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6 - Palliative and Hospice Care |
137
Psychostimulants
Methylphenidate Depression in
terminally ill
patients
Fatigue in
advanced
disease
2.5 mg in the morning MDD = 20 mg; if twice-daily
dosing, 2nd dose should not
be later than noon
Miscellaneous Antianxiety Agents
Buspirone Anxiety 7.5 mg twice daily
Appetite Stimulants and Agents Used for Appetite
Megestrol acetate Anorexia 160 mg/day MDD = 800 mg
Dronabinol Anorexia 2.5 mg twice daily MDD = 20 mg
Metoclopramide Anorexia
Gastric stasis–
induced
nausea and
vomiting
5 mg twice daily MDD = 80 mg
Anticholinergic Agents
Atropine Terminal secre
-
tions
0.4–0.6 mg every 4 hr prn Ophthalmic solution may be
administered sublingually;
anticholinergic side effects,
especially in the elderly
(delirium, lethargy, urinary
retention, constipation)
Hyoscyamine Terminal secre
-
tions
0.125 mg every 6 hr prn MDD = 1.5 mg; same side
effects as above
Glycopyrrolate Terminal secre-
tions
0.2–0.4 mg to 2 mg IV or
SC every 4 hr prn
Same side effects as above;
may be better tolerated
MDD, maximum daily dose; MAOI, monamine oxidase inhibitor; po, by mouth; PPI, proton pump inhibitor; prn,
as needed; GI, gastrointestinal; NSAID, nonsteroidal anti-inflammatory drug; CrCl, creatinine clearance; IV,
intravenous; SC, subcutaneous; SNRI, selective serotonin/norepinephrine reuptake inhibitor; SSRI, selective
serotonin reuptake inhibitor.
For additional information, see references 16 and 38.
Pruritus
Pruritus (itching) is not a common symptom in
palliative care, but when it occurs it can be very
bothersome for the patient. Severe itching seen
in patients with advanced disease is usually
associated with uremia, cholestasis, opioids,
solid tumors, and hematologic disorders. Previ-
ously, H
1
receptor antagonists were the drug of
choice for pruritus. However, in the palliative care
setting, pruritus is not usually due to histamine
release and, therefore, antihistamines are not
typically beneficial. Serotonin may have a role in
pruritus secondary to malignant disease, uremia,
and opioids. Therefore, selective serotonin reup-
take inhibitors (SSRIs) may be reasonable medi-
cations to try in these patients. It is better to start
with small doses; effects are usually seen within
24–48 hours. Another agent with similar benefits
is mirtazapine 15 mg at bedtime. Ondanse-
tron, a 5-HT
3
receptor antagonist, may be tried;
however, it is more expensive and may cause
constipation.
55
Anxiety and Depression
Depression is common among older adults with
advanced illness;
however, it is often under-
recognized and undertreated.
56,57
Diagnosing
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| Fundamentals of Geriatric Pharmacotherapy
patients exhibit signs and symptoms of patho-
logic anxiety (see Table 6-5). Usually, this type of
anxiety must be managed with SSRIs and buspi-
rone, the agents of choice for general anxiety
disorder in the elderly. These drugs, however, are
only advantageous if the patient has a 2-month
or longer life expectancy.
62,63
For acute anxiety,
benzodiazepines are best. If the patient also has
delirium, other agents such as typical and atyp-
ical antipsychotics may be used. Benzodiaze-
pines have an increased risk of causing falls and
cognitive impairment. Lorazepam and oxazepam
are the preferred agents because they have no
active metabolites and intermediate half-lives.
If
benzodiazepines worsen or cause delirium, low-
dose risperidone or haloperidol may be used.
38
Table 6-5. Behaviors Associated with
Pathologic Anxiety
Intense worry or dread
Physical distress (e.g., tension, restlessness)
Maladaptive behaviors (e.g., treatment
nonadherence, social withdrawal, avoidance)
Diminished coping
Inability to relax
Depression
Fatigue
GI upset
Dyspnea
Dysphagia
For additional information, see reference 38.
