Hospice (Unrein) Flashcards
(38 cards)
Hospes
Latin, describing both the host and the guest. The specifics of this word emphasize an interactive relationship between one and the other.
Pallium
Latin, referring to an outer garment. To palliate a patient is to cloak his/her symptoms.
Hospice:
The study of and care for patients with active, progressive, far-advanced disease whose prognosis is limited, and thus the focus becomes quality of life.
history of hospice
Cecily Saunders – Founder of the modern Hospice movement with St. Christopher Hospice in Great Britain in 1967.
“Appropriate therapy need not include every effort to prolong life regardless of its quality…”2
Palliative care
: The “relieving or soothing the symptoms of a disease or disorder.” Many people mistakenly believe this means patients receive palliative care only when they can’t be cured. Actually, palliative medicine can be provided by one doctor while other doctors work with you to try to cure the illness. Palliative care is for people of any age, and at any stage in an illness, whether that illness is curable, chronic, or life-threatening. In fact, palliative care may actually help patients recover from illness by relieving symptoms like pain, anxiety, or loss of appetite, as they undergo sometimes-difficult medical treatments or procedures, such as surgery or chemotherapy.
“Palliative care” Means specialized medical care for people with serious illnesses. This type of care is focused on providing patients with relief from the symptoms, pain and stress of serious illness, whatever the diagnosis. The goals to improve quality of life for both the patient and the family. Palliative care is provided by a team of physicians, nurses, and other specialists who work with a patient’s other health care providers to provide an extra layer of support. Palliative care is appropriate at any age and at any stage in a serious illness and can be provided together with curative treatment. Unless otherwise indicated, the term “palliative care” is synonymous with the terms “comfort care,” “supportive care” and similar designations.
Hospice Myths
Nothing else can be done/treatment failure.
Hospice hastens death – (NEJM August 2010).
Hospice takes away all the patient’s medications.
Hospice causes patients to become addicted to narcotics, or over-medicates patients – caution needs to be exercised (Bloomberg News December 2011).
Patients can never come out of hospice care or change their minds at the risk of losing benefits.
Patients can never change their minds to seek aggressive therapy.
Hospice is only for patients who are in the active process of dying.
Artificial hydration and nutrition prolongs life – (JAMA October 1999).
Withholding artificial hydration and nutrition is illegal (Karen Ann Quinlan and Cruzan v. Director, Missouri Department of Health).
Withdrawal of food and nutrition constitutes murder/suicide.
If a physician inadvertently prescribes too much pain medication to a patient, he/she can be criminally prosecuted (The Double Effect).
Medicare Hospice-Benefit Criteria
Terminal illness (qualifying diagnoses)
- Cancer
- HIV
- Cardiac Disease
- Pulmonary Disease
- Renal Disease
- Liver Disease
- Neuromuscular Disease
- Stroke/Coma
- Senile degeneration of the brain
Less than six months to live
- A service and a philosophy,not a place
Hospice Interdisciplinary Team
- Must consist of a physician, nurse case manager, dietary counselor, medical social worker, and bereavement counselor
The benefit specifically covers any modality needed to comfort the patient’s terminal illness
- Can be problematic if patient has multiple illnesses
End of Life Planning
End of life preparation/Advanced Directives
Families/medical durable power of attorney
May be in conflict with the patients wishes
- DNR
– DNAR
– AND
– Intent of CPR
– Not an absolute requirement for hospice
POLST/MOST Five wishes® Artificial nutrition and hydration Organ/tissue donation Risk-benefit ratio
Ethics
Four recognized ethical principals
- Autonomy - Patient self-determination
- Beneficence - Serving the patient’s well-being
- Nonmaleficence - Do no harm
- Justice - Fairness
Competence vs. Capacity
Ethical Dilemmas: Futility
Justice Potter Stewart
- Jacobellis v. Ohio, 1964
Treatment Goals – talk to the patient/families
- Most conflicts are communication issues and misunderstandings.
- – Right to refuse, not the right to demand
- Treatments are ethically neutral.
- There is no ethical distinction between withholding and withdrawing a life-sustaining treatment.
- Find out what the patient wants to know and who they may want to be in charge of their decision making, in whole or in part.
Ethical Dilemmas: The “Double Effect”
Primum non nocere The doctrine (principle) of double effect is often invoked to explain the permissibility of an action that causes a serious harm, such as the death of a human being, as a side effect of promoting some good end.1
- Origins are from Catholic Doctrine of the 13th Century by Thomas Aquinas. 1
- This theory is based upon the caregiver’s intent which is problematic.
