PALLIATIVE MEDICINE

The study and management of patients

with active, progressive, far advanced
disease whom the prognosis is
limited and the focus of care is the
QUALITY OF LIFE

Palliative Care by WHO

an approach that improves the quality of
life of patients and their families facing
the problems associated with lifethreatening illness, through the
prevention and relief of suffering
by means of early identification and
impeccable assessment and treatment of
pain and other problems, physical,
psychosocial and spiritual.;
.

 Active total care of patients and their

families by a multi-professional team
when the patients disease is no longer
responsive to curative treatment
consist of supporting services that
provide not only physical but
psychological as well as social and
spiritual care

HOSPICE CARE
Latin word hospes - stranger
Hospitalis - friendly, welcome
to the stranger
Hospitium - warm feeling
between guest and a host
Hospice

HOSPICE CARE
Medieval Hospice

St. Christophers
Hospice

Catholic Hospice

St. Josephs Hospice

Whatsoever you do to the

least of my brothers, that
you do unto me.

 The term HOSPICE CARE is rooted in the

idea of offering hospitality

such as shelter and place to rest, to sick

and weary travelers

It became a term applied to specialized

care for the dying patient since 1967 by
Dame Cicely Saunders at St.
Christophers Hospice in London

and it become worldwide practice in

end of life care.

Who are Palliative Care Specialist ?

Palliative Care specialist have completed fellowship training in
Supportive, Palliative and Hospice Care in an accredited hospital
in the Philippines or abroad

after they have completed a three-years residency in Family

Medicine (Philippines) or any specialty

They have been conferred a Fellow or Diplomate status by the

Philippines academy of Family Physicans (Philippines)
They work closely with medical oncologist, gynecologic, and
other specialist to arrive at a management plan that will offer
the patients life limiting illness the best possible outcome.

GOAL OF PALLIATIVE CARE

Affirms life and regards dying as a
normal process
Neither hastens nor postpone death
Provide relief from the pain and other
distressing symptoms
Integrates the PSYCHOLOGICAL AND
SPIRITUAL ASPECTS OF CARE

goals...
Offers a support system to
help the patient live as
actively as possible until
death
Offers a support system to
help the family cope during
the patients illness and in
their own bereavement

The Names
Palliative Care
when cure is no longer possible
aims to control symptoms and
sometimes to prolong life
ex. Palliative chemo, palliative surgery

Hospice Care
Is a compassionate caring for the
terminally ill patients
Aim is comfort and quality of life
Does not prolong life

 Terminal Care
refers to the last stages of an
illness when support for the
family may become especially
important
are generally used
interchangeably though can
give each a particular emphasis

When should a patient be referred?

Previous Approach

curative

Palliative
Palliative Care Approach

curative

palliative

Who should be referred?

Most patients will have an advanced cancer
Others: advanced disease with poor
prognosis
with worrying symptoms not readily
alleviated
HIV
Motor Neurone Disease
Chronic End Stage Respiratory/ Cardiac
Disease/Renal Disease

When should a patient be referred

Palliative care ?
When attempts at cure no longer
appropriate
death is anticipated in a foreseeable
time
the focus of palliative care is the
alleviation of symptoms
maintenance of comfort

Hospice : The Philippine Experience

The Terminal Phase

Agnes Bausa-Claudio, M.D.
Supportive, Hospice and Palliative Medicine

Terminal Phase
Period of inexorable and irreversible
decline in functional status prior to
death.
May unfold gradually over days or weeks
Fluctuating but ongoing decline in a
progressive illness

Goals of Palliative Care

in the Terminal Phase
Ensure the best possible quality of life for
the patient
Provide the best care and support for both
patients and their families.
Support not only during the course of the
illness but even after the patients death.
Integrates the psychological and spiritual
aspect of care

PRINCIPLES IN PALLIATIVE CARE

GOALS REDEFINED
Regular assessment for new causes of
suffering for both patient and the relatives

Care plans to address new sufferings.

Inadequately addressed symptoms and
distress is always remembered by
relatives and can cause intense
anguish for months and years to come.

