Palliative care and family medicine

# Hospice

## Overview
- Hospice is a philosophy that addresses the physical, psychological, social, and spiritual aspects of death and dying
Patients elect to pursue palliative rather than curative treatment
- Patients elect to pursue palliative rather than curative treatment
- Hospice care can be provided in any setting- patient's home, hospice home, nursing home, or hospital
- Patient's are eligible for hospice care if they have a any terminal illness with an estimated prognosis of less than six months
This includes non-cancer diagnoses, such as congestive heart failure, chronic obstructive pulmonary disease, failure to thrive, and dementia
- This includes non-cancer diagnoses, such as congestive heart failure, chronic obstructive pulmonary disease, failure to thrive, and dementia
- Hospice benefits cover all expenses related to the patient's terminal diagnosis that are deemed "reasonable and necessary for palliation"
This includes medications, skilled nursing, nursing aides, and hospital equipment, such as a hospital bed for the patient's desired location
Medicare pays hospice on a per diem basis that covers all medical care; this payment method often requires the attending physician to consider the cost of individual medications  and treatments when multiple methods are available to treat the same symptom
- This includes medications, skilled nursing, nursing aides, and hospital equipment, such as a hospital bed for the patient's desired location
- Medicare pays hospice on a per diem basis that covers all medical care; this payment method often requires the attending physician to consider the cost of individual medications  and treatments when multiple methods are available to treat the same symptom
- Hospice benefits provide the patient's family with bereavement support for up to one year following the death of the patient
- Patients appear to benefit most when hospice care is initiated at least two months prior to death

## Eligibility
- Medicare covers hospice care for if the following four criteria are met:
The patient is eligible for Medicare Part A
The patient enrolls in a Medicare-approved hospice
The patient has given written consent for hospice care
The patient's physician and the hospice medical director certify that the patient has a terminal illness with an estimated prognosis of less than six months
- The patient is eligible for Medicare Part A
- The patient enrolls in a Medicare-approved hospice
- The patient has given written consent for hospice care
- The patient's physician and the hospice medical director certify that the patient has a terminal illness with an estimated prognosis of less than six months

## Clarification of common misconceptions
- As long as a disease is running its "normal course," there is no penalty and the patient will not automatically be discharged from hospice if they survive longer than six months
Hospice care is initiated with two 90 day periods followed by unlimited extensions in 60 day intervals
- Hospice care is initiated with two 90 day periods followed by unlimited extensions in 60 day intervals
- Patients are not required to have a do not resuscitate order
- The patient's primary care physician can and often does serve as a member of the patient's hospice care team
The attending physician is often the patient's primary care physician
The attending physician is required to write admission orders, be available by telephone, and handle the routine day-to-day medical needs of the patient
- The attending physician is often the patient's primary care physician
- The attending physician is required to write admission orders, be available by telephone, and handle the routine day-to-day medical needs of the patient
- Most private insurers offer a benefit that is modeled after the Medicare Hospice Benefit
- Patients may leave and reenter hospice care if there are unforeseen fluctuations in their disease course
- Anyone, including friend's and family members, can refer a patient to hospice; the referral does not have to come from a physician or other medical professional
- Medical problems and hospital admissions that are unrelated to the patient's terminal diagnosis generally are still covered by the patient's insurance plan while a patient pursues hospice care

## Resources

### General resources
- National Hospice and Palliative Care Organization

### Tools for determining patient prognosis
- Karnofsky Performance Scale
- Palliative Performance Scale
- Palliative Prognosis Score

# Palliative care pharmacology

## Overview
- Palliative pharmacotherapy aims to relieve medical burdens while maintaining the patient's dignity and comfort
- Three main principles guide symptom management:
Start low and go slow
Treat to effect or adverse effect
Consider the effects of polypharmacy
- Start low and go slow
- Treat to effect or adverse effect
- Consider the effects of polypharmacy

## Dyspnea
- Shortness of breath is sensed in the central nervous system pain
Persistent dyspnea after maximization of pharmacologic and non-pharmacologic respiratory therapy should be treated with opioids
- Persistent dyspnea after maximization of pharmacologic and non-pharmacologic respiratory therapy should be treated with opioids

