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Integrating Palliative Care into Long-Term Care
Table 8 Suggested equianalgesic starting doses for selected oral opioids
Frail or elderly opioid-naïve patients
The practitioner may choose from the following suggested starting doses:
Morphine 2mg PO or SL 0.1cc morphine 20mg/cc (Roxanol®)
Oxycodone liquid 2mg PO or SL 0.1cc oxycodone 20mg/cc (Oxyfast®)
Oxycodone 2.5mg • ½ tablet 5mg oxycodone
• ½ tablet oxycodone 5mg/acetaminophen 325mg
(Percocet ®)
Hydromorphone 0.5mg PO 0.5cc hydromorphone 1mg/cc (Dilaudid®)
Hydrocodone 2.5mg PO ½ tablet hydrocodone 5mg/acetaminophen 500mg
(Vicodin®)
Adult Opioid-Naive Patients
The practitioner may choose from the following suggested starting doses:
Morphine 5mg PO or SL 0.25 cc morphine 20mg/cc (Roxanol®)
Oxycodone liquid 5mg PO or SL 0.25 cc oxycodone 20mg/cc (Oxyfast®)
Oxycodone 5mg • 5mg oxycodone
• 1 tablet oxycodone 5mg/acetaminophen 325mg
(Percocet®)
Hydromorphone 1mg ½ of 2mg tablet PO (Dilaudid®)
1 cc of hydromorphone 1mg/cc SL
Hydrocodone 5mg 1 tablet (Vicodin®) 5/500
Source: Permission granted by The Society for Post-Acute and Long-Term Care Medicine.
Palliative Care in the Long-Term Care Setting (LTC Physician Information Tool Kit Series).
Columbia, MD: 2012
217
the same opioid for breakthrough pain. OR start with an IR opioid and when
adequate analgesic is obtained, convert to an equianalgesic dose of same opioid
in its sustained-release formulation.
• Remember that the total dose of a mixed opioid (i.e., an opioid with acetaminophen) is limited by its 24-h accumulative dose of acetaminophen.
• Once the total daily dose of an immediate release opioid has been able to adequately control the patient’s pain, consider converting it to an equivalent dose of
a sustained-release opioid (see Table9 on the different formulations of sustainedrelease opioids).
• Note that the duration of analgesia for all immediate-release morphine preparations is 3–4h whether administered PO, SL, SC, or IV, while the onset of action
and its peak analgesic effect do vary (see Table10).
• The suggested opioid dose for breakthrough pain is 10–15% of the total daily
opioid dose usually given every 3–4h, though for a severe pain crisis it can be
administered as often as every 1–2h if needed.
• The total daily dose of an opioid can usually be safely uptitrated by 25–50% for
mild to moderate pain and 50–100% for moderate to severe pain in an opioid
tolerant patient
• When starting a patient on an opioid, ALWAYS start the patient on a bowel regi-
men to prevent constipation. A stimulant and/or osmotic agent are preferable.
• The use of an adjuvant analgesic may allow use of a lower dose of an opioid and
accordingly lessen the likelihood of opioid adverse effects.
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Table 9 Available formulations of sustained-release oral opioids
Morphine sulfate ER (MS Contin®)
Morphine sulfate ER (Kadian®)
Morphine sulfate ER (Avinza®)
Oxycodone ER (Oxycontin®)
Oxymorphone (Opana ER®)
a
Formulation must not be crushed
b
Capsules can be opened and contents administered in pudding or applesauce or per PEG
a
a,b
a,b
a
a
q 8h–12h 15,30,60,100,200mg ER
q 12h–24h 10,20,30,50,60,80,100,200 ER
Discontinued in USA
q 8h–12h 10,15,20,30,40,60,80 ER
Discontinued in USA
Table 10 Pharmacodynamics of immediate release morphine
Administered Peak analgesic effect Duration of analgesia
Oral/sublingual 45–60min 3–4h
Subcutaneous 15–30min 3–4h
Intravenous 5–15min 3–4h
P. Winn
Table 11 Common
and less common side
effects of opioids
Common Less common
Constipation (almost always) Hypotension
Somnolescence Diaphoresis
Nausea/vomiting Urinary retention
Dizziness Confusion, delirium
Sweating Bradycardia
Dry mouth Seizures
Asthenia Respiratory depression, apnea
Dysesthesias Paralytic ileus
Pruritus Paresthesia, hyperesthesia
Shock, cardiac arrest
In contrast to nonopioids and NSAIDs, opioids commonly used for the treatment
of pain have no analgesic ceiling. However, adverse drug effects may limit further
dose increases (see Table11) or require “rotating” to another opioid, especially if
adequate pain relief is not being achieved (see below).