GOALS REDEFINED
Changing goals for each stage
Decision making depends on the stage
the patient is in.
Along the continuum of evolving disease
Corresponding change in clinical goals
Moments reached when it is clinically,
ethically justified to withhold or
discontinue clinical treatments

Stage IV Cancer / Terminal Stage

Early

Intermediate

Late/
Terminal Phase
DEATH

Early years
Intermediate months
Late weeks
Terminal phase few days to hours

Illness Trajectories at End of Life

General patterns of illness trajectories. Lunney 2003 JAMA 289 : 2387-92.

Eight Phases of the Chronic Illness Trajectory

Corbin & Strauss
Phase Definition

Definition

1. Initial (Pretrajectory)

No signs or symptoms are present

2. Trajectory Onset (Including the

diagnostic period)

The first signs and symptoms

appear

3.Crisis

A potentially life-threatening
situation
occurs (eg, a condition requiring
emergency care)

4. Acute

Symptoms require control with

prescribed medicine

5. Stable

Symptoms are managed and

Controlled

6. Unstable

Symptoms become uncontrollable

by the previously adopted
regimen

.7. Downward

7Mental and physical status

deteriorates

8. Dying

8Death is preceded by a period of

days, weeks, or hours the dying
phase refers to a period of weeks,
days, or

Developed in the consensus conference on Palliative and

Supportive Care in Advanced Heart Failure, by Dale
Renlund, MD, and Sarah Goodlin, MD.

Cardiologist are afraid of

Hospice Care
Cardiologists often use this lack of
predictability in heart failure as a reason
not to broach the subject of dying or
think about hospice care, but this excuse
does not cut any ice with palliative-care
physicians.
"Because the model in cancer is that
patients get referred to hospice and then
their chemotherapy is stopped,

 cardiologists are often afraid of referring

their patients," - Pantilat.
"They fear that hospice staff will stop all
medications and tell their patients they
are going to die, and they don't like that.
" The focus is not death, but you have
to help people to understand that this
is a disease you can die from.
Dr. Steve Pantilat

WITH PERMISSION FROM THE FAMILY

HOME CARE

Loosing sight of goals of management

may lead to
inappropriate
treatment

may provoke
agonizing discussions
& difficult decisions

Atul Gawande, Annals of Medicine, Whose Body Is It,

Anyway?, The New Yorker, October 4, 1999, p. 84

Clinical Challenges
in the Terminal Phase
Compromised
oral intake

Food and fluid

intake

COMMON ISSUES IN TERMINAL PHASE

1.DO NOT RESUSCITATE/DO NOT

INTUBATE
2.ORAL AND PARENTERAL NUTRITION
3.NASOGASTRIC TUBE/PEG
4.BLOOD TRANSFUSION
5.ANTIBIOTICS
6.ROUTES OF DRUGS
7.MEDICATIONS

Compromised Oral Intake

due to Impaired Swallowing
REVERSIBLE CAUSES
Sedation from medications
Metabolic derangements
Hypercalcemia
Hyponatremia
Hyperkalemia
Uremia

IRREVERSIBLE CAUSES
Part of profound generalized
weakness seen during the end of life
Progressive physiologic decline
Mechanical dysphagia due to
obstruction by underlying tumors
enlarged lymphadenopathies.

Withdrawing/Witholding
Food and Fluid Intake
Food and water are widely held symbols of
caring
Withholding of artificial nutrition and hydration
may be easily misperceived as neglect by the
patient, family or other caregivers.
Patients, family members, and caregivers need
a lot of support as well as careful and thorough
explanation why they can do without feeding
the patient during in the terminal phase.

Artificial Nutrition and Hydration

in End of Life Care
Food & fluid intake generally diminishes in the terminal
stage of illness
When interest in food & fluids becomes minimal, the
patient should not be forced to receive them.
Eating and drinking no longer be relevant to the patients
who has already withdrawn and whos attention is now
inward or beyond
Theyre not hungry anymore

Dry mouth is misinterpreted as thirst

While patients may say they are thirsty, usually they really
mean their mouth is dry.
If patient is swallowing only a little, this is usually not due
to lack of strength, but a need to wet the whistle.
Suggest that families help keep the patients mouth moist
with ice chips or swabs.

