Integrating Palliative Care into Practice

Abstract

Practitioners in long-term care medicine are seeing an ever-increasing number of persons with chronic progressive illness who reside either at home or in a LTC setting (nursing facility, SNF, assisted living or residential care). As of 2001, 46% of all deaths in the United States occur in these settings. Accordingly, clinicians have advocated that palliative care practice can be generalized and applied to such patient populations [1]. A multidimensional model of successful aging despite chronic illness where disease and its physiological and functional limitations are offset by compensatory psycho-emotional and social interventions that result in emotional vitality, well-being, and engagement with life and spirituality has been set forth by some [2]. Such an approach to care embodies the true philosophy of palliative care. Palliative care can and should be integrated alongside the traditional treatment of disease, where disease-modifying treatments are not necessarily avoided if appropriate and congruent with patients’ goals of care. Such “total care” should be safe, effective, patient-centered, timely, efficient, and equitable, all consistent with the six aims of the Institute of Medicine 2001 report to improve health care in the United States.

Introduction

Practitioners in long-term care medicine are seeing an ever-increasing number of persons with chronic progressive illness who reside either at home or in a LTC setting (nursing facility, SNF, assisted living or residential care). As of 2001, 46% of all deaths in the United States occur in these settings. Accordingly, clinicians have advocated that palliative care practice can be generalized and applied to such patient populations [1]. A multidimensional model of successful aging despite chronic illness where disease and its physiological and functional limitations are offset by compensatory psycho-emotional and social interventions that result in emotional vitality, well-being, and engagement with life and spirituality has been set forth by some [2]. Such an approach to care embodies the true philosophy of palliative care. Palliative care can and should be integrated alongside the traditional treatment of disease, where disease-modifying treatments are not necessarily avoided if appropriate and congruent with patients’ goals of care. Such “total care” should be safe, effective, patient-centered, timely, efficient, and equitable, all consistent with the six aims of the Institute of Medicine 2001 report to improve health care in the United States.

Illness Trajectories

Generally, illness trajectories that lead to subsequent death can manifest in one of three ways:

A short period of rapid decline (usually a few weeks or months) as often seen in cancer

Prolonged dwindling over 6–8 years as seen in dementia, frailty, and generalized debility or

Long-term functional decline over 2–5 years, with intermittent serious episodes of illness, often associated with multiple ER visits and hospitalizations, with only partial recovery after each episode, and eventual death. This is most often seen in heart and respiratory failure.

Timely recognition of a patient’s illness trajectory and poor prognosis can serve as a springboard to advance care planning, to review goals of life, and to establish appropriate goals of care for patients and their families.

For persons who reside in nursing facilities, common causes of death are [3, 4]:

30–60% cardiovascular (includes sudden cardiac death, myocardial infarction, heart failure, and stroke)

1–23% pulmonary (COPD, pneumonia, lung cancer)

36% Alzheimer’s disease and other dementia

7–9% cancer

2–3% end-stage renal disease.

Irrespective of the place of residence, heart disease, cancer, stroke, lung disease, Alzheimer’s, influenza and pneumonia, and kidney disease are all in the top 10 leading causes of death in the US (in addition to unintentional injuries, diabetes, and septicemia). These diseases commonly afflict patients/residents in the LTC continuum who can thus benefit from the integration of effective palliative care with traditional medical treatment, whether it is during the early, middle, late, or terminal phase of their illness trajectory.

Principles of Palliative Care

Irrespective of the age of the patient, the clinical setting, place of residence/care, or whether the person is suffering from chronic progressive illness or an acute life-threatening illness, the core principles of palliative care are the same:

Reduce the symptom burden from pain and other distressful symptoms, including the relief of suffering.

Recognize and address the physical, psycho-emotional, social, and spiritual needs and dimensions of pain and other symptoms experienced by both the patient and family.

Provide medical treatment congruent with the wishes, values, preferences, beliefs, and concerns of the patient and family.

Provide care that is both interdisciplinary and interprofessional.

Practitioners should be committed to the highest quality (palliative) care that is both timely and comprehensive. To do so, regular clinical assessment, diagnosis, care planning, interventions, monitoring (response to interventions and the natural course of the disease), follow-up, and, if possible, anticipation and prevention of distressful symptoms and suffering are required. Care should be patient-centered and family-focused. Effective communication skills are essential. Practitioners and the interdisciplinary team (IDT) are challenged to provide seamless transitions in care between institutional, hospital, and home care settings.

