessary; or valproic acid
125–250mg every 6–8 to 12h, the latter upon awaking in the morning and at
bedtime, with a possible noontime or early afternoon dose.
Remember that even opioids and steroids can cause delirium. Also, haloperidol
and lorazepam can cause paradoxical agitation or restlessness in which case their
dose should be decreased (not increased!) or discontinued. It is not uncommon to
use a combination of haloperidol and lorazepam to treat delirium. Be aware that
patients with dementia are more sensitive to the adverse effects of antipsychotic
medications that includes sedation and EPS, and that antipsychotics have a “black
box” warning as they have been associated with an increased risk of sudden death
and cerebrovascular events. Communication with the patient and their family about
these risks and benets must occur. Overall, judicious medication management as
well as social, environmental, and practical interventions must all be implemented
in an attempt to prevent and treat delirium. For further information, refer to the
Chapter on “Dementia, Delirium, and Depression”.
Fatigue/Weakness/Lack ofEnergy
These symptoms commonly occur in patients with advanced illness and will
worsen during the last 6 months of life for patients whether on hospice or not. As
discussed in previous sections, it is important to consider the adverse effects of
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medication as a contributing factor, to elucidate any associated clinical signs and
symptoms, and to treat potentially reversible conditions. These symptoms often
present with increasing daytime sleepiness/sleep with the patient eventually
becoming bed ridden.
Fatigue can occur as a consequence of a patient’s primary disease or secondary
to other causes [5]. The pathophysiology of primary fatigue, though not well
understood, may be a consequence of dysfunction of the reticular formation, the
effects of proinammatory cytokines, deregulation of the hypothalamic-pituitaryadrenal axis, and alteration of skeletal muscle metabolism. While secondary
fatigue can be multifactorial and caused by anemia, infection/fever, dehydration/
electrolyte imbalance, undiagnosed hypothyroidism or vitamin D and/or B12 deciency, an untreated or unrecognized mood disorder/depression, poor sleep, inadequately treated chronic pain, side effects of medication including benzodiazepine
and opioids, and unintended though anticipated adverse effects of disease-focused
treatments such as chemotherapy and radiation. Whether primary or secondary
fatigue, practitioners must balance each treatment/intervention’s potential benet
versus risk burden.
Nonpharmacologic and Practical Considerations:
• Provide realistic prognostication and education to patient and family that these
symptoms are in keeping with expected course in the advanced/terminal phase of
his/her illness.
• Encourage the patient to better conserve energy by pacing activities and limiting
social/family visits if contributing to their exhaustion, be it physical, emotional,
and/or spiritual/religious.
• Consider psychosocial interventions or therapy.
• Encourage good sleep hygiene, nutrition, and pain control.
• Consider short-term physical therapy to improve safety of transfers and ambulation and to lessen fall risk.
Palliative Pharmacotherapy Considerations:
Once reversible etiologies of fatigue have been ruled out consider methylpheni-
date or modanil, though the majority of trials have demonstrated little or no efcacy. However, under certain situations a trial may be reasonable, but with careful
monitoring as to potential side effects.
• Methylphenidate: Start with low dose of 2.5mg twice daily to be administered in
the early and late morning; if tolerated, may increase to 5mg twice daily, but not
a higher dose (author’s recommendation). Discontinue if no improvement in
1–2weeks. Prudent use is advised in patients with heart disease or hypertension.
• Modanil: Limited research: Expensive so unlikely to have costs covered by
hospice.
• Corticosteroids: Consider prednisone 5–10mg/day or dexamethasone 8–12mg/
day, the latter in divided doses. Beware that steroids can cause confusion and
precipitate delirium, especially in the elderly and those with serious illness.
• Consider caffeinated beverages.
Integrating Palliative Care into Long-Term Care
211
Depression/Anxiety
At end-of-life patients often suffer from anxiety and depression attributable to psychiatric, psychological, and spiritual or religious distress. These symptoms are thoroughly discussed in UNIPAC 2 published by the American Academy of Hospice
and Palliative Medicine (AAHPM) [14]. While the use of anxiolytics and antidepressants is well known to practitioners this will not be discussed in this review.
However, several factors can contribute to anxiety and depression. These include
patient burden of non-pain and pain symptoms, loss of connectedness to family and
community, loss of dignity, striving to nd meaning (or not) to one’s life, and leaving a legacy (or not), being forgiven (or not) by family and others. Palliative care
must aim to balance a sense of hope (“hope for the best”) while helping the patient
and family to transition through the last months, weeks, and days of life (“prepare
for the worst”).
