Palliative and Hospice care

Question 1

What is Palliative Medicine?

Answer 1

• Palliative medicine was formally
  recognized by the American
  Board of Medical Specialties in
  2006.
• It is a holistic, team-based care
  approach for patients and their
  families experiencing serious
  illness.
• Palliative medicine is practiced
  in a variety of settings, and
  adaptable to patient
  populations and available
  resources

Question 2

High-level evidence for palliative care:

Answer 2

• improves patient and family quality
  of life
• reduces healthcare cost and
  utilization
• reduces patient/family financial
  burden, and in some cases,
• improves survival and length of life.

Question 3

Two main barriers identified to referrals for palliative care

Answer 3

1. The awareness of palliative care services among pts their
   families
2. The tendency of clinicians to equate palliative care with end of
   life care

Question 4

àOver half of hospice patients are
enrolled in hospice for ___ days or less

Answer 4

30

Question 5

How can you increase awareness of and utilization of Palliative Care?

Answer 5

• Perform the basic physical, psychological, Psychiatric, social, spiritual assessments and document patient choices and goals of care discussions in any specialty
  do you practice.
  v Document and sign POLST forms
  v Document code status
  v Bill for advanced care planning

Question 6

Criteria for Obtaining a Palliative Consult - Primary

Answer 6

• The “surprise question”
• Difficult to control physical or psychological symptoms
• ICU stay >7 days
• Lack of documented goals of care (POLST, AD, living will)
• Disagreement or uncertainty among pt, staff or family (i.e.
  prognosis, GOC)

Question 7

Criteria for a Palliative Medicine Consult - Secondary

Answer 7

• Awaiting or deemed ineligible for organ transplant
• Emotional/spiritual/existential/relational distress
• Request for palliative/hospice services
• Patient is a candidate/receiving consultation for:
• Feeding tube
• Tracheostomy
• Initiation of dialysis
• Ethics concerns
• LVAD or AICD
• LTACH placement
• Bone marrow transplant

Question 8

Interdisciplinary Team Assessment for palliative care

Answer 8

• Palliative assessment builds on the medical H&P by including
  holistic and comprehensive aspects of patient’s needs
• Each member of the interdisciplinary team performs their own
  assessment and then develops their own plan of care based on
  their skills and scope of practice & scope of competence

Question 9

Biopsychosocial Assessments for palliative care are interested in determining:

Answer 9

• how a patient is processing the
  information about disease
  management and prognosis,
• how they are adapting to any changes
  in functional status, change to their
  identity, daily routine, and
• how the patient/family are coping with
  the burdens, condition or prospect of
  dying

Question 10

Fentanyl transdermal

Answer 10

• efficacy based on pt’s amount of
  available fatty tissue (think about
  cachexia, muscle wasting, etc)
• Preferred in renal failure
• DON’T GIVE TO OPIOID NAÏVE
  PATIENTS, please

Question 11

Symptom Management in palliative care: Continuous Pain

Answer 11

1. Combine Short/Long Acting Opioids/Opiates
2. Find the initial effective dose
3. Start SA PO opioid q1-2h PRN for 1-2 days
4. Record how may PRN doses uses & ask about SE, efficacy (pain scale)
5. Goal is PRN 1-3 times/day

Question 12

Nausea symptom management: V.O.M.I.T

Answer 12

• Vestibular – Receptors: cholinergic, histaminicà scopolamine,
  promethazine
• Obstruction (non-mechanical) – Receptors: cholinergic, histaminic,
  5HT3 –> stimulate the mesenteric plexus/Senna
• (dys)Motility – Receptors: same as obstruction + 5HT4 à prokinetic like
  metoclopramide
• Infection/Inflammation – Receptors: same as obstruction +neurokinin1
• Toxins – Receptors: dopamine 2, 5HT3à

Question 13

The 5 Disease Trajectories

Answer 13

• Sudden Death
• Terminal Illness
• Major Organ Failure
• Frailty/Debility and Failure to Thrive
• The Catastrophic Event

Question 14

Sudden Death

Answer 14

• Sudden cardiac arrest,
  aortic/abdominal dissections,
  stroke, trauma/homicide/suicide,
  drug overdose
• The lesson: there is no time to
  prepare or tie up loose ends
• Therefore, it is never too early to
  talk to your patients about
  advance planning; even if they are
  in optimal health