 Evidence is limited but suggests that

continuing artificial fluids in the dying
patient is of limited benefit and should, in
most cases, be discontinued.
Ellershaw J, etal Care of the dying patient:
the last hours or days of life. BMJ, January 2003

Medications
Review of all medications being taken
Review of medications that might be
needed
Review of how much assistance and
instruction relatives might need in giving
medications if the patient is at home

MANAGEMENT OF PATIENTS
IN THE FINAL DAYS OF LIFE

Signs of IMPENDING DEATH

(Oxford Textbook of Palliative Medicine)

1. Profoundly weak
2. Essentially bedbound
3. Drowsy for an extended period of time
4. Disoriented with regards to time with severely limited
attention span
5. Increasingly uninterested to food and fluid
6. Finding it difficult to swallow medication
* Not found in books Communicates with dead loved ones

Signs & symptoms of death approaching

Clearest signs picked up thru day-by-day
assessment of deterioration
Symptoms develop suddenly over a matter of
days instead of usual weeks
exclude reversible cause of deterioration (infection,
hypercalcemia, or medications)

Each one (patient) is different

Goals for the last 24 hours

Ensure patients comfort
physical, emotional, & spiritual

Make end of Life peaceful & dignified

Care & support should be given to patient
& their carers
Make the memory of the dying process as
positive as possible

Investigations
Investigations at the end of life should
have a clear & justifiable purpose
Little need for investigations in the
terminal phase
Aim: COMFORT

REVIEW DRUGS & THEIR

ROUTES OF ADMINISTRATION
ESSENTIAL DRUGS
-Review route-

PREVIOUSLY
ESSENTIAL
Consider stopping

NO LONGER
ESSENTIAL
Stop

Analgesics

Steroids consider
tapering

Antihypertensives

Antiemetics

Replacement
hormones

Antidepressants

Sedatives

Hypoglycemics

Laxatives

Anxiolytics

Diuretics
Antiarrhythmics
Anticonvulsants

Anti-ulcer drugs
Anticoagulants
Long term antibiotics
Iron, vitamins

Oxford Textbook of Palliative Medicine. 3rd Ed. p.1123

SUGGESTED MINIMUM SET OF DRUGS

FOR THE TERMINAL PHASE
Drug

Route of
Administration

PO dose

Opoid

Morphine

Per orem
IV, SC
Per rectum

5-10 mg

Anticholinergic

Hyoscine-N
Butyl Bromide
(HNBB)

IV, SC, IM

10-20 mg

Class of drug

Antiemetic/
Anxiolytic

Haloperidol

SC, IM, IV

0.5 1 mg SC
1-5 mg IV
(usually 1.5 mg)

Tranquilizer Sedative

Midazolam
Diazepam

SC, IV
IV, IM, Per rectum

5-15 mg SC
2.5 10 mg IV

Antifungal

Nystatin Oral
suspension
Oxford Textbook of Palliative Medicine. 3rd Ed. p.1124

Management of symptoms
in the final days of life

Studies have shown that pain and

dyspnea are the most prevalent and
most distressing symptoms seen in
patients with serious life limiting
illnesses.
In actively dying cancers
51-100% suffered from pain
22-46% suffered from dyspnea.
Initiating End-of-Life Discussions With Seriously Ill Patients.
JAMA. November 2000.

 40% of patients had severe pain most

of the time in the last 3 days of life
Half of bereaved family members
thought their loved ones were in
moderate to severe pain 50% of the time
in the last 72 hours of life.
Study to Understand Prognoses and Preferences for Outcomes
and Risks of Treatments (SUPPORT) ; Oxford Textbook of
Palliative Medicine. 4 ed.

BEHAVIOR

EXAMPLES

Facial Expressions

Slight frown, sad, frightened face,

grimacing, wrinkled forehead, closed or
tightened eyes, any distorted
expression, rapid blinking

Verbalizations, Vocalizations

Sighing, moaning, groaning, grunting,

chanting, calling out, noisy breathing,
calling out for help

Body Movements

Rigid, tense body posture, guarding,

fidgeting, increased pacing, rocking,
restricted movements/gait, mobility
changes

Changes in Interpersonal
Interactions,

Aggressive, combative, resisting care,

decreased social interactions, socially
inappropriate, disruptive, withdrawn,
verbally abusive

Changes in Activity patterns or

Routines

Refusing food, appetite change,

increase in rest period or sleep,
changes in rest pattern, sudden
cessation of common routines,
increased wandering

Mental Status Change

Crying or tears, increased confusion,

irritability or distress

Journal of Pain and Symptom Management

Vol. 31 No. 2 February 2006; p170-192

Management of Pain
in the Terminal Phase
Pain is a subjective symptom.
Key components of assessment and
management of pain are unchanged in the final
days.
Decreased level of consciousness and/or
confusion affects the patients ability to report
pain
family and health care team should work together in
assessing comfort.