Practical Considerations:
• Provide empathic listening and supportive counseling to patient, family, and
caregivers. It is the responsibility of all members of the interdisciplinary team to
do so, including volunteers, practitioners, and at times the patient’s community
religious or spiritual leader.
• It is imperative to address the severity of depression and any suicidal ideation, as
well as patient’s access to means to commit suicide (or homicide) and to remove
accessibility to these means. Psychiatric consultation, possibly inpatient evaluation, may be necessary.
• Encourage patient life review, the meaning of life and the search for meaning
in dying.
• Facilitate social interaction and if tolerated, engage in recreational and distracting activities that provide individual patient meaning and satisfaction to every day.
• Consider holistic interventions such as guided imagery, aromatherapy, massage,
sand therapy, and Dignity Therapy.
• Support family and caregivers in adopting positive coping skills.
For further information on the assessment and treatment of anxiety and depres-
sion in post-acute and long-term care, refer to the Chapter on “Dementia,
Delirium, and Depression”. It is important for practitioners to understand that
depression can manifest differently in residents who face serious and life-limiting
illness than residents who do not, so their assessment and treatment can differ for
residents who have a greater life expectancy. For example, residents with a prognosis of less than 6months to live may have a desire for hastened death due to
overwhelming feelings of despair, hopelessness, and worthlessness and spiritual
and existential distress. Though antidepressants such as an SSRI may be appropriate in residents with a longer life expectancy, psychostimulants may be preferred as rst-line treatment for depression in patients with a prognosis of less
than 6 months to live. Note that caution must be used to tapper the dose of most
SSRI antidepressants (no need to taper uoxetine due to its long half-life) when
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being discontinued in order to prevent a discontinuation syndrome (most likely
to occur when discontinuing paroxetine due to its short half-life). The need to
discontinue an SSRI is likely to occur when a resident is no longer able to swallow at end-of-life. As such the emergence of this syndrome should be anticipated.
The discontinuation syndrome is characterized by signs and symptoms of headache, malaise, u-like symptoms, agitation, restlessness, irritability, anxiety, and
insomnia. An excellent palliative care resource on the assessment and treatment
of depression and anxiety is UNIPAC 2 on Psychiatric, Psychological and
Spiritual Care published by the American Academy of Hospice and Palliative
Medicine (AAHPM) [14].
Pain Management
Effective pain management is essential to providing high quality palliative care in
post-acute and LTC given the high prevalence of painful medical conditions in this
patient population. The goals of pain control include:
• To relieve pain.
• To alleviate suffering.
• To prevent/minimize disability.
• To optimize function.
• To preserve decision-making capacity.
Practitioners need to assess every patient for the presence of pain and “total
pain”; that is, the physical, psycho-emotional, social, and spiritual aspects of pain
and how each can affect the other. Successful pain management entails proper evaluation and implementation of interventions that address each component of a
patient’s total pain. As with any distressful symptom, pain is more optimally managed if its cause and pathophysiologic mechanisms can be determined, together
with an interdisciplinary approach and use of multiple treatment modalities, both
nonpharmacologic and pharmacologic. The AMDA Clinical Practice Guideline on
pain management [15] and its more recent pocket guide [16] and Geriatrics at Your
Fingertips [17] published by the American Geriatrics Society are excellent resources
that provide more in depth content than permits in this chapter. Also, the AGS
guidelines on the pharmacologic management of persistent pain in older persons is
a classic and noteworthy resource [18].
Key Components to the Recognition and Assessment of Pain Include the
Following:
• If possible, prevent the occurrence of pain or a painful condition. For example,
advanced osteoarthritis of one knee may result in contralateral hip pain: a total
knee arthroplasty may prevent the latter happening. Another example is prophylactically prescribing an anti-inammatory and analgesic in addition to an antiviral in an attempt to prevent the occurrence of postherpetic neuralgia.
Integrating Palliative Care into Long-Term Care
213
• Anticipate the occurrence of pain. For example, postsurgical incision pain; the
pain associated with the occurrence of peripheral neuropathy in diabetics; or the
onset of bone pain in cancer patients with known bone metastases.
• Identify the presence of pain or a painful condition. Remember to assess for
nonverbal cues of pain such as guarding on movement or on transfers, rubbing
and grimacing, and behaviors such as agitation, restlessness, withdrawn behavior, and sleeping poorly.
• Establish the pain’s location, intensity, temporal pattern, any exacerbating and
relieving factors and effect on (loss of) function and cognition. Consider using a
pain assessment scale. Most can be converted to a scale of 1–10.