Use of meperidine should be avoided because of its high potential to cause CNS
toxicity. Codeine is too constipating in relation to the dose required for an adequate
analgesic effect. It is NOT recommended to use three or more different opioids
because of the potential for adverse drug– drug or opioid–receptor interactions
(either unknown or unrecognized by practitioners). Different opioids interact to different degrees at the mu, delta, and kappa opioid receptors. For a patient on a transdermal fentanyl patch, an immediate release opioid such as morphine or oxycodone
will need to be prescribed for breakthrough pain. Transmucosal oral fentanyl (i.e.,
Actiq®) is only indicated for severe breakthrough cancer pain and its use should be
avoided in the post-acute and LTC setting.
Integrating Palliative Care into Long-Term Care
219
Table 12 Oral Morphine
Milligram Equivalents (MME)
Morphine 30 10 (1/3 oral dose)
Oxycodone 20–30 N/A
Oxymorphone 10 1 (1/10 oral dose)
Hydromorphone 7.5 1.5 (1/5 oral dose)
Meperidine 300 100 (1/3 oral dose)
Hydrocodone 30 N/A
Codeine 200 100 (1/2 oral dose)
(25 microgram fentanyl patch = 50 mg oral morphine/24 h,
×3days); N/A=not available as a parenteral formulation)
Source: Adapted from Principles of Analgesic Use. 7th edition.
2016. American Pain Society
Oral Parenteral
When changing from one opioid to another, whether because of inadequate pain
relief or unmanageable adverse effects of the opioid, use oral morphine milligram
equivalents (MME) as a common denominator for opioid dose conversion in order
to avoid either under-dosing or over-dosing and to maintain effective pain relief (see
Table12 on oral morphine milligram equivalents). In order to adjust for incomplete
cross-tolerance, the relative conversion of the total daily dose of the new opioid
should be decreased by 25–50%. When converting from one opioid to another it is
prudent to do so over 2 or 3days, with down titration of the opioid being discontinued coupled with the uptitration of the newly prescribed opioid, especially if the
patient is on a high dose of an opioid. This can avoid a withdrawal pain crisis.
Caution is warranted when prescribing opioids in an opioid-naïve patient where
the dictum, “start low and go slow” is advisable. A suggested starting dose of oral
morphine is 2–5mg every 3–4h or the equianalgesic dose of another opioid. The
use of a fentanyl patch when initiating opioid treatment in the frail elderly opioid-
naïve patient is not advised as the lower strength patches of 12mcg/h and 25mcg/h
provide an oral morphine milligram equivalent approximate dose of 25mg and
50mg, respectively, every 24h. Such doses will cause excess fatigue, sedation, loss
of appetite, and increase fall risk. Though expensive, the fentanyl patch has an ease
of use and can provide excellent analgesia in some patients, but is likely ineffective
in thin patients and those who weigh less than 105lbs due to an inadequate subcutaneous fat depot necessary for fentanyl absorption through the skin for eventual
release into the blood. A patient is considered to be opioid-tolerant when having
taken 60 MME daily for 7–10 consecutive days.
Morphine, oxycodone, and hydromorphone should be used cautiously in patients
with moderate to severe renal failure (GFR 30–50mL/min or less) because of the
risk of neurotoxic metabolite accumulation. Methadone and fentanyl are safe to use
for patients with advanced renal failure or on dialysis, though neither is dialyzable.
Non-opioid medications safe to use for patients with renal failure include acetaminophen and tramadol with the maximal daily dose of tramadol reduced to no more
than 50–100mg twice a day.
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P. Winn
Morphine and codeine doses may need to be reduced in patients with liver dis-
ease, especially those with cirrhosis. Fentanyl may be optimal to use in such patients,
unless there is inadequate subcutaneous tissue to enable its absorption.