Nausea and Vomiting
Up to 70% of palliative care patients experience
nausea and vomiting, often in the last 6 weeks
of life.
64
Uncontrolled nausea and vomiting are
extremely distressing and decrease a patient’s
quality of life. There are many causes, and the
specific origin of a patient’s symptoms should
be identified to best treat or prevent them. Some
causes of nausea and vomiting are constipa-
tion, medications, infection, bowel obstruction,
increased intracranial pressure, chemotherapy,
and untreated pain.
65
Nonpharmacologic thera-
pies are discussed in Chapter 11.
depression is difficult in elderly patients who
are in the final stages of life, especially if they
also have cognitive dysfunction.
58,59
Treatment
of depression in a palliative care patient is
dependent on the severity of the depression,
the patient’s ability to respond to nonpharmaco-
logical therapy (e.g., psychotherapy), and life
expectancy. First-line pharmacologic treatment
of depression in the elderly is usually initiated
with SSRIs, such as sertraline, citalopram, and
escitalopram. These are well tolerated, have few
drug-drug interactions, and have a low side effect
profile.
38
Another agent that may be beneficial is
mirtazapine; lower doses are more sedating, if
insomnia is a problem. Taking advantage of the
side effect profile of a medication can help treat
bothersome symptoms associated with the end
of life. The TCAs as well as the SNRIs may be
useful and should be considered in patients who
experience chronic pain or neuropathic pain
syndromes.
60
All of these agents take 4–6 weeks to show
an antidepressant effect. Unfortunately, if a
patient has <2 months to live, this would not allow
enough time for a benefit to be seen. Psycho-
stimulants (e.g., methylphenidate, dextroam-
phetamine) are beneficial in providing a rapid
response in mood elevation in certain situations
as described above. However, signs and symp-
toms of agitation must be monitored, because
this is a potential side effect.
58
Overstimulation,
another side effect, is rarely a concern because
terminally ill patients usually experience fatigue.
38
Anxiety is the most common mental disorder
and is prevalent at the end of life.
61
Early stages
of delirium may mimic anxiety, and undertreated
pain and dyspnea can cause or worsen anxiety.
The drugs discussed above are generally pref-
erable in palliative care, because the older
antipsychotics or antiemetics have side effects
that mimic anxiety (e.g., akathisia).
38
Untreated
anxiety may hinder the ability to achieve treat-
ment goals.
Nonpharmacologic management of anxiety
should be addressed, including identification
and treatment of the underlying cause (when
possible) as well as emotional support. Some
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Four main mechanisms of nausea and
vomiting are stimulation of the chemoreceptor
trigger zone, pathology of the cerebral cortex,
GI dysfunction, and vestibular activity. Pharma-
cologic treatment aims to block stimulation of at
least one of these mechanisms. Table 6-6 lists
common causes and possible medications to
treat different types of nausea in palliative care.
In terminally ill patients, stimulation of the chemo-
receptor trigger zone is the most common cause.
The most common neurotransmitters involved
are dopamine (D2), serotonin, and neurokinin-1.
Treatment is usually based on blocking the
actions of D2 at the D2 receptor. Initiate treat-
ment with low doses in the elderly to decrease
the chance of unwanted side effects. Chapter 11
discusses these agents in detail.
Other potential causes include gastritis,
gastroesophageal reflux disease, and peptic
ulcer disease. These should be treated with
histamine antagonists or proton pump inhibi-
tors.
64-67
Medications used to treat refractory
nausea and vomiting include combinations
of agents listed in Table 6-6 as well as agents
mentioned in Chapter 11.
38
KEY POINT:
In treating nausea, remember
(1) prevention is the best treatment,
(2) treatment via oral routes is as eective
as parenteral routes, (3) initiate with the
lowest eective dose, and (4) when selecting
an agent, consider the side eects.
Although many agents treat and prevent
nausea, no current standard exists for anti-
emetic therapy in the elderly, so that evidence
comparing the different agents in this patient
population is limited.
56
Anorexia
Anorexia is a loss of appetite resulting in
decreased intake. It is a common GI disorder
that may occur in patients with advanced illness.