• Determine whether the pain is acute, chronic (duration of 1month or more), new
onset, intermittent, incidental (i.e., related to movement), breakthrough pain, and
whether there are multiple causes and types of pain.
• Try to determine whether the pain is nociceptive (either somatic or visceral),
neuropathic, or inammatory, as suggested by the patient’s description of the
pain (see Table5).
• Identify any associated signs and/or symptoms such as headache, dizziness, nausea/vomiting, constipation, decreased urination, a swollen joint, or painful
extremity.
• Review any previous and current pharmacologic and nonpharmacologic treatments and their effectiveness, as well as any complementary and alternative
medicine therapy.
• Assess “total pain” by elucidating any psycho-emotional, social, and spiritual
dimensions to the physical pain, as well as the person’s cultural beliefs as to the
meaning of pain and his/her manner of expressing pain.
• Perform a focused physical exam, with particular attention to those body regions
or organs systems that appear to be related to or contributing to the pain.
• Assess the need for diagnostic testing, if likely to be helpful in determining a
diagnosis, always consider the pain or discomfort these tests may cause.
• Finally, determine the probable cause of the pain. Remember persons may have
multiple and different types of pain. Always evaluate for potentially reversible
causes of pain. For example, abdominal pain may be due to urinary retention, con-
Table 5 Classication of pain
Type of pain Descriptors
Nociceptive
• Somatic pain: Sharp, tender
• Visceral pain: Dull, cramping
• Bone pain: Throbbing, aching
Neuropathic Burning, tingling, stabbing shooting
Inammatory E.g., pleuritic, abdominal rebound, inamed
joints
Adapted from Von Roenn JH et al. Current Diagnosis and Treatment of Pain, Lange Series,
McGraw Hill 2006
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stipation, a rectal/fecal impaction, or caused by medication such as a bowel stimulant or bulk forming laxative. Prescribing an opioid analgesic in such a circumstance
would be considered inappropriate and could result in harm to the patient.
• Remember that conditions such as bladder spasms, contractures, improper positioning, pressure ulcers, muscle strain, oral thrush, urinary retention, fecal
impaction, or DVT can all cause pain.
Key Components to the Treatment of Pain Include the Following:
• Consider treatment options taking into account the patient’s health status, prognosis, and known advance directives for health care. Conduct a thorough discussion to support informed choice (i.e., informed consent) by the patient and family
or proxy decision maker.
• Establish an interdisciplinary treatment plan, part of which will be determined by
the disciplines involved at the patient’s care setting (i.e., nursing facility, SNF,
residential/assisted living, home or hospital, and possibly hospice).
• Set goals for pain relief. For example, the desired or acceptable intensity of pain
that can enable the achievement of positive functional outcomes in self-care, participation in desired personal and recreational activities, improved sleep, mood, and
cognition. Also, it is important to assess whether a certain level of sedation would
be acceptable to both patient and family in order to achieve effective pain control.
In up to 90% of persons with pain, practitioners can adequately control pain with
orally administered medication guided by the World Health Organization (WHO)
three-stepped analgesic ladder (see Table6). The WHO recommends administering
analgesic and co-analgesic (i.e., adjuvant) medication as follows:
• By mouth: Whenever possible, prescribe an oral analgesic. Avoid IM injections
as they can be painful; subcutaneous injections are less painful and may not be
practical in some care settings. Opioids in a concentrated liquid form can be
administered sublingually or transbuccally.
• Around-the-clock: Prescribe scheduled dosing for continuous and persistent pain
to minimize break through pain and choose an appropriate analgesic and dose for
breakthrough pain.
Table 6 The WHO three-Step analgesic ladder
Step 3. Severe
2. Moderate Morphine
1. Mild A/Codeine Hydromorphone
ASA A/Hydrocodone Methadone
Acetaminophen A/Oxycodone Levorphanol
NSAIDs A/Dihydrocodeine Fentanyl
Tramadol/apap Oxycodone
±Adjuvants ±Adjuvants ±Adjuvants
Adapted from: Technical Report Series 804: Geneva WHO.1990
Integrating Palliative Care into Long-Term Care
215
• According to the ladder: The initial choice of an analgesic and use of adjuvants
is based on the severity of the pain. Using a numerical pain scale, 1 through 3 can
be considered mild pain; 4 through 6 moderate pain; 7 through 9 severe pain,
and 10 excruciating pain.
• Adapted to the individual: The choice of analgesic should be based upon the
patient’s condition, comorbidities (such as liver and kidney disease and coexistent
dementia or delirium), drug safety and toxicity prole, ease of administration,
and goals of both pain relief and the desired outcome in treating the pain.