Methadone is gaining popularity in the treatment of chronic musculoskeletal
pain as well as for the treatment of cancer pain and neuropathic pain. Other indications for its use include refractory pain, intolerance to other opioids, or clinician concern about patient diversion of opioids. Methadone has several
mechanisms of action, is extensively metabolized in the liver and is minimally
renally excreted, and has a cost advantage of being cheap. However, its prolonged
and variable metabolism (half-life may vary from 45–180h) is such that its steady
state plasma concentration may not be reached until 10 days. It has complex
drug–drug interactions and has been associated with prolongation of the QT
interval and an increasingly higher cause of opioid related deaths. Thus, methadone should only be used by (or in consultation with) a physician who is experienced with its use. When treating frail elders, starting at a low dose of methadone
between 2.5mg and 5mg, two or three times a day would be prudent. Methadone
should never be used for the treatment of acute or breakthrough pain, as the risk
of respiratory depression is high. For more complete information on methadone
use in long-term care, refer to Appendix 4 of the AMDA Clinical Practice
Guideline on Pain Management in the Long-Term Care Setting [15]. For guidelines on the use of patient controlled analgesia (PCA), refer to References [19]
(UNIPAC Three) and [20].
Eligibility Guidelines forHospice
Practitioners in post-acute and LTC should consider, offer, and facilitate resident
access to hospice care as residents transition into the terminal phase of advanced
illness when residents would be eligible for the Medicare Hospice Benet (MHB).
Hospice is an underutilized benet with many patients being referred too late in
their illness to be able to fully benet from its services. The National Hospice and
Palliative Care Origination (NHPCO) reports that the proportion of hospice stays of
7 days or less to be 35% of hospice admissions, while long stays greater than
180days account for 10% of admissions. The Ofce of the Inspector General (OIG)
periodically audits hospice agencies that have a high number of long stay patients
as to their eligibility to have remained on hospice or not.
Practitioner knowledge of the general eligibility guidelines and disease-specic
guidelines (see Table13) for hospice can help prognosticate whether a resident with
advanced illness may have a prognosis less than 6months to live if the resident’s
condition would likely follow its natural progression ending in death. Such a determination can provide the opportunity to open a frank discussion with the resident
and family on advance care planning in order to decide upon a more palliative
approach to care whether or not the resident and family opt for life-sustaining treatment or not.
Integrating Palliative Care into Long-Term Care
221
Table 13
Disease-specic eligibility guidelines for hospice
Cancer
Widespread metastatic disease
Palliative Performance Scale (PPS) ≤70%
No longer seeking curative care
Dementia (e.g., Alzheimer’s disease)
Inability to ambulate due to dementia (FAST 7c)
No consistent meaningful speech
Life-threatening infections, multiple stage 3 or 4 skin ulcers
Inability to maintain sufcient uid and calorie intake
Heart disease
Poor response or intolerant to optimal medical treatment
NYHA Class IV CHF
EF ≤20% (helpful, not required)
Unexplained or cardiac-related syncope
HIV/AIDS
CD 4 count <25
Persistent viral loads >100,000/mL
Major Aids-dening refractory infections or other medical conditions
Signicant functional decline in ADLs
Neurologic diseases
(PD, ALS, MS, MD, Myasthenia gravis)
Rapid disease progression and critical nutritional state
Life-threatening infections in preceding 12months
Stage 3, 4 decubitus ulcers
Critically impaired breathing capacity, declines ventilator
Pulmonary disease
Disabling dyspnea at rest or with minimal exertion
Increasing visits to ER, hospitalizations
Hypoxemia on room air (<88%); hypercapnia of
pCO2
>50mmHg
FEV 1 <30% (helpful, not required)
Renal failure
Not seeking dialysis, not a candidate.(or refusing further dialysis)
Calculated creatinine clearance <10 (<15 for diabetics)
Creatinine >8 (>6 for diabetics)
Stroke
Coma (acute phase)
Dysphagia with insufcient intake of uids and calories
Post stroke dementia (See Dementia criteria)
Liver disease
INR >1.5 not on Warfarin
Serum albumin <2.5gm/dL
(continued)
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Table 13 (continued)
Refractory ascites
Previous spontaneous bacterial peritonitis
Hepatorenal syndrome
Recurrent variceal bleeding
Adapted from: National Hospice and Palliative Care Organization
P. Winn
General indicators (i.e., general eligibility guidelines for hospice) that a chronic
illness may have progressed to its terminal phase include the following:
• Frequent transfers to the ER.