It can be bothersome not only for patients but
also family members. The disorder can occur
alone, or in combination with many end-of-life
diseases, such as cancer, acquired immune
deficiency syndrome (AIDS), COPD, dementia,
and heart failure. Before initiating pharma-
cologic treatment, reversible and underlying
causes should be ruled out.
68
These include (but
are not limited to) pain, mucositis, delirium, GI
causes (e.g., constipation, nausea and vomiting,
delayed gastric emptying), depression, and
endocrine disorders (e.g., thyroid dysfunction,
metabolic abnormalities). Once these causes
are addressed, pharmacologic considerations
may be considered. These interventions will
likely have no impact on survival; therefore, treat-
ment is usually aimed at improving quality of life
by decreasing symptoms, which include lack
of appetite, nausea, early satiety, and fatigue.
69
However, it is important to note that when death
is imminent, patients are normally not hungry.
Fluids and food should never be forced on the
patient, for even the presence of food in the
stomach may produce pain.
If treatment is warranted, it should be
aimed at providing pharmacologic as well as
nonpharmacologic options. Nonpharmacologic
approaches include dietary alterations, such
as eating several small meals throughout the
day instead of three large meals, and advising
the patient to eat his or her favorite meals while
getting rid of meals with strong tastes or odors.
68
The dying patient is also likely to experience
dysgeusia, a condition in which the sense of
taste may be radically altered, causing foods
and beverages once pleasant to be perceived
as repellent. Helpful approaches will vary from
patient to patient.
Medications used to stimulate appetite
may offer symptomatic relief. Some of the most
common agents used to stimulate appetite are
listed in Table 6-4. Megestrol acetate and corti-
costeroids have the most evidence of efficacy in
anorexia. Other agents have been used, but with
limited evidence for improvement of appetite or
weight.
69
Megestrol acetate is the most studied
agent, although it is recommended for use with
caution in elderly patients. Starting doses of
160 mg/day have shown improvements in not
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| Fundamentals of Geriatric Pharmacotherapy
only appetite but fatigue and overall quality of
life as well. Although doses up to 800 mg/day
have been shown to be optimal for treatment
of anorexia in patients with cancer,
there are
dose-related side effects and increased costs at
higher doses.
70
Therefore, start at lower doses
and increase as clinically needed and tolerated.
The mechanism of action of megestrol acetate is
not completely understood; however, it is thought
to be related in part to glucocorticoid activity.
69
Corticosteroids are another class of medi-
cations that have shown temporary benefit (over
several weeks) in appetite in many randomized
controlled trials versus placebo. Corticoste-
roids have also shown improvements in pain (as
mentioned above), nausea, and well-being
69
;
however, none of these studies have actually
shown improvements in weight.
71-73
Due to the
risk of side effects with prolonged use, these
agents should be saved for patients with a life
expectancy of <6 weeks, and those with other
symptoms, such as nausea or pain.
69
At present,
no studies have shown the best dosing regimen
and schedule; however, it is considered appro-
priate in the geriatric population to start with
low doses given earlier in the day to avoid side
effects such as insomnia.
Table 6-6. Pharmacologic Therapy Used for Nausea and Vomiting
38
Cause of Nausea
and Vomiting Examples Pharmacologic Therapy
Chemoreceptor trigger
zone induced
1. Opioids
2. Chemotherapy
3. Bacterial toxins
4. Uremia
1. Butyrophenones (e.g., haloperidol)
2. Phenothiazines (e.g., prochlorperazine)
3. Metoclopramide
4. Serotonin antagonists (e.g., ondanse
-
tron, granisetron)
a
GI tract induced 1. Gastric stasis
2. GI obstruction
3. Drugs and diseases that decrease
gastric emptying (e.g., opioids
and occurs with diabetes mellitus,
chronic renal failure, and neuro
-
logical disorders)
4. Metastatic disease
5. Bacterial toxins
6. Chemotherapy
7. Radiation therapy
1. Metoclopramide
2. Anticholinergics (e.g., hyoscyamine)
Cerebral cortex induced 1. Anticipatory (anxiety, taste, or smell
induced)
2. Intracranial pressure induced
1. Anticipatory-induced nausea and
vomiting is usually treated with
anxiolytics, such as benzodiazepines
(e.g., lorazepam, alprazolam)
2. Intracranial pressure–induced nausea
and vomiting may be treated with
corticosteroids (e.g., dexamethasone)
b
Vestibular activity
induced
1. Opioids
2. Movement induced
1. Antihistamines
c
(e.g., meclizine)
2. Anticholinergics
c
(e.g., scopolamine)
a
These medications are used mainly for chemotherapy- and radiotherapy-induced nausea.