• With attention to detail: ensure optimal dosing: Consider drug pharmacokinetics
and pharmacodynamics, make appropriate dose adjustments in timely manner,
and always monitor for potential benet versus harm and adverse effects.
Optimal pain management also entails the choice of the most appropriate
analgesic(s) based upon the patient’s primary and comorbid diagnoses, the pathophysiologic mechanism underlying the type of pain (see Table 7), pain severity,
diagnosis, the potential adverse effects of each medication and nonpharmacologic
treatment, and the patient’s individual characteristics that can alter a drug’s metabolism, pharmacokinetics, and pharmacodynamics.
Caveats to Effective Pain Management Include:
• In most patients, prescribe at least one analgesic as scheduled, i.e., administered
routinely, rather than just as needed (i.e., PRN).
• Choose an appropriate analgesic and dose for breakthrough pain.
• Remember that most types of pain respond, at least partially, to an opioid.
• The maximum recommended dose of acetaminophen is 3000–4000mg/day, but
2000mg/day may be prudent if either renal or hepatic insufciency are present,
and in older adults.
• Use caution when prescribing an opioid/acetaminophen combination drug as the
ceiling dose of the acetaminophen may be reached before pain is adequately
controlled by the opioid component.
• The maximum dose of tramadol is 300mg/24h; it may precipitate confusion,
seizures, and serotonin syndrome. A lower daily dose should be prescribed in
older adults.
• Conventional nonselective NSAIDs (e.g., ibuprofen, naproxen) should only be
prescribed short term, that is days to no more than 3–4 weeks; precautions
Table 7 Select rst and second line analgesics based on type of pain
Consider
Type of pain
Nociceptive Pain: WHO Step 1 or 2 drug WHO Step 3 drug
Neuropathic Pain: TCAs, anticonvulsants WHO Step 2 or 3 drug
Bone Pain: NSAIDs, corticosteroids WHO Step 2 or 3 drug
Intracranial Pain: Corticosteroids WHO Step 2 or 3 drug
Visceral Pain: Anticholinergic, opioid Steroids, opioids
Source: UNIPAC Three. AAHPM 2017
First line Second line
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include risk for gastrointestinal bleeding, renal impairment, platelet dysfunction,
edema, increased blood pressure, and worsened heart failure.
• Long-term use of a NSAID would be appropriate when prescribed for bone pain
due to cancer metastases, but may need to be discontinued during the last days of
life when pills can no longer be swallowed.
• Selective COX-2 inhibitors (e.g., celecoxib) still have a signicant risk of a GI
bleed and renal insufciency.
• Consider holding or discontinuing ASA chemoprophylaxis when administering
a conventional or COX-2 NSAID.
• Consider prescribing a proton pump inhibitor or H-2 blocker in patients to lower
the risk for a GI bleed when prescribing a NSAID.
• Never prescribe a NSAID when a patient is taking warfarin as the risk for a GI
bleed is high.
• Consider a topical analgesic such as capsaicin cream, diclofenac gel, or a lidocaine patch for persons with one or two localized areas of musculoskeletal,
arthritic, or neuropathic pain.
• Remember the use of the lidocaine patch is noncontinuous, to be applied for only
12h during a 24-h period, while off the remaining 12h, and applying no more
than three patches at one time.
• Avoid use of meperidine because of its potential to cause undesirable CNS side
effects such as confusion and seizures due to the accumulation of its toxic metabolite normeperidine.
• Opioid with partial agonists activity such as butorphanol, pentazocine, buprenorphine and nalbuphine are not recommended because of their analgesic ceiling
effects and ability to counteract the analgesic effect of pure agonist opioids,
which can then precipitate an opioid-withdrawal pain crisis.
Opioid Analgesics
Opioids are both appropriate and effective for the treatment of moderate to severe
acute or chronic pain not relieved by other analgesics or modalities. Judicious prescribing can provide effective pain relief in patients in post-acute and LTC, with a
low risk of psychologic dependency or addiction. Scheduled low doses of opioids
can be very effective in the treatment of chronic pain associated with various chronic
musculoskeletal conditions that often afict the elderly. Note that physical dependency, characterized by withdrawal symptoms, can occur when regularly scheduled
opioids are abruptly discontinued. The gradual dose reduction of the opioid can
prevent this when being discontinued.
General Guidelines to the Use of Opioids Include:
• For acute pain: Start by prescribing an immediate-release (IR) opioid (see
Table8 for suggested equianalgesia starting doses).
• For chronic pain: Consider starting a low dose of a sustained-released opioid
(LA/ER), with a sufcient dose and dosing interval of an immediate release of
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