For the patient and family, the primary goals of palliative care include:

• Striving for the highest practical quality of life, despite late stage illness

• Being in control (autonomy) and maintaining dignity

• Relief of distressful symptoms and suffering (social, spiritual)

• Alleviate family burden (can be psycho-emotional, financial, practical)

• Coming to peace with spiritual issues and relationships

In LTC medicine, the goals of palliative care are similar to those of patients already under the care of practitioners. Also, medical care should be delivered in accordance with the ethical and legal framework of health care and the practitioner’s scope of practice and provided with cultural sensitivity and competency (see chapters on Ethical and Legal Issues and Working with Families and Healthcare Providers).

Symptom Assessment and Management

In persons with advanced illness, appropriate assessment is often challenging due to patient cognitive impairment, fatigue, and comorbidities. Nonpain symptoms are prevalent, often greater than pain, even in persons diagnosed with cancer (see Table 8.1). For any symptom experienced by patients, a stepped approach enables practitioners to intervene in a timely and effective manner.

Table 8.1. Symptoms in advanced illness

First, recognize each symptom and its sequelae.

• Establish its intensity, temporal pattern, any exacerbating/relieving factors, location, and effect on function and cognition.

• Determine whether the symptom is acute, chronic, or intermittent.

• Identify any associated symptoms.

• Review previous and current treatment for the symptom.

• Perform an appropriate, timely, and symptom-focused physical exam.

• Ascertain, if possible, the likely pathophysiology underlying the symptom.

• Consider whether any medication could be causing or aggravating the symptom.

• Identify potentially reversible causes.

• If necessary, use the least invasive diagnostic testing to minimize patient pain, discomfort, or suffering.

• Determine the most likely diagnosis, if possible.

• Always evaluate for the presence of any psycho-emotional, spiritual, social, or practical factors to the symptom.

• Initiate treatment based upon the primary illness, phase of illness, prognosis, comorbidities, patient/family preferences for care and care setting.

• Consider complementary and alternative therapies especially if requested by patients and families.

Any symptom can be complex and multifaceted, thus an interdisciplinary and transdisciplinary approach and treatment plan is more likely to be successful. First, try practical interventions in an attempt to alleviate each symptom, i.e., change in body position, room temperature or ventilation, or patient/family education. Second and foremost, consider pharmacologic interventions to alleviate each symptom. Finally, consider secondary medical and/or pharmacologic treatments directed at the underlying cause of the symptoms. Responses and outcomes, benefits, and burdens must be carefully monitored and treatments adjusted accordingly, acknowledging that the goals of care can change over time.

At times, distressful symptoms may inadvertently occur subsequent to interventions, but their overall benefits should outweigh their harm (the concept of double effect). In such a situation, it is reasonable to continue the treatment while adding another treatment to alleviate the adverse effects. In a critical situation, characterized by severe and intractable symptoms, use of palliative sedation may be the most humane and ethical option.

At the practitioner and systems level, use of uni- or multidimensional tools may be helpful to assess a variety of symptoms (Table 8.2) dependent upon ease of use and evidence-based palliative care. These suggested scales are not all inclusive. The Edmonton Symptom Assessment Survey (ESAS) assesses for the presence and intensity of multiple symptoms.

Table 8.2. Symptom assessment scales

Several reviews have more thoroughly detailed the management of pain and other symptoms that occur in patients with advanced illness who reside in long-term care facilities [5, 6] and in general practice [7]. Other excellent resources include the “UNIPAC” Series, a publication of the American Academy of Hospice and Palliative Medicine [8], the American Medical Directors Association Clinical Practice Guideline (CPG) on “Pain Management in the Long-Term Care Setting” [9], and references [10] and [11].

Anorexia

Anorexia is defined as a loss of appetite and may be associated with cachexia; the latter is a catabolic state characterized by severe weight loss. Either may occur in the late stages of any severe progressive illness.

Its management includes the following:

• Assess anorexigenic effects of medications such as chemotherapy, antidepressants, NSAIDs, opioids.