b
Dexamethasone may be used for nonspecific nausea and vomiting; the mechanism of action is unknown.
c
Use with caution in the elderly; may cause confusion, constipation, urinary retention, and orthostatic hypotension.
For additional information, see reference 38.
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Cannabinoids are well known for their ability
to increase appetite. Dronabinol and nabilone
are synthetic agents in this class. Using these
agents to stimulate appetite in diseases other
than AIDS-related cachexia is considered an
off-label use. Studies evaluating dronabinol at
doses of 2.5–5 mg twice to three times daily have
shown significant improvements in appetite in
patients with AIDS and cancer-related cachexia.
However, as with other agents, there was little
to no improvement in weight.
74,75
Another study
evaluating dronabinol versus megestrol acetate
for advanced cancer showed megestrol acetate
to be more beneficial for improving appetite.
76
These agents may also improve mood and
decrease nausea, but their use is often limited
due to central nervous system side effects.
69
In
elderly patients, these side effects may be exag-
gerated due to increased sensitivity to medica-
tions and other medications the patient may take
that affect the central nervous system. It is impor-
tant to remember to titrate the dose slowly based
on clinical response.
Metoclopramide is sometimes recom-
mended for treatment of anorexia; however, it
is usually reserved for patients with symptoms
of delayed gastric emptying that can lead to
nausea and early satiety. It has little effect on
appetite. Metoclopramide has prokinetic proper-
ties and increases motility through the GI tract.
By decreasing nausea and early satiety, it may
indirectly lead to increased appetite. Metoclo-
pramide requires dosing four times per day and
can have severe side effects.
69
Dosing for elderly
patients should be at the lower end of the recom-
mended range and adjusted for renal function.
Mirtazapine is known to cause weight gain
and increased appetite in patients treated for
depression.
77
Because of this effect, it has been
used for appetite stimulation in patients with
advanced diseases. It can also cause sedation,
which may be helpful for patients suffering from
insomnia. Mirtazapine clearance is decreased by
40% in elderly males and 10% in elderly females;
therefore, starting at a lower dose is best. Optimal
dosing regimens are not well defined due to lack
of controlled trials.
69
However, it is important to
remember to start at lower doses and increase
based on clinical effect and tolerance.
Fatigue
Fatigue is common in advanced disease.
56
There
are many studies evaluating assessment tools
for fatigue in patients with advanced disease,
but few of them have been validated in geriatric
patients.
78
There are limited data available about
the best treatment for fatigue.
Stimulants (e.g., methylphenidate)
are often
prescribed, but at present there are no studies
with definitive guidance or support for this. A
literature review of 19 controlled trials evaluated
methylphenidate in palliative care patients or
older patients with advanced disease. This review
showed conflicting results, had a small sample
size, and the authors were unable to conclude
whether this medication was effective.
79
Another
study found that overall, methylphenidate was
not effective in treating cancer-related fatigue;
however, in the patients with more advanced
disease or more severe fatigue, the study found
that the patients receiving methylphenidate did
better overall.
80
Although stimulants are used,
more studies are needed to assess their use in
palliative care.
Dyspnea
Dyspnea, described as shortness of breath,
chest tightness, inability to get enough air, and
a feeling of drowning or suffocation, tends to
worsen in the last weeks of life.
81,82
These symp-
toms are more common in older patients and
produce a decreased quality of life.