Management of Dyspnea
in the Terminal Phase
One of the most feared symptoms and is
extremely frightening to dying patients.
In the absence or unavailability of a definitive
treatment for the cause proper symptomatic
treatment should be given to assure comfort,
regardless of the cause

Management of Dyspnea
in the Terminal Phase
Some treatments applicable as palliative care
at an earlier stage are no longer appropriate
When death is imminent it is rarely justified to
drain either a pleural or a pericardial effusion.
continue treatment with antibiotics

Unless it can be confidently expected that the

patient will be much more comfortable as a
result of the intervention.

Opioid treatment for dyspnea

Consistent with good medical practice.
Unlikely to be associated with hastened
death or drug dependence when titrated
properly
Altered
perception of
breathlessness

decreased ventilatory
response to hypoxia
and hypercapnia
reduced oxygen
consumption at rest

Opioid treatment for dyspnea

Morphine is titrated against the rate of
respiration to achieve a resting rate of 15-20
breaths/min.
Dosage for dyspnea:
10 mg tab every 4 hours or
3mg IV every 4 hours

Patients already on opiods for analgesia

Increase dose by 50% to address both pain and
breathlessness.

Drugs for Severe Dyspnea

in the Opioid-naive
DRUG

Dose

Morphine

515 mg q 4 h and titrate

Oxycodone

510 mg q 4 h and titrate

Hydromorphone** 0.52 mg q 4 h and titrate

**not available in the Philippines

 Some patients who are breathless

become very anxious.
Benzodiazepines are highly effective
anxiolytic medications

Non-Pharmocologic
Interventions for Dyspnea
Elevating the head of the bed to a
comfortable height
Having a fan blowing cool air towards the
patient.
Oxygen support at 3-5 L/min
titrated to empirical effect rather than based
on a pulse oximeter

Benzodiazepines that can be used

and safely combined with opioids
DRUG

ROUTE

DOSAGE

LORAZEPAM *
0.52.0 mg

PO, SL,
mucosal,
or IV

Q1 PRN until settled,

then dose routinely
Q46 h to keep settled

DIAZEPAM
510 mg

PO, IV

Q1 h until settled
then dose routinely
Q68 h PRN

CLONAZEPAM
0.25 2.0 mg

PO

Q12 h

MIDAZOLAM
0.5 mg

IV then by
continuous SC
or IV infusion

Q15 min IV until settled,

* No longer available in the Philippines

Management of
Agitation and Delirium
85% of patients experience delirium in the last
weeks of life
46% present with agitation.
Manifestations:
restlessness, paranoia, and combativeness.

Witnessing any of these can be extremely

upsetting for the family
Leaves a lasting image after the patients death

Management of
Agitation and Delirium
If death may be hours, or a day or two away,
there is no purpose served in attempting to
define and reverse possible cause/s of
delirium.
Except with hypoglycemia
can be both diagnosed, managed and treated
immediately.

Management of
Agitation and Delirium
DRUG

SC

LEVOMEPROMAZINE

2.5mg q 6-8
to 50mg q4
(intermittent dose)

HALOPERIDOL

0.5 mg q12
5mg q4

MIDAZOLAM

2.5mg q6-8h up to
5-10mg q4 h

(added to a neuroleptic for

additional sedating effect)

PHENOBARBITAL

(added to above medications for

adequate sedation)

CONTINUOUS
INFUSION

SIDE EFFECTS

12.5-200mg
/24 h

Anti-cholinergic
effects to aggravate
delirium with
ongoing use

5-15mg/24 h

Not as sedating as
levomepromazine

20-100mg/24h

Used alone:
disinhibition and
increased
restlessness

(intermittent dose)

50-100mg q8,
adjusted empirically
to effect

200-400/24h

Non-pharmacologic management of
Agitation and Delirium
Continuity of care
Keeping familiar persons at the bedside
Limiting medication, room, and staff
changes
Limiting unnecessary catheterization
Avoiding restraints

