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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3055_Библиотеки_им_академика_М_И_Перельмана.pdf
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and falls, e.g., tricyclic antidepressants (imipramine, doxe-
pin, amoxapine, trimipramine).
• Be familiar with the Beers Criteria to avoid medications
that should not be used in older adult.
• See Beers Criteria: onlinelibrary.wiley.com/doi/10.1111/
jgs.1370.
• In treating insomnia, avoid diphenhydramine and benzo-
diazepine medications. Evaluate carefully for fall risk
before prescribing any sedating medications.
Don’t Miss This!
1. Minimize the use of medication whenever possible. Review
the patient’s medication list at every visit, and remove
unnecessary and duplicative medications. Review the
Beers Criteria to avoid medications that can be harmful to
older adults.
2. Assessing and improving function and social supports are
major focus of geriatric care.
3. Care of the older adult is best delivered by a multidisci-
plinary team including social work, physical and occupa-
tional therapy, mental health, and nutrition services.
4. Advanced directives and goals of care should be clarified
initially and updated periodically with any change in health
status.
5. Dementia care requires education and support of the
patient and caregiver. Recognizing and alleviating care-
giver stress should be part of good dementia care.
References
1. U.S. Department of Health and Human Services. Administration
on aging statistics. Administration for Community Living. Last
modified 9/8/2014.
2. Warshaw G, Bragg E, Fried L, Hall W. Consensus among directors
of geriatrics academic programs. JAGS. 2008;56(10):1796–801.
3. Berkman LF, Leo-Summers L, Horwitz RI. Emotional sup-
port and survival after myocardial infarction. Ann Intern Med.
1992;117:1003–9.
3. Home Care/Care of Elderly
78
4. Pahor M, Guralnik J, Salive M, et al. Disability and severe gas-
trointestinal hemorrhage. A prospective study of community-
dwelling older persons. JAGS. 1994;42:816–25.
5. Lachs M, Feinstein A, Cooney L, et al. A simple procedure for
general screening for functional disability in elderly patients.
Ann Intern Med. 1990;112(9):699–706.
6. Trang V, Farish S, Jenkins M. A meta-analysis of effectiveness of
influenza vaccine in persons aged 65 years and over living in the
community. Vaccine. 2002;20(13–14):1831–6.
7. Christenson B, Lundbergh P, Hedlund J, et al. Effects of a large-
scale intervention with influenza and 23-valent pneumococcal
vaccines in adults aged 65 years or older: a prospective study.
Lancet. 2001;357(9261):1008–11.
8. Centers for Disease Control and Prevention (CDC). Updated
recommendations for use of tetanus toxoid, reduced diph-
theria toxoid, and acellular pertussis (Tdap) vaccine in adults
aged 65 years and older—advisory committee on immuniza-
tion practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep.
2012;61(25):468–70.
9. Kimberlin D, Whitley R. Varicella-zoster vaccine for prevention
of herpes zoster. N Engl J Med. 2017;356:1338–43.
10. Uspstf. Recommendations For Primary Care Practice. https://
www.uspreventiveservicestaskforce.org.
11. Lee SJ, et al. “Eprognosis: estimating prognosis for elders”.
Division of Geriatrics at the University of California San
Francisco. eprognosis.org. Accessed 29 Sep 2015.
12. Nelson M, Rejeski W, Blair S, et al. Physical activity and public
health in older adults: recommendation from the American
College of Sports Medicine and the American Heart Association.
Circulation. 2007;116(9):1094–105.
13. Uchino BN, Cacioppo JT. The relationship between social sup-
port and physiological processes: a review with emphasis on
underlying mechanisms and implications for health. Psychol
Bull. 1996;119(3):488–531.
14. Alzheimer’s Association. Alzheimer’s disease facts and figures.
Alzheimers Dement. 2016;12(4):459–509.
15. Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion:
the confusion assessment method: a new method for detection
of delirium. Ann Intern Med. 1990;113(12):941–8. https://doi.
org/10.7326/0003-4819-113-12-941.
16. Taylow W, Aizenstein H, Alexopoulos G. The vascular depression
hypothesis: mechanisms linking vascular disease and depression.
Mol Psychiatry. 2013;18:963–74.
V.M. LoFaso
79
17. American Geriatrics Society and British Geriatrics Society.
AGS/BGS clinical practice guideline: prevention of falls in older
persons: summary of recommendations. New York: American
Geriatrics Society.
18. Mathias S, Nayak USL, Isaacs B. Balance in elderly patients: the
“get- up and go” test. Arch Phys Med Rehabil. 1986;67:387–9.
19. JAGS. American Geriatrics Society 2015 updated beers criteria
for potentially inappropriate medication use in older adults.
J Am Geriatr Soc. 2015;63:2227–46.