Ethical Dilemmas: Physician assisted suicide
Now referred to as physician assisted death or death with dignity
“The deliberate action taken by the physician to help a patient commit suicide.”1
Oregon (1994), Washington (2008), Montana (2009), and Vermont (2013), New Mexico (2014), California (2015), Colorado (December 2016)
Colorado, introduce and defeated in the 2015 and 2016 legislative session, so the legislature put it on the ballot. The Colorado End-of-Life Options Act became law December 16, 2016
Euthanasia
“The act of ending a patient’s life when carried out by the physician personally.”1
The reasons that patients ask to end their lives are a sense of hopelessness, loss of control, or an unmet symptom control (pain).
Symptom Management
A complete History and Physical is required
- Pain must be continually reassessed, including patient and care-giver compliance with a prescribed program.
- Patient self reporting of pain is the single most reliable method of evaluating pain.
“Total Pain”
- The recognition of pain that is beyond the just the physical.
- Patients often suffer from spiritual/existential, emotional/psychological and social/interpersonal pain.
- What is the meaning of pain to the patient?
- – Some patients believe that this is something that they must endure.
Two roads to death
usual- normal- sleepy- lethargic- obtunded- semicomatose- comatose- dead
Difficult: restless- confused- tremulous- hallucination- mumbling- myoclonus- seizures- semicomatose- comatose- dead
What do we treat first?
Physical pain must be treated first in order to address the other sources of total pain.
Types of Physical Pain
Nociceptive
- Somatic: Aching, stabbing, throbbing
- Visceral: Spastic, cramping, squeezing pressure; Poorly localized
Neuropathic: Burning, shooting, tingling, numbness
Opioids
Mechanism of Action
- Modulation of pain through mu, kappa, and delta receptors in the peripheral and central nervous systems. These receptors work by inhibiting calcium channels which prevents or induces the release of neurotransmitters (i.e., Substance P).
Opiates modulate the sensation of shortness of breath in the respiratory center of the brain.
With proper medical supervision, these medications are safe and effective and the drugs of choice in patients near the end of life that are having pain or dyspnea.
Which opioids go with which kinds of pain
Mild to Moderate Pain
- Codeine
- Hydrocodone (in 2014 was moved to a schedule II narcotic)
Moderate to Severe Pain
- Morphine
- Hydromorphone
- Oxycodone
- Fentanyl
- Methadone (NMDA antagonist as well as an opiate agonist)
Opioids- Route Varies based upon the clinical situation
Oral – preferred
IV, transdermal/topical, SQ, PR, transmucosal
Intrathecal, epidural, or nerve block invasive and requires highly technical setting and expertise
IM – undesirable
** Meperidine
Opioids side effects
CONSTIPATION
Nausea
Somnolence
Myoclonus and neurotoxicity – unusual, but important consideration
Barriers to effective narcotic use and misconceptions about opiates:
Physicians are reluctant to prescribe for fear of DEA retribution and/or lack of experience with high doses.
- Federal and local politicians and regulatory agencies are looking at the issue as well – Colorado was second in the nation in 2006 for deaths from prescription drug abuse, it was 24th in 2013
Nurses can be reluctant/uncomfortable to administer for fear of causing harm/respiratory depression.
Fear of causing addiction.
“Morphine is what they give people to help kill them or when they are going to die.”
No maximum dosage.
* Heroin
Adjuvant Pain Medications
Acetaminophen
NSAIDS
- Inflammation (bone pain)
Corticosteroids
- Edema (cerebral), inflammation (bone pain), appetite stimulation
Anticholinergics
- Antispasmodic, reduce secretions
Antidepressants, anticonvulsants, antiarrhythmics
- Inhibitors ion channels and/or mediators of neurotransmitters (dorsal spinal columns descending pathways modulate pain responses)
Alternative Pain Management
Palliative Sedation
- Old terminology was “terminal” sedation.
- Extremely rare, utilized after all other measures have been exhausted.
- Generally believed not to hasten death, but to allow the patient to die peacefully from the natural course of the terminal illness, or allow for a “wind-down” period.
- Used for a short period of time followed by reassessment and reduction.
- Use in existential suffering is controversial.
Constipation
Often caused by low fluid intake, inactivity, autonomic dysfunction metabolic abnormalities, medications.
This is the one time that bulk-laxatives are not recommended.
Methylnaltrexone, injection
Naloxegol, oral
Treatment
- Stimulant laxatives, senna, dulcolax
- Enemas
Prevention (prophylaxis)