Retained Respiratory Secretions

Death Rattle
noisy, moist breathing, caused by fluid
pooling in the hypopharynx

Due to loss of capacity to clear upper

respiratory secretions
Changes in mental status
Weakness in the last few days of life

Retained Respiratory Secretions

92% of patients have excessive
respiratory secretions within hours to
days of dying.
Distressing to family members or
caregivers.
Education regarding this issue may be as
effective as positioning and medication

Medications for
Retained Respiratory Secretions
Continuous
infusion

DRUG

SC

* HYOSCINE
HYDROBROMIDE
(SCOPOLAMINE)

0.3-0.6 mg
q2/ prn

HYOSCINE-NBUTYLBROMIDE
(HNBB)

20 mg stat

60-90 mg

0.2 -0.4 mg
q4 / prn

indicate a poor
response
intermittent
dosing

* GLYCOPYROLATE

ATROPINE 1%
EYE DROPS

0.6-2.4 mg /24h
or higher

EFFECT

Causes sedation and confusion

Does not cross BBB

less sedating than Scopolamine

Not as effective as scopolamine

Less likely to cause sedation and
delirium (Does not cross BBB as readily)

One to two drops orally or under the tongue;

titrate every eight hours
* Not available in the Philippines

Non-pharmacologic Intervention for

Increased Secretions
Proper positioning of the patient to
facilitate drainage.
Suctioning is generally NOT
recommended unless secretions are
accessible in the oropharynx.
Deeper suctioning is traumatic and likely
to cause further secretions.

SYMPTOM CRISIS
IN THE END OF LIFE
Sudden development of symptom distress during
the final phase of illness.
May represent a fatal event.
Complications of crisis occur in individuals with a
known vulnerability for them
May leave unforgettable images that will add to
grief for months-years to come.

SYMPTOM CRISIS
IN THE END OF LIFE
Planning is crucial
Discuss clearly and openly with caregivers and
family members
Management of potential crisis thru proper
information and education
Capacity/capability to manage symptom crisis as it
arises.
Especially for those who opt for home care.

FAMILY SUPPORT
IN THE TERMINAL PHASE

AS DEATH APPROACHES
Ideally rapport has been established
with the patient and family members/
caregivers
Ideally advanced care plans have been
properly and thoroughly discussed
Wishes of the patient with regards to
management
Wishes of the family in the circumstance that
the patient is unable to decide

In the Hospital...

Death & Dying

}Aim of Treatment Make a person as comfortable
as possible QOL Gap Theory Expectation
vs. Reality
}Lower the expectation to lessen the
dissapointments
Primary measures for use
}Cardiac rescucitation
in acutely ill patients
}Artificial respiration
- Aim is to assist a patient
}Intravenous infusion
in the initial period towards
Recovery
of Health
}Expensive enteral & parenteral
feeding
}NGT
}Anitibiotics

 To use such measures in patients who are

clearly close to death
Have No expectancy of a Return to Health
Not a justified expense
INAPPROPRIATE
Those who are close to death (terminally ill, it is
often APPROPRIATE TO GIVE DEATH A
CHANCE

Q. When may medical therapies,

procedures, equipment and the like be

withheld or withdrawn from a patient.
THE CATECHISM OF CATHOLIC CHURCH
Discontinuing medical procedures that are
burdensome, dangerous, extraordinary, or
disproportionate to the expected outcome can
be legitimate;
it is the refusal of "over-zealous"
treatment. Here one does not will to cause
death; one's inability to impede it is merely
accepted.

 The key principle in this statement is that one

does not will to cause death. When a person has
an underlying terminal disease, or their heart, or
some other organ, cannot work without
mechanical assistance, or a therapy being
proposed is dangerous, or has little chance of
success, then not using that machine or that
therapy results in the person dying from the
disease or organ failure they already have. The
omission allows nature to takes its course. It
does not directly kill the person, even though it
may contribute to the person dying earlier than if
aggressive treatment had been done.

 The decisions should be made by the

patient if he is competent and able or,
if not, by those legally entitled to act
for the patient, whose reasonable will
and legitimate interests must always
be respected.

Yes, Im OK and ready to go!

THANK YOU!