• More frequent hospitalizations.
• Signicant weight loss (5% in 1month; 10% in the past 6months).
• Multiple stage 3–4 decubitus ulcers/injuries.
• Serum albumin less than 2.5g/dL.
• Recurrent life-threatening infections such as pneumonia, pyelonephritis,
or sepsis.
• Resident has a progressively declining functional status as determined by either
a Karnofsky Performance Scale (KPS) score of <70% or an increasing dependency in 2 or more of 6 Basic Activities of Daily Living or Tasks of Daily Living.
The Palliative Performance Scale (PPS) is similar to the KPS and takes into
account ambulation, physical activity, ability for self-care, oral intake of food
and uids, and level of consciousness.
• Use of these scales can help practitioners better prognosticate how far advanced
is a resident’s illness.
• The Functional Assessment Staging (FAST) is a scale (scored 1–7) used to deter-
mine the severity of loss of function in dementia, 1 being no functional difculty
and 7 presence of signicate loss of ability to speak, ambulate, smile, and hold
their head up independently.
• The KPS, PPS, and FAST [21] scales are readily available from any hospice.
When the guidelines for disease-specic eligibility for hospice are not fully met,
the presence and severity of comorbid medical conditions and/or psychosocial factors may support eligibility. For example, advanced COPD or dementia may further
support eligibility for hospice in a resident with late-stage heart failure. Finally,
there is excellent predictive value in the “surprise question”: “Would you be surprised if a certain patient died in the next 12months?”; if so, then it would be appropriate to consider hospice care. Note that the diagnoses of failure to thrive,
generalized debility, and nonspecic terminal illness are no longer accepted as a
terminal condition under the MHB.
Certication for hospice requires that two physicians, usually the hospice medi-
cal director and the attending or referring physician, sign a statement certifying that
the patient’s medical prognosis supports a life expectancy of 6 months or less if the
individual’s illness follows its natural and expected progression. Once on hospice, a
patient must be recertied for each benet period. Recertication requires a narrative statement by the hospice medical director as to continued eligibility. With the
Integrating Palliative Care into Long-Term Care
223
MHB, the rst two hospice certication periods are each 90days and all subsequent
periods are 60days with no limit as to the number of 60 day periods. However,
continued eligibility for hospice requires that the eligibility parameters present on
admission to hospice continue to be met and that physical, functional, and/or nutritional decline continues to support that life expectancy is 6months or less if the
individual’s illness follows its natural course. Note that every 60-day recertication
period after 6months now requires a face-to-face visit by the hospice medical director or a nurse practitioner contracted by the hospice, to determine and verify continued eligibility for hospice. Every patient on hospice has the right to revoke their
hospice benet at any time in order to seek life-sustaining or curative treatment. In
such circumstances, if the treatments are of no further benet, these patients can be
readmitted to hospice if the hospice eligibility guidelines are still met.
Billing by practitioners for services rendered to patients on hospice can be confus-
ing and dependent upon the Local Medicare Intermediary (now called Medicare
Administrative Contractors). It is recommended that practitioners clarify hospice billing practices with their Medicare Administrative Contractor (MAC) or the hospice.
End ofLife Care
As patients with advanced serious and life-limiting illness enter the last months and
weeks of life, practitioners need to recognize this terminal phase and to inform
patients and family accordingly. If not already done, goals of care need to be
reviewed and modied through advanced care planning to determine whether the
patient and family want to continue to pursue life-prolonging treatments or are amenable to hospice care, with palliative care integrated into either choice. Care must
be taken to establish clear and medically appropriate goal-concordant care that
ensures a shared understanding between practitioners, patients, and family [22].
Irrespective of where a patient resides, interdisciplinary management is essential to
maintaining hope, dignity, and the best possible quality of life until the patient dies.
Eventually however, continuing life-sustaining treatments (such as IV uids, PEG
tube feeding, blood transfusions, antibiotics, pacemakers, ICDs, and hemodialysis)
during the last weeks and days of life can become overly burdensome, and cause
more harm, pain, and suffering than benet to both the patient and the family. As
such, consideration will need to be given as to discontinuing such treatments.
