Fellows-in-Training Newsletter

Spring 2002

Comprehensive Palliative Care: How to provide "Intensive Care" at the end of life

Robert M. Arnold, Cynthia X. Pan, Sharon Carmody

As geriatricians, we promote successful aging and maintenance of function. But most of us also care for sick or dying patients who suffer from significant symptoms and morbidity. We have the opportunity to comfort patients and family members, and relieve their suffering. Thus, it is crucial that geriatricians are trained to provide good palliative care. We need help and input from graduating geriatrics fellows in order to achieve this goal.

To better understand fellows' needs, the Robert Wood Johnson Foundation has commissioned a survey of all graduating fellows' experience and competencies in palliative care. The survey was developed with the input of key AGS and ADGAP members and experts in geriatrics education like Dr. Rosanne Leipzig at Mount Sinai and Dr. Evelyn Granieri at the University of Pittsburgh. AGS has consistently supported efforts to improve palliative care via research, education and advocacy.

The survey will be distributed via the mail and Internet in early April 2002. The Internet site is http://palliativecaresurvey.ucsur.pitt.edu/Geriatric.html. We hope graduating fellows will fill it out as the answers will help improve the palliative care education of future geriatricians. The following case illustrates several basic palliative care concepts central to good care of patients in the last 48 hours of life:

Case. Mrs. J is a 92-year-old woman with a PMHx remarkable for CHF, DM, CAD, and renal insufficiency who presented with a change in mental status. Workup revealed an inoperable intracerebral bleed. Conversation with the family resulted in a decision to make the patient "comfort measures only." She was transferred to a medical bed.

When confronted with an acutely dying patient, health care providers are often unsure of what they can do "when nothing more can be done." Issues to be addressed include:

The patient's needs:

1. Focus on comfort. Are all interventions aimed at comfort? QID finger sticks for blood sugar control are irrelevant. Review all medicines and stop those that do not contribute to patient's comfort.
2. Artificial hydration and nutrition (AHN). AHN will not change this patient's course. Most people stop experiencing hunger after ketosis begins, ~12-18 hours after caloric intake is stopped. Focus on good mouth care.
3. Treat pain or shortness of breath with opioids. Opioids should be titrated to symptoms--not respiratory rate or hypoxia. Treat acute pain with bolus doses of 3-5mg MSO4, followed by continuous infusion for continuous pain. Use lower doses to treat SOB.
4. Agitation or restlessness occurs in some dying patients - a syndrome known as terminal delirium. Neuroleptics and short acting benzodiazepines are the main treatments.
5. Finally, dying patients often make a gurgling noise due to increased secretions - the "death rattle." This noise is not correlated with patient distress but it is disturbing to the family. Rx: change the patient's position or decrease secretions with Levsin or Scopolamine.

The family's needs:

Dying patient's family as they often are experiencing intense emotions. Ask about the following:

1. Do they have physical needs that you can help with? Write them excuse letters for work, bring them water or juice, allow them to sleep over at the hospital.
2. What are their spiritual/religious needs?
3. Explain what they are likely to see during the dying process. For example, dying people often have changes in respiratory pattern (e.g., Cheyne Stokes respiration or breathing with mandibular movements), decreased urine output, and can lose their ability to communicate.
4. Focus the environment on comfort. Remove monitors and alarms that distract families. Encourage family to bring in pictures or music that is meaningful to the patient.
5. Teach the family to nurture the patient in alternative ways such as massaging patient's hands, turning patient comfortably, or providing mouth care.

REMEMBER TO LOOK FOR THE FELLOWSHIP SURVEY IN YOUR MAILBOX IN APRIL!!

Fast Facts and Concepts End of Life Physician Education Resource Center
www.eperc.mcw.edu