• Evaluate whether it could be caused by or related to other symptoms such as nausea, constipation, or pain.

• Assess for any potentially reversible medical condition such as rectal fecal impaction, urinary retention, oral candidiasis, or other treatable causes such as GER, gastritis, or gastroparesis.

• Initiate practical interventions: small, frequent meals; administer medications separate from or with meals; encourage good mouth care; try a variety of foods; improve the social and environmental aspects of eating.

Treat the primary symptom (i.e., anorexia) with an appetite stimulant such as:

• A corticosteroid: prednisone 5–20 mg/day; dexamethasone 4–8 mg/day.

• A progestin: megestrol 400–800 mg/day (trial 4–8 weeks).

Note that the appetite stimulant effect of corticosteroids often decreases after several weeks. Megestrol is associated with lower limb edema and an increased risk of DVT. Consider oral nutritional supplements, though subsequent decreased intake at meals can occur as a result of their use. If used, it is preferable to use nutritional supplements that are lactose free, especially in the elderly or African Americans who have a higher prevalence of lactose intolerance. There is insufficient evidence to recommend the use of cannaboids (dronabinol), cyproheptadine, an androgenic steroid (oxandrolone), or thalidomide, though a therapeutic trial may be worthwhile in individual cases. A patient’s advance directive for health care may either request or preclude artificially administered nutrition and hydration. (See the Weight and Nutrition chapter for further discussion.)

Dyspnea

Dyspnea is defined as discomfort in breathing that includes the sensation of breathlessness, shortness of breath, or an increased work of breathing. Often it is not associated with tachypnea or hypoxemia. Its management includes the following:

• Initiate practical interventions such as the use of a fan, ensure a comfortable ambient temperature, eliminate respiratory irritants, reposition the person.

• Assess for potentially reversible causes: pneumonia, pleural effusion, pulmonary embolus, heart failure, anemia, bronchospasm.

• Identify any associated symptoms such as aspiration, excessive respiratory secretions, anxiety, social or financial problems, spiritual suffering.

• First-line pharmacotherapy for palliation of dyspnea is an opioid administered every 3–4 h. For mild dyspnea in an opioid-naïve patient, start with morphine sulfate 2.5–5 mg PO or the oral morphine equivalent (OME) of another opioid, (refer to OME interconversion Table 8.12 later in this chapter). Titrate the opioid dose upward 25–50% every 12–24 h to attain sufficient relief of dyspnea.

• Optimize medical treatment of the primary respiratory or cardiac condition (i.e., COPD, heart failure).

• Consider addition of a low-dose benzodiazepine for breakthrough or refractory dyspnea as anxiety can be a major contributing factor.

• Consider other medical treatments based upon their benefits and burdens, phase of illness, patient preferences, and advance healthcare directives.

• Remember that patients with dyspnea often do better with a scheduled dose of an opioid (and an anxiolytic) rather than received as needed (PRN). Opioids are effective in treating dyspnea in patients with COPD, though less effective in patients with cancer or heart failure. Use of nebulized opioids is questionable, though they may warrant a therapeutic trial in a more refractory patient. Though the use of oxygen may reverse hypoxemia, dyspnea may not improve. Beware of the potential for oxygen therapy to cause hypercapnia and subsequent obtundation or respiratory arrest.

Not infrequently a family member may request that the dyspneic patient receive oxygen. Despite it being of no benefit to the patient, it may alleviate the distress families experience while observing their dyspneic family member. When using an opioid for dyspnea, it is prudent to aim for a respiratory rate no less than 14–20 breaths per minute.

Nausea and Vomiting

The most rational approach to managing nausea and/or vomiting is to understand its four main pathophysiologic mechanisms and the neurotransmitters that mediate the emetic reflex in the brain (Table 8.3). This will allow for a much more rational and effective choice of antiemetic drugs.

Table 8.3. Major mechanisms of nausea/vomiting

Management of nausea/vomiting includes:

• Determine whether any medications are emetogenic such as chemotherapeutic agents, some antibiotics, bowel stimulants, opioids, NSAIDs.

• Identify potentially reversible causes such as GER, gastroparesis, constipation, urinary retention, adynamic ileus, UTI.

• Consider emotional and spiritual factors, including anticipatory anxiety related to medical treatments.

