Download - CARE OF DYING PATIENT Dorothy D. Sherwood, M.D. 6/11/2005

CARE OF DYING PATIENTCARE OF DYING PATIENT

Dorothy D. Sherwood, M.D.Dorothy D. Sherwood, M.D.

6/11/20056/11/2005

WEB ResourcesWEB Resources

http://www.whocancerpain.wisc.edu/ihttp://www.whocancerpain.wisc.edu/index.htmlndex.html

http://epec.net/EPEC/webpages/indexhttp://epec.net/EPEC/webpages/index.cfm.cfm

http://www.hospicecare.com/http://www.hospicecare.com/

http://www.whocancerpain.wisc.edu/index.html

http://www.whocancerpain.wisc.edu/index.html

http://epec.net/EPEC/webpages/index.cfm

http://epec.net/EPEC/webpages/index.cfm

Caring for the dying patientCaring for the dying patient

““No procedure, no medicine, and no No procedure, no medicine, and no words can thwart death, and the words can thwart death, and the physician is faced with a morass of physician is faced with a morass of difficult emotions in the patient, difficult emotions in the patient, family, staff, and self.” family, staff, and self.”

Caring for the dying patientCaring for the dying patient

Physicians role in the final stages of Physicians role in the final stages of illness:illness: Guide patient and family through the Guide patient and family through the

process.process. Prevent and treat physical, emotional, Prevent and treat physical, emotional,

and spiritual suffering and spiritual suffering Assist in defining and achieving Assist in defining and achieving

appropriate goals for the end of life. appropriate goals for the end of life. A focus on comfort and quality of lifeA focus on comfort and quality of life

Sharing Bad NewsSharing Bad News

1.1. Find an appropriate setting and timeFind an appropriate setting and time2.2. Be preparedBe prepared3.3. Ask the patient who should be presentAsk the patient who should be present4.4. Align – “What do you know?”Align – “What do you know?”5.5. Be brief and simple – tailored Be brief and simple – tailored 6.6. Be honestBe honest7.7. ListenListen8.8. SupportSupport9.9. Offer next stepsOffer next steps10.10. DocumentDocument

Advance Care PlanningAdvance Care Planning

1.1. Arranging a private setting and sufficient time Arranging a private setting and sufficient time

2.2. Determining what the patient and family know about the illness Determining what the patient and family know about the illness and prognosisand prognosis

3.3. Exploring what they are hoping for and what the team can and Exploring what they are hoping for and what the team can and cannot do to meet these expectationscannot do to meet these expectations

4.4. Suggesting realistic goals and indicating how they can be Suggesting realistic goals and indicating how they can be achieved and explicitly addressing unreasonable and unrealistic achieved and explicitly addressing unreasonable and unrealistic expectationsexpectations

5.5. Responding empathically to emotional reactions Responding empathically to emotional reactions

6.6. Making plans and following through Making plans and following through

7.7. Reviewing and revising plans at inflection points Reviewing and revising plans at inflection points

Whole Patient AssessmentWhole Patient Assessment

Physical Assessment Physical Assessment Psychological Assessment including, Psychological Assessment including,

evaluation of decision-making evaluation of decision-making capacitycapacity

Social AssessmentSocial Assessment Spiritual Assessment Spiritual Assessment

Physical SymptomsPhysical Symptoms

Pain Pain Periodicity, Location, Intensity, Periodicity, Location, Intensity,

Modifying Factors, Effect of Treatment, Modifying Factors, Effect of Treatment, Functional Impact, Impact on PatientFunctional Impact, Impact on Patient

Interventions: WHO 3 step Interventions: WHO 3 step pharmacological approach pharmacological approach

Non-opioidsNon-opioids Mild opioidsMild opioids Strong opioidsStrong opioids

Physical AssessmentPhysical Assessment

JUDICIOUS EVALUATION OF THE CAUSE JUDICIOUS EVALUATION OF THE CAUSE

PREVENTION AND MANAGEMENT OF SECONDARY PREVENTION AND MANAGEMENT OF SECONDARY COMPLICATIONS COMPLICATIONS

SYMPTOM MANAGEMENT WITH MINIMAL SIDE SYMPTOM MANAGEMENT WITH MINIMAL SIDE EFFECTS EFFECTS

REGULAR PATIENT FOLLOW-UP TO ASSESS REGULAR PATIENT FOLLOW-UP TO ASSESS SYMPTOM INTENSITY AND TREATMENT SYMPTOM INTENSITY AND TREATMENT COMPLICATIONS COMPLICATIONS