55
Symptoms
may be worsened or caused by medication
side effects (e.g., chemotherapy),
83
decreases
in muscle mass in older adults, pulmonary
edema associated with heart failure, anemia as
seen with end-stage kidney disease,
84
infection,
depression, bronchospasm, and anxiety.
81,82,85,86
Dyspnea is subjective, and patient self-report is
the only dependable marker. Nonpharmacologic
treatment may be helpful, such as identifying and
avoiding triggers that can cause attacks (e.g.,
strong perfumes, smoking), using fans or open
windows to improve air circulation, correct posi-
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| Fundamentals of Geriatric Pharmacotherapy
tioning to provide comfort (especially in patients
with COPD), and relaxation exercises that may
decrease anxiety.
38
In the pharmacologic management of
dyspnea, many studies show improvement with
the use of opioids. Opioids are often consid-
ered first-line therapy in end-of-life care, once
other causes are ruled out, or if treatment of
other causes does not completely ease the
dyspnea.
85,86
In dyspnea, the main mechanism of
action of opioids is the reduction of the response
to hypoxia and hypercapnia, thereby decreasing
the patient’s awareness of the breathing state.
38
Doses used are much smaller than those for pain
treatment and may be given every 1–2 hours as
needed.
61
A long-acting opioid may be initiated
for patients requiring frequent administration to
control their symptoms.
Benefit has been shown with both oral and
parenteral opioid dosing, but it is unclear whether
using nebulized opioids is of any benefit.
87
Regardless, many patients and physicians report
decreased dyspnea symptoms with nebulized
opioids. Advantages are fast action and possibly
fewer side effects (due to decreased bioavail-
ability). Several uncontrolled trials have shown
benefit with nebulized morphine at doses of
10–40 mg.
88,89
Studies have shown that although
dyspnea symptoms decrease with opioid use,
respiratory rate does not change,
35,90
indicating
safety with opioid use.
91,92
Other options for treatment of dyspnea are
benzodiazepines and use of oxygen. Benzodi-
azepines may help with feelings of anxiety asso-
ciated with breathlessness.
93
In the elderly, low
doses of benzodiazepines, such as lorazepam
0.25 mg every 6–8 hours as needed, should
be used. Studies evaluating the use of oxygen
for management of dyspnea suggest that for
patients without hypoxia, using oxygen for
dyspnea is no better than breathing room air.
94
Other treatment options for dyspnea
depend on the underlying cause. For example,
in patients with advanced heart failure, diuretics
are the mainstay of treatment.
95
Eventually, these
patients may develop diuretic resistance and
require other pharmacologic treatment, such as
isosorbide dinitrate, hydralazine, and inotropic
agents (e.g., milrinone, dobutamine).
60
For
patients suffering from end-stage COPD, bron-
chodilators (e.g., albuterol, ipratropium) or oral
steroids for inflammation may be considered.
Nebulized bronchodilators may be more effec-
tive in patients who cannot use inhalers because
they are weak and have a difficult time actuating
the inhaler. It may also be useful to consider
adding a cough suppressant such as dextro-
methorphan or hydrocodone in patients who
have dyspnea from extreme coughing.
38
KEY POINT:
Studies have shown that
although dyspnea decreases with opioid
use, respiratory rate does not change,
indicating safety with opioid use.
Agitation and Delirium
Agitation, hallucinations, and delirium are asso-
ciated with cognitive impairment and result in
patient and family distress.
96
Delirium is one of
the most common reasons to use palliative seda-
tion, discussed below.
97
Reversible causes of
delirium or agitation such as infection, untreated
pain,
98,99
dehydration, metabolic disturbances,
side effects of drugs, urinary retention, consti-
pation or fecal impaction, and alcohol or drug
withdrawal
100,101
should be identified and treated.
Once delirium is identified with no reversible
causes, there are mixed recommendations as to
the best management.
Delirium occurs in >80% of terminally ill
patients, usually during the last few days of life.
Patients with delirium may demonstrate confu-
sion or an inability to either continue or alter
attention. Sundowning is a common phenom-
enon in terminally ill, end-of-life patients, particu-
larly those suffering from delirium, characterized
by daytime sleepiness and nighttime agitation or
inability to rest. Patients may demonstrate hypo-
active delirium or delirium with agitation; either
way, treatment is still the same.
