Hospice is a type of care and a philosophy of care that focuses on the palliation of a terminally ill or seriously ill patient’s symptoms. These symptoms can be physical, emotional, or psychosocial in nature. Hospice care focuses on bringing comfort, self-respect, and tranquility to people in the final year of life. Patients’ symptoms and pain are controlled, goals of care are discussed and emotional needs are supported. Hospice believes that the end of life is not a medical experience, it is a human experience that benefits from expert medical and holistic support that hospice offers. (source)
Palliative care, often called comfort care, (pronounced pal-lee-uh-tiv) is specialized medical care for people with serious illnesses. Palliative care is not necessarily hospice, as its treatment modalities can be applied to non-terminally ill patients. It is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness—whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. (source)
As nurses we care for individuals at all stage of life, from birth to death. We use a combination of science, skill and art to fight disease and or fix whats broken. At a certain point curative measures are either no longer effective or futile. When curative measures are no longer indicated we can shift our healthcare might from healer to helper. When you take care of a patient that meets criteria (as described below) talk to the provider and ask if a palliative care consult might be in order. From my experience I suggest you (assuming you’re a bedside nurse) don’t be the first to bring palliative care up to the family or patient. This can present a conflict of interest to the family as they might think that “this nurse just wants my dad to die”.
Indications for Palliative Care Consult
- Ask yourself, “Would I be surprised if this patient died in the next year?” If the answer is “no,” then consider a palliative consultation.
- Patients with advancing dementia, end-stage renal failure, end-stage liver failure, congestive heart failure, advanced lung disease, advanced ALS/MS, have palliative needs
- Frequent emergency room visit for the same diagnosis
- Frequent hospital admissions for the same diagnosis in the last 30 days
- Prolonged hospital or ICU stay (7-14 days) without evidence of improvement
- Declining ability to complete activities of daily living
- Difficult to control physical or emotional symptoms
- Patient or family needs help making complex care decisions
- Physician needs support with difficult conversations about prognosis
- When dyspnea becomes emergent in advanced cancer patients, it may indicate a phase in their illness in which resources should be shifted from acute intervention to palliative and supportive care measures (source).
Terminally ill patients commonly experience substantial pain (source). Effective pain management in the terminally ill patient requires an understanding of pain control strategies. Ongoing assessment of pain is crucial and can be accomplished using various forms and scales. It is also important to determine if the pain is
- Nociceptive (somatic or visceral pain) Nociceptive pain can usually be controlled with nonsteroidal anti-inflammatory drugs or corticosteroids
- Neuropathic (continuous dysesthesias or chronic lancinating or paroxysmal pain). Neuropathic pain responds to tricyclic antidepressants or anticonvulsants.
Relief of breakthrough pain requires the administration of an immediate-release analgesic medication. If a significant amount of medication for breakthrough pain is already being given, the baseline dose of sustained-release analgesic medication should be increased. If pain does not respond to one analgesic medication, physicians should use an equianalgesic dose chart when changing the medication or route of administration. Opioid rotation can be used if pain can no longer be controlled on a specific regimen. The impact of unresolved psychosocial or spiritual issues on pain management may need to be addressed. (source)
- Ask the patient about the presence of pain. Use a pain scale if possible to obtain an objective measure of the patients report of pain. See below.
- Perform a comprehensive pain assessment, using the PQRST method. Check the H & P for documented pain issues.
- Avoid IM route, if possible
- Treat persistent pain with scheduled medications
- Ordinarily 2 drugs of the same class (e.g. NSAIDS) should not be given concurrently; however 1 long-acting and 1 short-acting opioid may be prescribed concomitantly.
- Short-acting strong opiates (morphine, hydromorphone, oxycodone) should be used to treat moderate to severe pain. Long- acting strong opiates (e.g. Oxycontin, MS Contin, Fentanyl patch) should be started once pain is controlled on short-acting preparations. Never start an opioid naïve patient on long-acting medications.
- Titrate the opiate dose upward if pain is worsening or inadequately controlled: Increase dose by 25- 50% for mild/moderate pain; increase by 50-100% for mod/severe pain.
- Manage breakthrough pain with short-acting opiates. Dose should be 10% of total daily dose. Breakthrough doses can be given as often as Q 60min if PO; Q 30min if SQ; Q 15min if IV. (As long a patient has normal renal/hepatic function)
- When converting patient from one opioid to another, decrease the dose of the second opioid by 25-50% to correct for incomplete cross-tolerance.
- Manage opioid side effects aggressively. Constipation should be treated prophylactically.
With narcotics come constipation. Heres why.
Do not start opioid therapy without an appropriate bowel regimen (softener + stimulant); Titrate regimen to one soft BM Q 1-2 days.
- Colace (softener) 100mg BID, Senna (stimulant) 1tab BID
- Increase Senna 2 tabs BID
- Increase Senna 3 tabs BID
- Increase Senna 4 tabs BID and add Sorbitol 30cc BID, Miralax QD, or Bisacodyl 2 tabs BID
- Increase Sorbitol 30cc TID or Miralax BID or Bisacodyl 3 tabs TID, if no BM by 4 days consider enemas
Be Aware Of Fecal Impaction.
Lube your iron gloved hand up and get to work.
With chronic pain, illness, poly-pharmacy and constipation palliative patients are often plagued with nausea and vomiting. What can you do about it? Click the link below, its pretty good.
The National Hospice Study showed that for patients in the last six weeks of life, dyspnea occurred in 70% of patients (source). Dyspnea is often associated with other common symptoms: fatigue, cough, anxiety, and pain.(source) This cluster of symptoms is usually studied together, and caregivers are often asked to assess all of them using various types of analog or graphic rating scales. In planning interventions for dyspnea, it is important to assess the degree of distress the dyspnea causes for the patient and in turn the caregiver.(source)
Once you’ve figured out your patient is short of breath and this is bothering them, click the lungs below to learn how to treat them.