Pain ( continued)Pain ( continued) Short acting opioids – titrate 25 to 50 % Short acting opioids – titrate 25 to 50 %

each dose until controleach dose until control Use adjuvants such as BZD to reduce Use adjuvants such as BZD to reduce

anxietyanxiety Long acting opioids – titrate every 48 to Long acting opioids – titrate every 48 to

72 hours. 72 hours. Add bowel regimentAdd bowel regiment Assess for nausea, fatigue, confusion, Assess for nausea, fatigue, confusion,

respiration depressionrespiration depression


Fatigue and Weakness – Life style Fatigue and Weakness – Life style adjustments – educationadjustments – education Glucocorticoids – last about 1 monthGlucocorticoids – last about 1 month Dextroamphetamine – 5 to 10 mg am and noon. Dextroamphetamine – 5 to 10 mg am and noon.

Dyspnea – investigate and treat reversibleDyspnea – investigate and treat reversible Does not correlate with objective measurementsDoes not correlate with objective measurements Opioids and BZDOpioids and BZD Scopalamine to dry secretionsScopalamine to dry secretions OxygenOxygen


Insomnia – Insomnia – BZDBZD Relieve other symptomsRelieve other symptoms


Nausea, vomiting, anorexiaNausea, vomiting, anorexia Antiemetic agentsAntiemetic agents

Antihistamine – dimenhydrinate, meclizineAntihistamine – dimenhydrinate, meclizine Anticholinergic – ScopalamineAnticholinergic – Scopalamine Antidopaminergic – prochlorperazine, Antidopaminergic – prochlorperazine,

droperidoldroperidol 5-HT3 Antagonists – Ondansetron, 5-HT3 Antagonists – Ondansetron,

granisetrongranisetron


Nausea (continued)Nausea (continued) Prokinetic agentsProkinetic agents

5-HT4 agonist – Metoclopromide5-HT4 agonist – Metoclopromide OthersOthers

BZD – anticipatory nausea with chemoBZD – anticipatory nausea with chemo Glucocorticoids – chemo induced nauseaGlucocorticoids – chemo induced nausea Canabinoids – chemo induced nauseaCanabinoids – chemo induced nausea


ConstipationConstipation Encourage FluidsEncourage Fluids StimulantsStimulants

Senokot – 2 to 4 Tabs per daySenokot – 2 to 4 Tabs per day Prune JuicePrune Juice Bisacodyl – 5 to 10 mg /dayBisacodyl – 5 to 10 mg /day

OsmoticOsmotic Lactulose – 15 – 40 ml q 4 – 8 hoursLactulose – 15 – 40 ml q 4 – 8 hours MOM – 15-30 cc qdMOM – 15-30 cc qd Mg Citrate – 125 – 250 cc/dMg Citrate – 125 – 250 cc/d Miralax 17 grams po qdMiralax 17 grams po qd

Stool SoftenersStool Softeners Sodium docusate – 300 to 600 mg a daySodium docusate – 300 to 600 mg a day Calcium docusate – 300 to 600 mg a dayCalcium docusate – 300 to 600 mg a day


Others:Others: CoughCough SwellingSwelling ItchingItching DiarrheaDiarrhea DysphagiaDysphagia DizzinessDizziness Loss of libidoLoss of libido Fecal and urinary incontinenceFecal and urinary incontinence NeuropathyNeuropathy

Physical AssessmentPhysical Assessment

EVALUATING SUCCESS IN THE PHYSICAL DOMAINEVALUATING SUCCESS IN THE PHYSICAL DOMAIN 1.1. Access: How much trouble do you have getting the Access: How much trouble do you have getting the medical care you need?medical care you need?

2.2. Physical: How much do you suffer from physical Physical: How much do you suffer from physical symptoms, such as pain, shortness of breath, fatigue, or symptoms, such as pain, shortness of breath, fatigue, or bowel or urination problems?bowel or urination problems?