38
Pharmaco-
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logical treatment may only be necessary if the
patient is aggressive or agitated. Those who are
not agitated may only require comfort.
Antipsychotics (conventional or atypical)
are the most common agents used for treat-
ment of agitation. Use of these medications
for treatment of delirium is an off-label use. In
palliative care, haloperidol is the drug of choice.
Doses <2 mg/day are usually well tolerated and
nonsedating. In some cases, the goal of therapy
is sedation; for example, patients with terminal
delirium who are agitated or aggressive, with
whom chlorpromazine may be used, because
it provides more sedation than haloperidol.
100-103
Although chlorpromazine can cause ortho-
static hypotension, this is not a concern when
patients are confined to a bed and at the end
of life. If patients are unable to swallow, both of
these medications may be given sublingually or
rectally, although these are not approved dosage
routes. Haloperidol can also be given subcuta-
neously
104
at 50% of the oral dose.
35
Atypical antipsychotics (e.g., quetiapine,
risperidone, olanzapine) may be used to manage
delirium. Risperidone is available in a rapidly
dissolving oral dosage form for those unable to
swallow. Olanzapine is commercially available
for intramuscular injection. These alternative
dosage forms may be beneficial in certain situ-
ations. Benzodiazepines given alone for treat-
ment of delirium may worsen the delirium and
confusion. Occasionally, it is beneficial to add
benzodiazepines to antipsychotics if sedation is
necessary.
105
Terminal Secretions
Terminal secretions, also known as the death
rattle, occur when the patient has only days
or hours left to live. Studies show that terminal
secretions are predictive of impending death,
with up to 76% dying within 48 hours of onset.
106
Patients lose the ability to swallow their oral
secretions, which accumulate in the airway and
as air passes through the mucus cause a rattling
or gurgling sound.
106
This is disconcerting to the
patient’s family present at the bedside. Treatment
is usually indicated due to the distressing impact
on the family. Sometimes, elevating the head of
the bed and positioning the patient somewhat
on one side may help the secretions drain out of
the airways. Symptoms should also lessen as the
patient becomes more dehydrated. If there is no
improvement, or if the symptoms cause extreme
anxiety among family, anticholinergic agents may
be used.
106-109
These medications help to further
reduce secretions. They do not decrease existing
secretions and, therefore, work best when given
at symptom onset. Anticholinergics that may be
used include atropine, hyoscyamine, and glyco-
pyrrolate. Doses for the elderly should be given
at the lower end of those prescribed in younger
adults. These medications should not be used in
those who experience secretions secondary to
pneumonia or pulmonary edema.
109
Proportionate Palliative Sedation
Sometimes, it may be difficult to control intrac-
table physical symptoms in actively dying
patients. In these circumstances, intractable
symptoms at the end of life may be managed
by using increasingly higher levels of seda-
tion, known as proportionate palliative seda-
tion.
110-112
The goal of this type of treatment is to
ease unmanageable suffering in patients who
are imminently dying (i.e., days to 1–2 weeks
left). The purpose is not to end a patient’s life or
to speed up death. Situations in which propor-
tionate palliative sedation may be considered in
an actively dying patient after other treatments
have failed are intractable nausea and vomiting,
unmanageable pain, agitated terminal delirium,
and unrelenting dyspnea.
16
This type of treat-
ment is intended to attain the least amount of
sedation needed in order to control the patient’s
symptoms. Treatment of the patient’s other symp-
toms should be continued as well, in addition to
the sedation.
Proportionate palliative sedation is different
from palliative sedation to unconsciousness.
The latter is a controversial type of management
in which the end goal is unconsciousness to
relieve unmanageable symptoms. Proportionate
palliative sedation is intended only to sedate the
patient enough to control the symptoms. Some-
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| Fundamentals of Geriatric Pharmacotherapy
times, unconsciousness is unavoidable, but
that is not the goal. Ordinary sedation is another
management strategy that should be distin-
guished from proportionate palliative sedation.