The physiologic changes of dying, although complex, can be effectively man-
aged if practitioners and the interdisciplinary team understand the etiologies and
underlying pathophysiology of each distressful symptom and use appropriate nonpharmacologic and pharmacologic interventions. Given each patient’s terminal illness and comorbidities, palliative drugs, equipment, and supplies should be available
in anticipation of the emergence of distressful symptoms that are likely to occur at
the end of life.
As death approaches, patients and families should be advised that fatigue and
weakness will increase while the desire for food and uid intake is reduced due to
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P. Winn
the loss of both appetite and thirst. Reduced cardiac output and intravascular volume depletion result in tachycardia, hypotension, peripheral cooling, cyanosis,
and mottling. Urine output will diminish with eventual anuria. Neurologic dysfunction will occur, leading to a decreased level of consciousness and eventual
coma. Note that 10% of dying patients may experience an agitated delirium during
the last days of life. When this occurs satisfactory symptom management can be
very challenging.
Practical interventions to maintain patient comfort include periodic reposition-
ing; decreasing food and uid intake to prevent choking or aspiration; maintaining
a moist oral mucosa; and providing moisture and lubricating agents to the conjunctiva and lips. Family members should be encouraged to participate in this care as it
can often provide them with a sense of fulllment in having helped to comfort their
loved one at end of life.
Nonessential drugs (e.g., aspirin, multivitamins, calcium supplements, lipid-
lowering agents) should be discontinued. Practitioners should also consider the benets and risks of continuing drugs such as antidepressants, antihypertensives,
warfarin, antiarrhythmics and thyroid replacement. Other drugs, such as diuretics,
ACE inhibitors, and hypoglycemic agents (even insulin) may require a dosage
reduction or even discontinuation. Be aware that reduced hepatic function and renal
perfusion can precipitate an opioid-induced terminal delirium. If this occurs, consider (1) reducing the opioid dosage while ensuring that pain is still adequately
controlled and (2) prescribing a low dose antipsychotic and gradually uptitrating
until an effective outcome is achieved.
During the last few days of life, medication reconciliation is essential to avoid
polypharmacy and its potential sequelae, especially as “comfort medications” are
administered to manage pain and distressful symptoms and suffering. Polypharmacy
can become a major issue that must be addressed.
Remember that a peaceful death is just as important to the family as to the patient,
perhaps even more so. Practitioners should be wary for the potential for surveyor
citation under F-Tag 757 that each resident’s drug regimen be free from unnecessary
drugs. For example, the prescription of either an opioid or an antipsychotic for anxiety could be construed as unnecessary.
General guidelines on the use of comfort-directed pharmacologic treatment dur-
ing the last days of life include:
• For tachypnea or breathlessness: Use low doses of an immediate release opi-
oid with or without a benzodiazepine, each administered sublingually or
transbuccally.
• For excessive respiratory or oral secretions: Consider an anticholinergic agent
administered sublingually (e.g., hyoscyamine or an ophthalmic solution of atropine) or topically (e.g., transdermal scopolamine patch). It is benecial to educate the family and staff to minimize use of suction as it can paradoxically
stimulate the production of even more secretions.
• For pain: Use a concentrated oral formulation of either morphine (e.g., Roxanol®
20mg/cc) or oxycodone (Oxyfast® 20mg/cc). Either can be administered sublin-
Integrating Palliative Care into Long-Term Care
225
gually or transbuccally. Avoid IM or SC injections if possible as these can be
painful.
• For anxiety or agitation: Use a benzodiazepine or an opioid, possibly an antipsychotic. Remember any of these can cause paradoxical agitation.
• For restlessness or delirium: Perform a careful medication review and rule out
a rectal fecal impaction or urinary bladder retention. The former will require disimpaction while the latter, placement of a Foley catheter. Ensure adequate pain
control. If needed, consider treatment with an antipsychotic, with or without a
benzodiazepine. Remember that either can cause paradoxical agitation.
• For fever: If distressing to the patient, schedule doses of acetaminophen administered orally, per rectum or per PEG (if present).
• If excessive sweating: Review medications, consider cooling the room, use a
fan, and consider an opioid dose reduction (as opioids can cause sweating) and
even cause a fentanyl patch to no longer adhere to skin.