• Initiate practical, nonpharmacologic interventions such as offering smaller, more frequent meals of blander food, relaxation techniques, appropriate body positioning while eating or when being fed either orally or by PEG tube.

• Prescribe pharmacologic treatment based on the major cause(s) of nausea/vomiting (Table 8.3).

• Combination pharmacotherapy based on each medication’s different antiemetic physiologic mechanism may be required especially if nausea/vomiting has multiple etiologies or is refractory. Dexamethasone, metoclopramide, and low-dose antipsychotics have central antiemetic effects. Low-dose haloperidol (0.5–2 mg) or olanzapine (2.5–7.5 mg) may be useful in alleviating nausea/vomiting through several of the four common pathophysiologic mechanisms. But, beware of the likely side effects of serotonin receptor antagonists (headache, constipation, fatigue, xerostomia) and of anticholinergics and antihistamines (drowsiness, fatigue, confusion, dry mouth, constipation, urinary retention, blurred vision). Metoclopramide, like the antipsychotics, can also induce the EPS of dystonia and tardive dyskinesia.

Dronabinol has an antiemetic effect as well (start at 2.5 mg twice a day to a maximum of 20 mg/day). Common adverse reactions of dronabinol can include somnolescence, asthenia, paranoia, nausea, and vomiting. If nausea/vomiting is induced from an opioid, it may require either a dose reduction of the opioid or rotation to another opioid.

Constipation

Many patients who reside in a long-term care setting experience constipation, especially if terminally ill. Constipation can occur because of a combination of poor fluid intake, low dietary fiber, impaired mobility, and constipating drugs such as opioids, anticholinergics, iron, and calcium preparations and antihypertensives such as calcium channel blockers, diuretics, and clonidine.

Management of constipation includes the following:

• Prevention is paramount.

• Identify potentially reversible causes, including medication-induced and medical conditions such as a fecal impaction, metabolic disturbances (hypercalcemia, hypothyroidism), GI causes (especially be aware if obstruction is present), and neurologic causes (such as nerve root or spinal cord compression or the visceral neuropathy that may occur in Parkinson’s disease).

• Be aware of life-threatening causes such as a bowel obstruction or narcotic bowel syndrome.

• Practical interventions include making toilets accessible, establishing a bowel routine, and encouraging increased fluid intake (if tolerated).

• Reduce the anticholinergic medication load if possible.

• Establish an individualized bowel regimen according to each laxative’s mechanism of action (Table 8.4). Combination therapy is often required.

  Table 8.4. Stepwise regimen to prevent or treat constipation, “The sixth vital sign”

• Monitor for side effects of laxatives that can include bloating, cramping, nausea, and diarrhea.

• Bulk-forming laxatives are usually not recommended because they can exacerbate constipation in underhydrated and less mobile patients and often cause or worsen bloating, nausea, or vomiting.

Remember to prevent opioid-induced constipation; as the dose of the opioid is increased, so must the laxative dose be increased. Stimulant laxatives such as senna are most effective for opioid-induced constipation.

Stool softeners have poor effectiveness, but can be considered initially in some patients upon initiating a bowel regimen, i.e., the “laxative ladder”. Remember that some patients may also require use of a rectally administered lubricating agent (glycerin) and/or stimulant (bisacodyl) in combination with the oral agents to ensure adequate defecation. Be aware that rectal fecal impaction can cause “paradoxical” diarrhea or urinary retention, either of which may or may not be evident.

Delirium

Delirium is an acute confusional state that is characterized by a fluctuating course through the day/night, inattention, and disorganized thinking and speech. Delirium can be either hyperactive or hypoactive. A good caveat to consider is that any acute illness or any medication (either recently prescribed or its dose increased or possibly decreased) can precipitate delirium especially in frail patients with advanced illness.

Management of delirium includes the following:

• Identify potentially reversible causes, especially whether it may be medication-induced.

• Discontinue nonessential medications and reduce anticholinergic load.

• Practical interventions include: familiarize the patient to the environment, improve sleep and the sleep–wake cycle, reduce environmental stimuli and optimize hearing and eyesight (i.e., hearing aides “in,” eyeglasses “on”), and adequate hydration.

• Increase mobility by removing/minimizing use of any physical restraints, including Foley catheters.