## Gastrointestinal symptoms

### Nausea, vomiting, and bowel obstruction
- Conservative therapy includes NPO status, nasogastric suction, antiemetics, octreotide, and dexamethasone
Haloperidol is low cost and may be as efficacious as ondansetron
Promethazine is often ineffective in palliative care
Octreotide decreases intraluminal intestinal fluid
Dexamethasone decreases obstruction due to edema
- Haloperidol is low cost and may be as efficacious as ondansetron
- Promethazine is often ineffective in palliative care
- Octreotide decreases intraluminal intestinal fluid
- Dexamethasone decreases obstruction due to edema

### Constipation
- Constipation occurs in nearly half of palliative care patients
- The incidence increases to almost 90% when palliative care patients are treated with opioids
- The incidence increases to almost 90% when palliative care patients are treated with opioids
- A 2011 Cochrane review showed no significant difference between various laxatives with regard to stool frequency for the treatment of constipation in palliative care patients
- This same review demonstrated that methylnaltrexone increases stool frequency at 4 hours (OR = 7.0, 95% CI, 3.8 - 12.6) and 24 hours (OR 5.4, 95% CI 3.1 - 9.4) in palliative care patients with constipation
- Patients treated with methylnaltrexone reported increased rates of flatulence and dizziness, but the agent's side effect profile is not currently well known
- Patients treated with methylnaltrexone reported increased rates of flatulence and dizziness, but the agent's side effect profile is not currently well known

## Pain

### Opioids
- Basal dosing intervals for opioids should be based around peak effect, not duration of action
Basal dosage should be increased by 25-50% when pain is mild-moderate and 50-100% when pain is severe
- Basal dosage should be increased by 25-50% when pain is mild-moderate and 50-100% when pain is severe
- Breakthrough dosing should be ordered at 10-20% of the 24-hour morphine equivalent
- Rotate to a second opioid when the first opioid fails to control the patients pain at the highest tolerated dosage
Incomplete cross-tolerance can occur between opioids, so reduce dose equivalent to 50-75% when rotating opioids
- Incomplete cross-tolerance can occur between opioids, so reduce dose equivalent to 50-75% when rotating opioids
- Avoid combination opioid preparations (Percocet, Roxicet, Percodan, Ibudone, etc.) due to risk of non-opioid toxicity
- Neuropathic pain, social pain, psychological pain, spiritual pain, and previous substance use are common reasons for the failure of opioids to adequately control pain
- Nausea, vomiting, sedation, and mental status changes are the most common initial adverse effects of opioids
These effects usually fade with continued opioid usage
Treat nausea with a prophylactic antiemetic for 3-5 days when initiating opioids
Sedation can be treated with low-dose methylphenidate
- These effects usually fade with continued opioid usage
- Treat nausea with a prophylactic antiemetic for 3-5 days when initiating opioids
- Sedation can be treated with low-dose methylphenidate
- Constipation does not abate with continued opioid usage
Always initiate a bowel regimen of a stimulant laxative-stool softener or stimulant laxative-osmotic laxative combination when a patient is treated with opioids
Continue the patient's bowel regimen even if the patient has minimal solid oral intake
Methylnaltrexone can be used to treat opioid induced bowel dysfunction in non-obstructed patients
- Always initiate a bowel regimen of a stimulant laxative-stool softener or stimulant laxative-osmotic laxative combination when a patient is treated with opioids
- Continue the patient's bowel regimen even if the patient has minimal solid oral intake
- Methylnaltrexone can be used to treat opioid induced bowel dysfunction in non-obstructed patients
- At high doses or rapidly increased dosages, opioids can cause neuroexcitation (hyperalgesia, delirium, myoclonus)

### Non-opioids
- Non-steroidal anti-inflammatory agents, corticosteroids, and bisphosphonates are effective for bone pain

## Delirium
- Common causes are polypharmacy, urinary retention, constipation, and infection
- Preventative measures include:
Having family/friends at the patient's bedside
Limiting changes to the patient's medications and room
Minimizing staff changes
Avoiding indwelling catheters and restraints whenever possible
- Having family/friends at the patient's bedside
- Limiting changes to the patient's medications and room
- Minimizing staff changes
- Avoiding indwelling catheters and restraints whenever possible

## Upper respiratory secretions
- Loss of the ability to clear upper respiratory secretions leads to the classic "death rattle"
- Non-pharmacologic interventions include patient positioning and gentle suction
- Pharmacologic interventions include hyoscyamine, glycopyrrolate, scopolamine, octreotide, and atropine eye drops

## Resources

### General resources
- End of Life/Palliative Education Resource Center
- National Cancer Institute
- New hampshire Hospice and Palliative Care Organization opioid use guidelines