377Palliative Care Pathways
PALLIATIVE CARE
Palliative care is an area of health care that specifically focuses on relieving and preventing the suffering of patients from diagnosis onward. It facilitates effective communication between the patient and practitioner, and it supports the goals of cure, life prolongation, quality of life (QOL), or acceptance of death. These efforts are not initially end-of-life care but can facilitate discussion. It is also helpful in determining code status and signing of a physician orders for life sustaining treatment (POLST) form. Discussion can provide effective management of expectations, treatment-associated toxicities, and channels for supportive care within the medical field and/or community.
• The ultimate goal is to provide the best possible QOL for people facing the pain, symptoms, and stress of serious illness. It is appropriate throughout all stages of an illness. It can be provided along with treatments that are meant to cure.
• Palliative therapies not only improve a patient’s QOL, but also have been shown to extend life. In a study of patients with metastatic non–small cell lung cancer, patients were randomized to receive either early palliative care integrated with standard oncologic care or standard oncologic care alone. Despite the fact that fewer patients in the early palliative care group than in the standard care group received aggressive end-of-life care (33% vs. 54%, p = 0.05), median survival was longer among patients receiving early palliative care (11.6 vs. 8.9 months, p = 0.02) (1).
• Palliative surgical or medical intervention can relieve symptoms and lead to less pain for the patient. In these instances, correction of the terminal disease is not anticipated or achieved. Approximately 10% of procedures are performed for palliative intent, not cure.
HOSPICE
Hospice care is palliative care that typically occurs when a patient is considered to be terminal, or within 6 months of death.
END-OF-LIFE DISCUSSION
It can be quite difficult discussing the implications of a life-threatening illness with a patient and the family. There are a few things to keep in mind when discussing terminal disease and end-of-life care:
• Hope is important, but not a plan.
• Emotions run high: negative emotions such as fear, anxiety, frustration, and depression are common and are manifested in a variety of ways by patients and their caregivers.
• Respect is important. Health care providers should listen to and honor the perspectives and choices of patients and their families.
378MULTIDISCIPLINARY APPROACH
A multidisciplinary approach is important.
• Effective palliative care involves a team approach. This involves the patient and her physician and may also include palliative care physicians; specialists; general practitioners; nurses; nursing assistants or home health aides; social workers; chaplains; and physical, occupational, and speech therapists.
COMMUNICATION
Communication is the most important factor in terminal care.
• Timing of discussion: soon after the diagnosis of advanced or recurrent cancer. Options for palliative care should be discussed.
• Ensure that legal documents are drawn up: these include a living will, power of attorney, advance directive.
• Specific issues to address with the patient: the need for ventilatory support, total parenteral nutrition (TPN), the need for emergent surgery, interventional procedures for relief of acute symptoms, invasive procedure endpoints and indications, do not resuscitate (DNR) consent, timing for discontinuation of supportive measures, location for death (hospital vs. home).
DELIVERING BAD NEWS
SPIKES METHOD
This is a six-step protocol.
• Step 1: Set up the interview: arrange for privacy, involve significant others and family, sit down, connect with the patient and family, minimize interruptions (phone/pager on vibrate).
• Step 2: assess the patient’s Perception: what is your understanding of your situation?
• Step 3: obtain the patients Invitation: how would you like for me to give you information about your test results?
• Step 4: Knowledge and information giving to the patient: provide a warning: “I’m afraid I have bad news.” Ensure the appropriate level of comprehension and vocabulary of the patient. Avoid excessive bluntness. Give the information in small bites and assess the patient’s understanding at each step.
• Step 5: address the patient’s Emotions with empathetic response: observe and identify the patient’s emotion; let the patient know you have identified the emotion.
• Step 6: Strategy and summary: establish a plan to address the patient’s goals of care and QOL as well as fears. Frankly discuss expectations and goals for both patient and loved ones.
MANAGEMENT OF SPECIFIC SYMPTOMS
• Dyspnea: causes and treatment options
Pneumonia: antibiotics and pulmonary toilet.
Lymphangitic tumor: diuretics, glucocorticoids.
Pneumonitis, radiation therapy (XRT) or chemotherapy induced: glucocorticoids.
Pulmonary embolus (PE): anticoagulation, inferior vena cava (IVC) filter.
Pleural effusion: indwelling catheter, thoracentesis, video-assisted thoracic surgery (VATS), pleurodesis (bleomycin, talc, tetracycline).
Airway obstruction by tumor or adenopathy: XRT, glucocorticoids, stent.
Bronchoconstriction: chronic obstructive pulmonary disease (COPD)/asthma: bronchodilators, glucocorticoids.
Retained or excess secretions: anticholinergic drugs.
Massive ascites causing SOB: paracentesis with or without indwelling catheter.
Anxiety manifested as hyperventilation: anxiolytics, behavioral therapy.
Additional measures: facial cooling with fan, chest physical therapy.
Consider supplemental oxygen but this does not always correlate with symptomatic resolution.
Systemic opioids.
• Anorexia: reversible causes: constipation, pain, medications, hypercalcemia, mucositis, and bowel obstruction. Treatments: gastrokinetic agents such as metoclopramide, low-dose corticosteroids, progestone agents (Megace), antidepressants (Remeron), cannabinoids such as dronabinol, palliative surgery with bowel diversion.
• Nausea: sixty percent of patients have nausea and vomiting. Causes: usually from various receptors in the gastrointestinal (GI) tract. It is important to rule out cerebral metastasis. Other causes are uremia, electrolyte imbalances, and hypercalcemia. Treatment: use of antiemetics at optimal dosing and route of administration, use scheduled around-the-clock dosing, and add second agent when monotherapy fails rather then switch agents
Dopamine antagonist: chlorpromazine 6.25 mg PO/IM/IV q8 hours; prochlorperazine PO/PR/IM/IV 10 to 50 mg q4 to 8 hours; Metoclopramide 5 to 20 mg PO/IV q2 to 8 hours; haloperidol 0.5 to 1 mg q8 hours PO/IV.
Anticholinergic: clopalamine transdermal 1.5 mg q3 days; hydroxyzine 6.25 to 25 mg qHS.
H1 antihistamine: diphenhydramine POIV/IM 12.5 to 50 mg q6 hours; promethazine PO/IM 12.5 to 25 mg q8 hours.
5HT3 antagonist: ondansetron P/IV/SL 4 to 20 mg q4 to 8 hours; dolasetron 100 mg PO q24 hours; granisetron 2 mg PO q24 hours; palonosetron 0.01 mg/kg IV q24 hours, transdermal 3.1 mg q24 hours, IV 0.25 mg q24 hours.
Steroids: dexamethasone PO/IV 4 to 24 mg daily.
Cannabinoids: dronabinol 7.5 to 15 mg PO q3 to 4 hours.
Benzodiazepines: lorazepam IV/PO 0.5 to 2 mg q4 hours.
• Malignant ascites: treatment: paracentesis, indwelling (pleurX) drains, diuretics may relieve ascites associated with portal hypertension from hepatic metastasis. Vascular endothelial growth factor (VEGF) targeting agents reduce ascites well.
• Malignant bowel obstruction:
Types: mechanical: from tumor obstruction. Compressive: from external ascites compression. Functional: from carcinomatosis coating the surface of the bowel obstructing peristalsis.
Treatment:
Conservative management: nasogastric tube (NGT), intravenous fluid (IVF), bowel rest NPO, pain, and nausea control. Steroids may reduce bowel edema (decadron 4 mg q6 hours), and octreotide may reduce secretions.
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