• Determine whether pain could be contributing to the delirium, and if so, treat it appropriately.

• First-line medication therapy is with low-dose haloperidol (no more than 2–3 mg/day), often in divided doses.

• Second-line medication may include a low-dose benzodiazepine, usually lorazepam 0.5–1 mg PO/SL every 6–8 h, more frequent if necessary; or valproic acid 125–250 mg every 12 h or upon awaking in the morning and at bedtime.

Remember that opioids and steroid medications can cause delirium. Both haloperidol and lorazepam can cause paradoxical agitation or restlessness in which case their dose should be decreased (not increased) or discontinued. It is not uncommon to use combination therapy with both haloperidol and lorazepam. Beware that patients with dementia are more sensitive to the antipsychotic medications’ adverse effects of sedation and EPS, and that these medications have been associated with an increased risk of sudden death and cerebrovascular events. Overall, judicious medication management as well as social, environmental, and practical interventions must all be implemented in an attempt to prevent and treat delirium.

Pain Management

Effective pain management is the cornerstone of high-quality palliative care in LTC medicine. There is a high prevalence of potentially pain producing medical conditions in this patient population. The goals of pain control include:

• Relief of pain

• Relief of suffering

• Prevent/minimize disability and maximize mobility

• Preserve decision-making capacity

It is always necessary for practitioners to assess each patient for the presence of pain and for “total pain”, that is the physical, psycho-emotional, social, and spiritual components of pain and how each can affect the other. Successful pain management entails evaluation and interventions that address each component of a patient’s total pain. As with any distressful symptom, pain is more optimally managed if its cause and pathophysiologic mechanisms can be understood, together with an interdisciplinary approach and use of multiple treatment modalities, both nonpharmacologic and pharmacologic. The most recent AMDA Clinical Practice Guideline on pain management [12] and the AGS publication, Geriatrics at Your Fingertips [13] are excellent up-to-date resources that provide more in-depth content than this chapter permits. Also, the recently updated AGS guidelines (2009) on the pharmacologic management of persistent pain in older persons are another noteworthy resource [14].

Key components to the evaluation of pain include the following:

If possible, prevent the occurrence of pain or a painful condition. For example, advanced osteoarthritis of one knee may result in contra-lateral hip pain: a total knee arthroplasty may prevent this happening. Another example is prescribing medication in an attempt to prevent the occurrence of postherpetic neuralgia.

Anticipate the occurrence of pain. For example, postsurgical incision pain, the pain associated with the onset of peripheral neuropathy in diabetics, or onset of bone pain in cancer patients with known bone metastases.

Identify the presence of pain or a painful condition. Remember to look for nonverbal cues of pain such as guarding on movement or on transfers, rubbing and grimacing, or other behaviors such as agitation, restlessness, and insomnia.

Establish its location, intensity, temporal pattern, any exacerbating and relieving factors, and effect on (loss of) function and cognition. Consider using a pain assessment scale.

Determine whether the pain is acute, chronic (duration of 1 month or more), new onset, intermittent, incidental (i.e., related to movement), or breakthrough pain, and whether multiple sources of pain are present.

Try to determine whether the pain is nociceptive (either somatic or visceral), neuropathic, or inflammatory, according to the patient’s description of the pain (see Table 8.5).

Table 8.5. Classification of Pain

Identify associated signs and/or symptoms such as headache, dizziness, nausea/vomiting, constipation, decreased urination, a swollen joint, or extremity.

Review previous and current treatments and their effectiveness, including pain medications, therapies, including nonpharmacologic, and any complementary and alternative medicine interventions.

Assess “total pain” by elucidating any psycho-emotional, social, and spiritual dimensions to the physical pain, as well as the person’s cultural beliefs as to the meaning of pain and manner of expressing pain.

Perform a detailed physical exam, with particular attention to those body regions or organs systems that appear to be related to or contributing to the pain.

Assess the need for diagnostic testing, if likely to be helpful in determining a diagnosis, always considering the potential pain or discomfort these tests may cause.

Determine the probable cause of the pain. Remember persons may have multiple and different types of pain. Always evaluate for reversible causes of pain. For example, abdominal pain may be due to urinary retention, constipation, rectal/fecal impaction, or caused by medications such as stimulant or bulk-forming laxatives.