3.3. Patient-clinician relationship: How much do you believe Patient-clinician relationship: How much do you believe your physicians and nurses respect you as an individual?your physicians and nurses respect you as an individual?

4.4. Information: How clear is the information you receive Information: How clear is the information you receive from the health care team about what to expect regarding from the health care team about what to expect regarding your illness?your illness?

Psychological AssessmentPsychological Assessment

DepressionDepression GriefGrief AnxietyAnxiety DeliriumDelirium HopelessnessHopelessness IrritabilityIrritability Impaired concentrationImpaired concentration Confusion Confusion


Decision Making Capacity:Decision Making Capacity: Patient autonomy, informed consent, and the Patient autonomy, informed consent, and the

right to self-determination are key principles of right to self-determination are key principles of patient-focused, end-of-life care. patient-focused, end-of-life care.

The physician should evaluate:The physician should evaluate: Does the patient understand what is being discussed?Does the patient understand what is being discussed? Can the patient make rational and appropriate choices Can the patient make rational and appropriate choices

based on the available options and alternatives? based on the available options and alternatives? Does the patient have insight into the consequences of Does the patient have insight into the consequences of

decisions?decisions?


Depression – “How often do you feel down, Depression – “How often do you feel down, depressed?”depressed?”

TreatmentTreatment Stimulants –Stimulants –

Dextroamphetamine 5 to 10 mg twice daily am and Dextroamphetamine 5 to 10 mg twice daily am and noon – up to 15 mg noon – up to 15 mg

Pemoline – absorbed through the buccal mucosa- Pemoline – absorbed through the buccal mucosa- 18.75 mg am and noon18.75 mg am and noon

SSRISSRI Mirtazepine – treats anorexia, insomniaMirtazepine – treats anorexia, insomnia Others – refer Others – refer


AnxietyAnxiety Alprazolam – 0.25 mg to 1 mg po tid or qidAlprazolam – 0.25 mg to 1 mg po tid or qid SSRI’sSSRI’s

DeliriumDelirium Atypical NeurolepticsAtypical Neuroleptics

Olanzapine – 2.5 to 5 mg po qdOlanzapine – 2.5 to 5 mg po qd Risperidone – 1 – 3 mg po q 12 hoursRisperidone – 1 – 3 mg po q 12 hours

AnxiolyticsAnxiolytics Lorazepam – 0.5 – 2 mg q 1 to 4 hours po/iv/imLorazepam – 0.5 – 2 mg q 1 to 4 hours po/iv/im Midazolam – 1 – 5 mg continuous infusionMidazolam – 1 – 5 mg continuous infusion

Anesthesia Anesthesia Propofol - .3 to 2 mg per hour continuous infusionPropofol - .3 to 2 mg per hour continuous infusion

Spiritual AssessmentSpiritual Assessment

1. What is your faith or belief?1. What is your faith or belief?

2. Is it important in your life?2. Is it important in your life?

3. Are you part of a spiritual or religious 3. Are you part of a spiritual or religious community?community?

4. How would you like your health care provider 4. How would you like your health care provider to address these issues in your health care?to address these issues in your health care?

Spiritual AssessmentSpiritual Assessment

1. How much does this illness seem 1. How much does this illness seem senseless and meaningless?senseless and meaningless?

2. How much does religious belief or your 2. How much does religious belief or your spiritual life contribute to your sense of spiritual life contribute to your sense of purpose?purpose?

3. Since your illness, how much do you live 3. Since your illness, how much do you live life with a special sense of purpose?life with a special sense of purpose?

Social AssessmentSocial Assessment

FinancialFinancial

40% report that their terminal illness has been a huge 40% report that their terminal illness has been a huge financial burdenfinancial burden

Is associated with preference of comfort care over life-Is associated with preference of comfort care over life-prolongationprolongation

Increases psychological distressIncreases psychological distress Consult a social worker early to assure the family of access Consult a social worker early to assure the family of access

to all the benefits availableto all the benefits available Relationships

Assisting the patient and his/her family through the dying process

Who does the patient rely on for physical needs? Emotional needs?

Download - CARE OF DYING PATIENT Dorothy D. Sherwood, M.D. 6/11/2005

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