Palliative medicine

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Palliative Care in the ED

  • Palliative care is defined as specialized medical care for patients suffering from severe illness
  • Focused on alleviating symptoms and psychosocial distress, with truly patient-centered approach
  • Palliative and curative care are not mutually exclusive
    • Given misconceptions that palliative care = hospice, important to introduce role of pall care team to patient/family as specialists in symptom control, communication, and psychosocial support
    • E.g. "Have you ever heard of a specialty called palliative care? I recommend it for all my patients who have a serious disease like [yours]. While your [oncologist focuses on killing cancer, cardiologist optimizes your heart etc.], the palliative care doctors really focuses on symptoms and side effects, and they tend to be great communicators and really good at making sure that what's most important to you and your family is front-and-center during all of your medical care"
  • Consider palliative care team consultation/referral particularly for patients at the end of life, with poor prognosis, or with overwhelming symptom burden

Dyspnea

  • Opioids are the first-line treatment for palliation of dyspnea.
    • Opioids decrease the chemoreceptor response to hypercapnia, thereby depressing the central respiratory drive and mitigating anxiety[1]
  • In Patients who are already taking opioids regularly, administer 5% of their total daily morphine dose to manage dyspnea.[2]
  • Admit to hospital or hospice inpatient when a a patient is experiencing refractory dyspnea despite initial palliative resuscitation
  • Not a time to reclarify goals of care
  • Reassurance is key to family
  • O2, NIPPV
  • Bedside Fan

Dehydration

  • Anorexia does not cause distress, no evidence for IVF, TPN
  • Normal to decrease PO intake in last weeks of life
  • Swabs on mouth/lips to prevent dry lips
  • Artificial tears for dry eyes

Delirium

  • Reassurance in normal part of dying process, not "going crazy at the end"
  • Common to see deceased relatives
  • Quiet, well lit room, windows preferable, familiar faces present
  • Haloperidol 0.5-1mg IVP show to be useful, benzodiazepines as additional adjunct


Secretions[3]

  • "Death Rattle"
    • Refers to the sound that is made when air passes through a dying patient's pooled secretions within the posterior oropharynx
    • Not harmful but distressing symptoms to the family.
  • Proper positioning
  • Aggressive suctioning should be avoided, as comfort of the patient is the goal.
  • Glycopyrrolate 0.1mg IV or 0.2mg PO
    • Prevents new secretions & reduces respiratory gurgling.
    • Does not cross blood-brain barrier & therefore does not contribute to terminal delirium

Acute Pain[4]

  • Opioids are the principle treatment for pain in terminally ill patients.
  • Be cautious with morphine in terminally ill patients who have renal impairment as this can lead to opioid induce neurotoxicity.
    • Use hydromorphone or fentanyl.
  • Morphine: 4mg IV x 1 and IV folus q 15 minutes PRN
  • Hydromorphone: 1mg IV x 1 and 1 mg IV bolus q 15 minutes PRN
  • Fentanyl: 25mcg IV x 1 and 25 mcg IV bolus q 15 minutes PRN
  • If pain is unrelieved for 30 minutes, increase bolus dose by 50-100%
  • If not opioid-naive, give up to 20% of total daily opioid dose.
  • Referral to Palliative Care for refractory to pain control despite appropriate medications.

Agitation/Restlessness/Confusion

  1. Full examination - look for sources of pain/distress including constipation, urinary retention, pressure ulcers
  2. Review medication list and delete all non-essential medication to reduce anticholinergic burden: American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults
  3. Pain is a leading cause of delirium (see Acute Pain protocol). If not effective then…
  4. Haloperidol (Haldol).
    1. Haloperidol has the best data in treating agitation or delirium in this patient population.
    2. Haloperidol 1mg IVP q1 hour PRN
  5. Benzodiazepines
    1. Caution needed with benzodiazepines because they can cause paradoxical agitation in elderly patients.
    2. Lorazepam 1mg PO or SQ q 1 hour PRN
  6. Delirium refractory to initial medications then referral to Palliative Care

Nausea/Vomiting

  1. Reverse underlying cause if possible (GI obstruction, vertigo, constipation, medication)
  2. Treat empirically with metoclopramide (Reglan) or ondansetron (Zofran). If not effective then…
  3. Haloperidol (Haldol). If not effective then…
  4. Lorazepam. If not effective then…
  5. Referral to Palliative Care 6

Constipation

  1. Rule out impaction/obstruction
  2. Start Senna 2 tabs or polyethylene glycol (Miralax) powder: 17g in any liquid every day. If no daily bowel movement, can increase up to 3 times daily Miralax or 2 tabs Senna twice daily. If not effective after 48 hours…
  3. Dulcolax suppository: 1 or 2 per rectum every morning after breakfast. If not effective after 48 hours…
  4. Enema - warm tap water, repeat until results (DO NOT use Fleets because of risk of hyperphosphatemia, hypocalcemia, arrhythmia). If no effect…
  5. Referral to Palliative Care

Disposition at End of Life

  1. All life sustaining care desired
    • Self explanatory
  2. Comfort + limited life sustaining interventions
    • Admit with time limited trial (establish this beforehand) for antibiotics or NIPPV
  3. Comfort measures only
    • Admit to hospice unit/palliative care service or manage acute symptoms in ED then dc with home hospice

Rescue Medications for Symptom Distress

Once acute symptoms are controlled, switch to standing (around the clock) regimen of the effective dosage, every 4 hours for morphine, every 6 hours for haloperidol, lorazepam, and metoclopramide

Drug Indication Route Starting Dose Starting Frequency
Haloperidol
  • Restlessness
  • Anxiety
  • Agitation
  • Confusion
  • Nausea/Vomiting
  • Oral Sublingual
  • IV
0.5 mg Every 1 hour until calm. Increase to 1 mg if no relief from starting dose.
Lorazepam
  • Restlessness
  • Anxiety
  • Agitation
  • Nausea/Vomiting
  • Oral
  • IV
  • SC
0.5 mg Every 1 hour until calm. Increase to 1 mg if no relief from starting dose.
Metoclopramide
  • Nausea/Vomiting
  • Oral
  • IV
5-10 mg Every 6 hours
Ondansetron
  • Nausea/Vomiting
  • Oral
  • IV
4 mg
  • Every 8 hours. Increase to 8 mg if no relief from starting dose.
    • If using for opioid-induced nausea, give 30 minutes before morphine to prevent nausea
Morphine Sulfate
  • Pain
  • Dyspnea
  • Oral
5-10 mg
  • Every 3-4 hours.
    • Increase dose by 50% for pain unrelieved by starting dose at 1 hour for oral and 15 minutes for IV dose.
    • Introduce laxative
Morphine Sulfate
  • Pain
  • Dyspnea
  • IV
2-4 mg
  • Every 3-4 hours.
    • Increase dose by 50% for pain unrelieved by starting dose at 1 hour for oral and 15 minutes for IV dose.
    • Introduce laxative

External Resources

  • Fast Facts : great quick-reference resource for practical/specific info on myriad palliative care topics

See Also

  • Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.
  • Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.
  • Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.
  • Vertelney, Haley, MD, et al. “Pain Relief in Palliative Care.” ACEP Now, vol. 40, no. 7, 2021, pp. 1–6.