In this type of practice, sedatives are used to aid
in sleep or to help treat anxiety symptoms, but
consciousness is preserved.
110
It is important to follow appropriate guide-
lines when initiating proportionate palliative
sedation, such as transferring the patient to
an individual room, allowing family unlim-
ited visiting rights (according to the patient’s
wishes), measuring and documenting baseline
assessment of symptoms, and continuing other
successful symptom management along with
the sedation. The healthcare team should initiate
treatment and assess symptoms according to
a formal protocol, including having the physi-
cian present when the infusion is initiated and
remaining available until unrelieved symptoms
are stabilized, monitoring to determine the
patient’s level of sedation needed to control the
unrelenting symptoms, and having a provision
to increase the dose if the symptoms are unre-
lieved over a mutually agreed-on time frame. A
dose increase is accomplished by administering
an additional bolus dose and then increasing the
infusion rate by 20% to 30%.
The most common agent used for palliative
sedation is midazolam. Other agents used are
lorazepam and phenobarbital.
112
The infusion
should be maintained at a rate that is adequate
to control the symptoms. If proportionate pallia-
tive sedation is chosen as an option for symptom
management for the dying patient, it is impor-
tant to provide family support, with updates and
attention to their emotional needs and grief.
112
G W D O
After a loved one dies, family and friends go
through a process of grief, There are different
types of grief. Prior to death, the patient and
family may experience what is known as antici-
patory grief. The patient may think about his or
her life and consider what he or she might have
changed, as well as express feelings of love,
gratitude, and forgiveness.
113
Grief occurs after the patient dies and
includes a wide spectrum of feelings and expe-
riences.
114
Family members may experience
disbelief, longing, anger, and acceptance in
no particular order. Although family and friends
will never completely forget their sense of loss,
this feeling should lessen over time. A severe
sense of loss and grieving that lasts more than
6 months may indicate complicated grief. This
type of grief usually affects a person’s work or
social life.
16
There are tools that may be implemented
and used for guidance when responding to grief.
One tool is called the EASE Tool. This tool stands
for Educate family and friends about how their
feelings accompanying normal grief are accept-
able; Assess common grief reactions; Support
the family by listening; and Explore with them
what methods may help them best while they are
grieving.
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6 - Palliative and Hospice Care |
145
C 1: P C C
Setting:
Hospital.
Subjective:
CF is a 76-year-old African American woman admitted to the hospital 3 days ago from the
geriatric clinic, where she has been followed for several years. Her chief complaint at hospital
admission was altered mental status, reported by her daughter, who accompanied her to clinic.
Beginning 3 months ago she developed right-sided facial palsy and blurry vision. Head CT scan
at that time was negative. She subsequently developed urinary incontinence and gait distur-
bance with impaired coordination and imbalance. Over the past 10 days, she stopped eating
and became confused. In the hospital she was treated with aggressive hydration for acute
kidney injury, ceftriaxone for a urinary tract infection, and an enema for constipation. She had
no advanced directives and was full code at this time. Further workup revealed a lung mass on
chest CT scan and two metastatic lesions on her brain MRI. Palliative care was consulted for
recommendations with pain/symptom management and discussion of goals of care. The pallia
-
tive care team, consisting of a physician, advanced practice nurse, pharmacist, and chaplain
met the patient at bedside with family present.
Past Medical History:
Hypertension, diabetes, lung cancer S/P resection 19 years ago.
Medications:
Prior to admission CF was taking amlodipine 10 mg daily, meloxicam 7.5 mg daily, metformin
500 mg twice daily, carboxymethylcellulose eye drops to right eye. At present she is on a
normal saline infusion 100 mL/hr, ceftriaxone 1 g IVPB daily, heparin 5,000 units q 8 hours,
sliding scale regular insulin, vitamin D 1000 units daily, carboxymethylcellulose eye drops to
the right eye as needed, and milk of magnesia 30 mL daily.
Social History:
Widowed x10 years with six children and five grandchildren. Currently lives with sister in rural
part of the state. Current smoker of ½ pack for 60 years. No alcohol or illicit drugs. She is
Baptist, and her religion/spirituality are very important to her.