20. Abrams A, Baron E et al. American Medical Association/
American Academy of home care physicians: medical man-
agement of the home care patient. In: Ramsdell JW, Joanne
G. Schwartzberg; 2007.
21. Unwin B, Maj MC. The home visit. Am Fam Physician.
1999;60(5):1481–8.
22. Fardellone P. Predicting the fracture risk in 2008. Joint Bone
Spine. 2008;76(6):661–4.
23. Lachs, M., Berman, J. “Under the radar: New York State elder
abuse prevalence study” Prepared by Lifespan of Greater
Rochester, Inc., Weill Cornell Medical Center of Cornell
University, and New York City Department for the Aging; 2011.
24. Yaffe MJ, Wolfson C, Lithwick M, Weiss D. Development and
validation of a tool to improve physician identification of elder
abuse: the elder abuse suspicion index (EASI)©. J Elder Abuse
Negl. 2008;20(3):276–300.
3. Home Care/Care of Elderly
81© Springer International Publishing AG 2018
E. Sydney et al. (eds.), Handbook of Outpatient Medicine,
https://doi.org/10.1007/978-3-319-68379-9_4
Palliative care, and the medical subspecialty of Palliative
Medicine, is specialized medical care for individuals living
with serious and often life-threatening illness. It employs an
interdisciplinary approach to provide relief from the symp-
toms and stress of a serious illness. The goal is to improve
quality of life for both the patient and the family [1]. Palliative
care can be delivered in conjunction with disease-directed
(curative) care as a continuum, and toward the end of life, it
transitions to hospice care. Symptoms, such as shortness of
breath, constipation, nausea, pain, delirium, insomnia, and
anxiety/depression, are closely managed to help improve
quality of life and relieve suffering and discomfort. While the
patient is the central focus of management in palliative care,
the specialty recognizes the importance of providing support
to the patient’s caregiving unit throughout the disease pro-
cess, including bereavement support.
Chapter 4
End-of-Life Care/Pain
Management/Palliative
Tabitha N. Goring
T.N. Goring, MD (*)
Hospital Medicine Service, Department of Medicine,
Memorial Sloan Kettering Cancer Center,
1275 York Avenue, Box #438, New York, NY 10065, USA
e-mail: Goringt1@mskcc.org
82
Palliative Care vs. Hospice Care
Hospice care is a type of palliative care, but not all palliative
care is hospice care. The two terms should not be used inter-
changeably. Hospice care is the delivery of palliative care
services to someone who is terminally ill with an estimated
prognosis of 6 months or less if the disease runs a normal
course [2]. Both palliative care and hospice care are a multi-
disciplinary approach toward pain control, symptom manage-
ment, and psychosocial and spiritual support for the patient
and the family. Palliative care can and should be offered at
anytime during a potentially life-limiting illness and can be
delivered concomitantly alongside life-prolonging treatment.
Palliative care is not intended to be limited to only the last
6 months of life. Once it is determined that the patient’s life
expectancy is <6 months, the patient can elect to enroll in the
hospice benefit, at which time palliative care transitions to
hospice care. Services delivered are similar, but once transi-
tioned to hospice, medical treatments with curative intent are
relinquished. Hospice care can be delivered in various care
settings including the patient’s home, a designated hospice
facility, a nursing home, or a hospital. The word “hospice” is
sometimes confusing because the term can be used to
describe an actual place or a type of care. Both Medicare and
some private insurance companies cover hospice services
depending on the qualifying diagnosis. Most patients receiv-
ing hospice care do have cancer; however, there are multiple
non- cancer qualifying diagnoses for which services are
offered such as dementia, ALS, Parkinson’s disease, end-stage
CHF/COPD/cirrhosis, stroke, or HIV/AIDS, to name a few.
Two physicians must certify the clinical need for hospice ser-
vices and attest based on clinical judgment, that the patient
has a less than 6-month life expectancy, if the illness takes its
normal course [2]. Hospice services are multidisciplinary and
should include a physician, nurse, nurse’s aides, social worker,
chaplaincy, nutritionist, psychologist, and other staff as
deemed appropriate.
T.N. Goring
83
Role of the Primary Care Physician vs.
Palliative Care Subspecialist Referral
Primary care physicians are well positioned to deliver
effective palliative care. Palliative care specialists have spe-
cial training in advanced pain management, symptom man-
agement, hospice eligibility, and bereavement. Basic pain
management and symptom control can be initiated and
managed without a subspecialty referral. One key goal of
palliative care is to reduce emergency room visits and fre-
quent unnecessary hospitalizations which are uncomfort-
able for the patient at the end of life. A palliative care
subspecialty referral should be considered under the fol-
lowing circumstances: complex family dynamics, compli-
cated pain management, ongoing symptomatology
refractory to conventional treatments, complex goals of
care, challenging end-of-life discussions, and/or in cases
where the primary clinician is uncomfortable with any
aspect of delivering palliative care.