Remember that other conditions such as bladder spasms, contractures, improper positioning, pressure ulcers, muscle strain, oral thrush, urinary retention, fecal impaction, or DVT can all cause pain.

Key components to the treatment of pain include the following:

Treatment options should take into account the patient’s health status, prognosis, known advance directives for health care as well as preferences for care, and thorough discussions to ensure informed choices by the patient and family or proxy decision-maker.

Promote an interdisciplinary treatment plan, part of which will be determined by the disciplines available at the patient’s care setting (i.e., nursing facility, SNF, residential/assisted living, home, or hospital).

Set goals for pain relief. For example, the desired or accepted level of pain reduction that promotes the achievement of positive functional outcomes in self-care, participation in desired personal and recreational activities, and improved sleep, mood, or cognition.

In up to 90% of persons with pain, practitioners can adequately control pain through orally administered medications guided by the World Health Organization’s (WHO) three-step analgesic ladder (see Table 8.6). The WHO recommends administering analgesic and coanalgesic (i.e., adjuvant) medications as follows:

Table 8.6. The WHO 3-step analgesic ladder

By mouth: whenever possible, prescribe an oral analgesic. Avoid IM injections as they can be painful; subcutaneous injections are less painful. Opioids in a concentrated liquid form can be administered sublingually or transbuccally.

Around-the-clock: scheduled dosing for continuous pain and to minimize breakthrough pain

According to the ladder: the initial choice of analgesic and use of adjuvants is based on the severity of the pain. Using the numerical pain scale, 1 through 3 can be considered mild pain, 4 through 6 moderate pain, 7 through 9 severe pain, and 10 excruciating pain.

Adapted to the individual: the choice of analgesic should be based upon the patient’s condition, comorbidities (such as liver and kidney failure; coexistent dementia or delirium), drug safety and toxicity profile, ease of administration, and goals of both pain relief and the overall desired outcome.

With attention to detail: ensure correct dosing, consider drug pharmokinetics and pharmacodynamics, make appropriate dose adjustments in timely manner, always monitor benefit verses potential harm and adverse effects.

Optimal pain management entails the choice of the most appropriate analgesic(s) based upon the primary and secondary diagnoses, the physiologic mechanism underlying the pain (see Table 8.7), pain severity, diagnosis, the potential adverse effects of each medication and/or treatment modality, and the patient’s individual characteristics that can alter each drug’s pharmokinetics and pharmacodynamics.

Table 8.7. Select first- and second-line analgesics based on type of pain

Several caveats for pain management include:

• In most patients, prescribe at least one analgesic as scheduled, i.e., administered routinely, rather than just as needed (i.e., PRN).

• Choose an appropriate analgesic and dose for breakthrough pain.

• Most types of pain respond, at least partially, to an opioid.

• The maximum dose of acetaminophen is now 2000–3000 mg/day, but 2,000 mg/day if renal or hepatic insufficiency is present.

• The maximum dose of tramadol is 300 mg/24 h; may precipitate confusion, seizures, serotonin syndrome.

• Conventional nonselective NSAIDs (e.g., ibuprofen, naproxen) should be used only short term – that is, a few days to 3–4 weeks; precautions include risk for gastrointestinal bleeding, renal impairment, platelet dysfunction, and exacerbation of edema, blood pressure, and heart failure.

• Selective COX-2 inhibitors (e.g., celecoxib) still have a significant risk of GI bleeding and renal insufficiency.

• Consider holding or discontinuing ASA chemoprophylaxis when administering a conventional or COX-2 NSAID.

• Consider concomitant proton pump inhibitor therapy in patients at increased risk for GI bleeding when prescribing a NSAID.

• Never prescribe a NSAID if the patient is taking warfarin as the risk for GI bleeding is too high.

• Consider use of a topical analgesic such as capsaicin cream, diclofenac gel, or a lidocaine patch for persons with one or two localized areas of musculoskeletal, arthritic, or neuropathic pain.

• Remember that use of the lidocaine patch is noncontinuous, that it is to be applied for only 12 h each 24-h period, off the remaining 12 h, applying no more than three patches at a time.

• Avoid use of propoxyphene and meperidine due to their potential for causing undesirable CNS side effects such as confusion or seizures.