Question 15

Terminal Illness

Answer 15

• Cancer, tuberculosis
• Opportunity for advance care
  planning, palliative, hospice,
  “getting affairs in order”
• Slow steady decline followed
  by precipitous decline then
  death

Question 16

Major Organ Failure

Answer 16

• Progression or “normal disease
  trajectory” of chronic diseases
  such as: heart failure, kidney
  disease, pulmonary
  disease/COPD, PHTN, some
  neurological diseases
• Slow, progressive decline in
  function punctuated by crises
  or exacerbations

Question 17

Frailty/Debility

Answer 17

• Dementia, Parkinson’s, other
  neurodegenerative diseases
• Crises are rare and changes in
  status are sometime
  imperceptible
• Slow, protracted decline
• Exacts a heavy toll on
  caregivers

Question 18

The Catastrophic Event

Answer 18

• Stroke, Hip fx, MI, fall/trauma
  resulting in brain injury

Question 19

Five signs emerge most during the last 3 days before death:

Answer 19

1. Pulselessness of the radial artery
2. Respiration with mandibular movement
3. Decreased urine output
4. Cheyne-Stokes breathing (apnea on/off)
5. Death Rattle (terminal respiratory secretions)

Question 20

Eight Additional Death Signs

Answer 20

• Non-reactive pupils
• Decreased Response to verbal stimuli
• Decreased Response to visual stimuli
• Inability to close eyelids
• Drooping of the nasolabial fold
• Hyperextension of the neck
• Grunting of the vocal cords
• Upper gastrointestinal bleeding

Question 21

Signs of Imminent Death

Answer 21

• Weakness, fatigue, functional decline
• No longer able to independently transfer
• Decreased oral intake
• No evidence to back increased caloric intakes alters course
• Are they dehydrated?
• Strong debate for & against parenteral fluid
• Non-oral routes of drug administration may be needed

Question 22

Death Rattle

Answer 22

• Accumulation of airway secretions & decreased ability to
  swallow
• Usually due to fatigue or neurological dysfunction

Question 23

Death rattle symptoms

Answer 23

• Symptoms: gurgling, crackling, dyspnea, agitation, decreased sleep, coughing
  spells, predisposes to infections (pneumonia)
• Distressing to family
• Educate & reassurance
• Some Solutions:
• Positioning
• Encourage to cleanse the mouth

Question 24

Hospice Benefit INCLUDES

Answer 24

• Services from a hospice-employed physician, nurse practitioner (NP), or other physicians (PA - ahem)chosen by the patient
• Nursing care
• Medical equipment
• Medical supplies
• Drugs to manage pain and symptoms
• Hospice aide and homemaker services
• Physical therapy
• Occupational therapy
• Speech-language pathology services
• Medical social services
• Dietary counseling
• Spiritual counseling
• Individual and family or just family grief and loss counseling before and after the patient’s death
• Short-term inpatient pain control and symptom management and respite care

Question 25

To qualify for hospice:

Answer 25

• A principal hospice diagnosis (ICD-10)
• A prognosis of 6 months or less based on the clinical guideline established if the disease follows its “usual course”

Question 26

T/F you can initiate palliative care at the diagnosis of a diagnosis

Answer 26

T

Question 27

Documenting Decline: Clinical Status

Answer 27

• Recurrent or intractable serious infections such as pneumonia, sepsis
  or pyelonephritis
• Progressive inanition as documented by:
• Weight loss of at least 10% body weight in the prior six months, not due to reversible
  causes such as depression or use of diuretics;
• Decreasing anthropomorphic measurements (mid-arm circumference, abdominal girth),
  not due to reversible causes such as depression or use of diuretics;
• Observation of ill-fitting clothes, decrease in skin turgor, increasing skin folds or other
  observation of weight loss in a patient without documented weight;
• Decreasing serum albumin or cholesterol.
• Dysphagia leading to recurrent aspiration and/or inadequate oral intake documented by
  decreasing food portion consumption

Question 28

Documenting Decline: Signs & Labs

Answer 28

• Decline in systolic blood pressure to below 90 or progressive postural hypotension;
• Ascites;
• Venous, arterial or lymphatic obstruction due to local progression or metastatic disease;
• Edema;
• Pleural/pericardial effusion;
• Weakness;
• Change in level of consciousness.

Question 29

T/F Lab testing is not required to establish HOSPICE eligibility

Answer 29

T