Key History Components Unique
to the Palliative Care Assessment
Palliative symptom
Previous palliative procedures and medications
Detailed pain assessment
Determine patient’s disease awareness
Values/preferences/religion
Support system
Assessment
Goals of care and advance care planning
Disposition
4. End-of-Life Care/Pain Management/Palliative
84
Management of common palliative
symptoms—shortness of breath, constipation,
nausea, and pain
Shortness of Breath
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
initially evaluated as any patient with SOB. Determine
whether the underlying cause is reversible or can be improved
by minimally invasive measures. Both medical management
and surgical management may be options. Discuss the degree
of work-up desired by the patient, considering extent of dis-
ease and functional status. If not clarified previously, discus-
sions about intubation and code status should be initiated
and the patient’s wishes documented. Shortness of breath is a
symptom that should be stabilized and managed aggressively
in order to ensure the patient’s comfort. Assess for reversible
causes and consider referral to an inpatient facility to stabi-
lize the respiratory status—hospital vs. inpatient hospice
facility vs. continuous home care if enrolled in hospice.
Reversible causes should be addressed to the extent that the
patient can be returned to an acceptable baseline. Invasive
procedures can be pursued if they are congruent with the
patient’s goals of care. In the actively dying patient, the focus
is on comfort and control of the patient’s respiratory drive in
order to minimize labored breathing and distress. 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 facil-
ity—hospital or inpatient hospice for O2 via this modality—if
that is in keeping with the patient’s goals. Opiates, including
morphine, are well known to have positive effects on control
of dyspnea and/or air hunger [3]. Morphine is the most
commonly used opiate, but any opioid analgesic agent can be
T.N. Goring
85
administered for air hunger. Opioids can be delivered orally,
sublingually, subcutaneously, transdermally, intrathecally, or
via an intravenous drip (Fig. 4.1).
Shortness of Breath
Check for potentially
reversoble causes:
Bronchospasm → Nebs
Ativan IV to suppress
respiratory drive
Morphine for air
hunger SL or vis IV drip
Chlorpromazine
PO/SQ or infusion
CHF → consider
BNP/Echo → Lasix
Pneumonia → Abx +/-
Steroids
Pleural Effusion →
thoracentesis, PleurX
Anxiety → anxiolytics
Acute or Chronic PE →
LMWH
If pt is actively dying:
Consider positioning,
fan, breathing training
Consider O2 via NC
and titrate up to Pulse
Ox of 92%
Assess Respiratory Rate
Check Pulse Ox
Ascultate Lungs
Refer to CXR (if available)
ABG (if appropriate)
Fig. 4.1 Algorithm for shortness of breath at the end of life
4. End-of-Life Care/Pain Management/Palliative
86
Constipation
Constipation can be a very uncomfortable symptom in the
palliative care population and should be managed aggres-
sively for comfort. Opioid use, chronic dehydration (poor PO
intake, anorexia, vomiting, diarrhea), and limited mobility are
the main factors that place this population at such high risk
for constipation.
Initial evaluation includes a thorough H&P. Key history
includes stool frequency, opioid use, and medication history.
Key physical exam includes hydration status, a thorough
abdominal exam to r/o bowel obstruction ± rectal exam to r/o
stool impaction, if indicated. Determine if there is an under-
lying, 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, bowel training, and/or encourage exer-
cise. Anorectal testing, colonic transit testing, defecography,
and surgery are usually too invasive and unlikely to be ben-
eficial in the palliative care population. Biofeedback, or pel-
vic floor training, could be considered. Appropriate treatment
includes stool softeners, laxatives (bulk, osmotic, stimulant),
rectal suppositories, and enemas in escalating doses and com-
binations. There are currently no evidence- based guidelines
on the order in which to give laxatives, but the American
Gastroenterological Association provides guidelines for ini-
tial management of constipation [4]. Know the difference
between stimulant (bisacodyl, senna) and osmotic (polyethyl-
ene glycol, lactulose, sorbitol, milk of magnesia (MOM),
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 liquids. Stimulant laxatives, for example, may
cause excessive cramping. Prescribe the form most comfort-
able for the patient at the lowest dose to encourage a bowel
movement (Fig. 4.2).
T.N. Goring
87
Constipation
History and Physical
Perform Abdominal Exam
Abdominal Distention → Consider
Upright KUB xray to r/o
obstruction/perforation
Consider Rectal Exam r/o impaction
Discontinue non-essential
constipating meds
Step 1Step
2S
tep 3
Increase Dietary Fiber
Bulk-Forming Laxative
(Psyllium)
Laxative + Suppository/Enema
Polyethylene Glycol/Senna
+/- Promotility Agents
Lactulose/Mag Citrate/
Polyethylene glycol
Chronic Opiate Use →
Methylnaltrexone (SQ) if no
bowel obstruction
Stool Softeners (Docusate)
Gentle Laxative (MOM)
Fig. 4.2 Management of constipation in palliative care
4. End-of-Life Care/Pain Management/Palliative