Compounded formulations applied topically on the skin may be effective for
restlessness, though evidence is lacking. For example, compounded ABH gel contains Ativan/lorazepam, Benadryl/diphenhydramine, and Haloperidol. Review of
compounded topicals is beyond the scope of this chapter so practitioners are encouraged to contact a local compounding pharmacy or hospice agency.
Pearls for the Practitioner
• Integrate palliative care into the traditional care provided to patients throughout
the post-acute and long-term care continuum irrespective of whether they choose
to continue disease-directed or curative therapies.
• Support informed patient and family decision making through advance care
planning consistent with patient values and preferences for care.
• Determine, if possible, the pathophysiologic and clinical factors underlying each
pain and non-pain symptom in order to choose the most appropriate nonpharmacologic and pharmacologic treatment.
• Treat pain with the use of multiple modalities, both nonpharmacologic and pharmacologic as well as complementary and alternative therapies (the latter if
requested by patient/family).
• Choose the most appropriate analgesic based on the type of pain, pain severity,
potential adverse effects, and the patient’s individual characteristics.
• Always initiate a bowel regimen to prevent constipation when prescribing an
opioid and remember to intensify the bowel regimen as the dose of the opioid is
increased.
• Consider education on Risk Evaluation and Mitigation Strategy (REMS) on the
use of opioid analgesics.
• Anticipate which symptoms are most likely to occur during the patient’s illness
trajectory in addition to identifying, assessing, treating, and monitoring for distressful symptoms, and if possible, preventing their emergence.
• Consider both the general and disease-specic guidelines as a prognostic tool
when evaluating patients for hospice.
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• Consider palliative sedation to alleviate intractable and intolerable pain or suffering that persists despite aggressive palliative care.
• Use resources in your community offered by health care professionals who have
an expertise in palliative care and hospice, including the PA and LTC facility
medical director!
Suggestions for Further Reading
• AMDA White Paper on Palliative Care and Hospice in Long Term Care. (last
accessed online August 4, 2021)
• Essential Practices in Hospice and Palliative Medicine. Fifth Edition. 2017.
AAHPM.Chicago, IL
– UNIPAC 1: Medical Care of People with Serious Illness
– UNIPAC 2: Psychiatric, Psychological and Spiritual Care
– UNIPAC 3: Pain Assessment and Management
– UNIPAC 4: Nonpain Symptoms Management
– UNIPAC 5: Communication and Teamwork
– UNIPAC 6: Ethical and Legal Practice
– UNIPAC 7: Pediatric Palliative Care and Practice
– UNIPAC 8: COPD, Heart failure, and Renal Disease
– UNIPAC 9: HIV, Dementia, and Neurological Conditions
• Equianalgesic Guide for Adults and Children. Revised 2019. AAHPM. (a fourpaged fold out)
• Pain Management in the Post-Acute and Long-Term Care Setting: Clinical
Practice Guideline. 2021. The Society for Post-Acute and Long-Term Care
Medicine. Columbia, MD
• Pain Management in the Post-Acute and Long-Term Care Setting. Pocket Guide.
2018. The Society for Post-Acute and Long-Term Care Medicine. Columbia,
MD (A spiral bound concise 27-page pocket size guide printed in thin cardboard)
• Primer of Palliative Care. 7th edition. 2019.
• Periyakoil VS, Denney-Koelsch EM, White P, Zhukovsky DS, Quill
TE.Chicago, IL.
• Emanual LL and Librach SW. (Editors). Palliative Care: Core Skills and Clinical
Competencies. 2nd edition. Elsevier Saunders. 2011.
• McPherson ML. Demystifying Opioid Conversion Calculations: A Guide for
Effective Dosing. American Society of Health-System Pharmacists. 2nd ed. 2018.
• Chochinov HM.Dignity Therapy: Final Words for Final Days. Oxford University
Press Inc. 2012.
• Matzo M. and Sherman D. (Editors). Palliative Care Nursing Education: Quality
Care to the End of Life, Fourth Edition. Springer Publishing Company,
NewYork. 2015.
• Winn P.Essentials of Hospice: What Every Practitioner Needs to Know but Are
Afraid to Ask. Internal Medicine Review, Vol 5, Issue 1. 2019
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