Review of Systems:
Positive for weight loss, concentration difficulties, disorientation, and memory problems; also
positive for not able to close right eye, constipation, gait disturbance, and urinary incontinence.
Objective:
Wt 53.4 kg, Ht 66˝, BP 150/90 mmHg, P 90 BPM, T 98°F, RR 18/min
Physical Examination:
Pleasant cachectic elderly woman lying in bed in no acute distress. Dry mucus membranes and
skin. Facial droop on the right. Positive screen for delirium (acute onset, fluctuating, inatten
-
tive). The rest of the physical exam was noncontributory.
Labs:
Sodium 143 mEq/mL, potassium 4.6 mEq/mL, chloride 106 mEq/mL, calcium 10.5 mEq/mL,
BUN 42 mEq/mL, serum creatinine 1.6 mEq/mL, glucose 120 mg/dL, WBC 9.45, Hgb 15.3, Hct
44.5%, platelets 618, vitamin D 20.6 ng/mL.
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146
| Fundamentals of Geriatric Pharmacotherapy
Assessment:
Patient with dehydration and UTI on admission which are now resolved and altered mental
status improved. Palliative care consulted for review of goals of care, given new diagnosis of
recurrent lung cancer with brain metastases. Patient is also experiencing delirium, constipa-
tion, and lack of oral intake.
Plan:
1.
Discussed goals of care and hospice with family and patient, noting patient was delirious.
Patient agreed that family could make decisions for her. Her children are in agreement
that she would not wish for aggressive treatment and would agree to Do Not Resuscitate
status based on previous conversations with her. Patient will be transferred to an inpatient
hospice or nursing home with hospice now that she is stable.
2.
Begin dexamethasone 2 mg IV daily and nicotine transdermal patch 21 mg daily.
3.
Discontinue sliding scale insulin and vitamin D, and do not re-initiate metformin or amlo
-
dipine at discharge. Continue home medication of meloxicam at discharge.
4.
Begin morphine sulfate 1–2 mg IV every 1–2 hours as needed for pain or agitation.
Replace milk of magnesia with senna 8.6 mg daily.
5.
Contact minister of local church for spiritual support after discharge.
Rationale:
1. For African American patients, family and close friends are often an important source of
support for making healthcare decisions surrounding the end of life. Involving the family is
an important step in identifying the patient’s wishes for most people from this culture. The
palliative care team can be instrumental in explaining issues and involving appropriate
individuals to ascertain the patient’s wishes. The experience with death and dying and
the interprofessional composition of the team are key to achieving good outcomes in this
setting.
2.
The patient’s symptoms of palsy, gait disturbance, and delirium may be due to the
metastatic lesions or may be secondary to either associated brain edema or (for delirium)
withdrawal from cigarette smoking. Beginning dexamethasone and nicotine may address
the symptoms to improve quality of life over the next few weeks.
3.
Treatment of hypertension and diabetes mellitus to prevent long-term morbidity and
mortality is no longer a priority given the estimated life expectancy. Similarly, treating
vitamin D deficiency is unlikely to affect any of CF’s current complaints. Reducing pill
burden is a goal at this time.
4. Most hospice patients have pain complaints or agitation resulting from pain. Meloxicam
may be continued as a component of pain management, but having low, frequent doses of
morphine sulfate available on an as-needed basis for an opioid-naive patient is appro
-
priate for breakthrough pain and an expected escalation of pain that will occur as the
disease progresses. An appropriate bowel regimen would include a motility agent such as
senna or bisacodyl.
5.
Including spiritual advisors familiar to the patient and family at the end of life provides
continuity and support.
Case Summary:
This case provides an example of palliative care providers working with a patient and family
to revise goals of care and identify hospice as an alternative to dying in the hospital. Review
of medications for appropriateness given the new goals of care with a focus on symptom
management rather than long-term prevention of morbidity and mortality is a role for phar
-
macists involved in palliative care. Offering support adapted to a patient’s cultural beliefs and
spiritual needs completes the holistic approach required for the best outcomes.
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