• Partial opioid agents such as butorphanol, pentazocine, buprenorphine, and nalbuphine are not recommended either because of their analgesic ceiling effects or ability to counteract the analgesic effect of pure agonist opioids; these medications can precipitate an opioid withdrawal pain crisis.

Opioid Analgesics

Opioids are both appropriate and effective for the treatment of moderate to severe acute or chronic pain not relieved by other analgesics or modalities. Judicious prescribing can provide effective pain management in the various patient populations served by LTC medicine with a low likelihood of psychological dependency or addiction. Scheduled low doses of opioids can be very effective in the treatment of chronic pain associated with various chronic musculoskeletal conditions that afflict the elderly. Be aware that physical dependency, characterized by withdrawal symptoms, can occur when regularly scheduled opioids are abruptly discontinued. Gradual dose reduction can prevent this if an opioid is to be discontinued.

General guidelines to the use of opioids include:

For acute pain: start by prescribing an immediate-release opioid preparation (see Table 8.8 for suggested equianalgesic starting doses).

Table 8.8. Suggested equianalgesic starting doses for selected oral opioids

For chronic pain: consider starting a sustained-released opioid, with a sufficient dose of an immediate-release opioid for breakthrough pain.

Remember that the total dose of a mixed opioid (i.e., an opioid with acetaminophen) is limited by its 24 h dose of acetaminophen.

Once the total daily dose of an opioid has been established to adequately control the patient’s pain, consider converting it to an equivalent dose of a sustained-release opioid (see Table 8.9 on the different formulations of sustained-release opioids that are available).

Table 8.9. Available formulations of sustained-release oral opioids

Note that the duration of analgesic action for all immediate-release morphine preparations whether administered PO, SL, SC, or IV is 3–4 h, though their onset of action and peak effect do vary (see Table 8.10).

Table 8.10 Pharmacodynamics of immediate-release morphine

The opioid dose for breakthrough pain is 10–15% of the total daily opioid dose, administered every 1–2 h as needed.

One can usually and safely titrate up the total 24 h dose of an opioid 25–50% for mild to moderate pain and 50–100% for moderate to severe pain.

When starting a patient on an opioid, ALWAYS start the patient on a prophylactic bowel regimen to prevent constipation. A stimulant and/or osmotic agent are preferable.

Adjuvant analgesics can allow use of a lower dose of an opioid and thus decrease the likelihood of opioid adverse effects.

In contrast to nonopioids and NSAIDs, opioids commonly used for the treatment of pain have no analgesic ceiling. However, adverse drug effects may limit further dose increases (see Table 8.11) or require “rotating” to another opioid, especially if adequate pain relief is not achieved (see below).

Table 8.11. Common and less common side effects of opioids

As already noted, propoxyphene and meperidine should be avoided because of their high potential for CNS toxicities. Codeine is too constipating in relation to the dose required for an adequate analgesic effect. Using two or more different opioids together is not recommended because of the potential for adverse drug–drug or opioid–receptor interactions, either unknown or unrecognized by clinicians. Different opioids interact to different degrees at the mu, delta, and kappa opioid receptors. One exception is the patient on the fentanyl patch, where an immediate-release opioid such as morphine or oxycodone needs to be used for breakthrough pain. Transmucosal oral fentanyl (i.e., Actiq ^®) is only indicated for severe breakthrough cancer pain and its use should be avoided in the LTC setting if at all possible.

When changing from one opioid to another, whether because of inadequate pain relief or unmanageable adverse effects of the opioid, use morphine equivalents as a common denominator for opioid dose conversion. Morphine equivalents can usually avoid underdosing or overdosing, while maintaining or obtaining effective pain relief (see Table 8.12 on OMEs). When using morphine equivalents, the dose of the new opioid is converted via decreasing its dose by 25–50% in order to adjust for incomplete cross-tolerance. When converting from one opioid to another, it may be prudent to do so over 2 or 3 days: with downward titration of the opioid being discontinued, coupled with the upward titration of the newly prescribed opioid. This is especially important if the patient is on a high dose of opioid in order to avoid a pain withdrawal crisis.

Table 8.12. Oral morphine equivalents (mg)

Caution is warranted when prescribing opioids in an opioid-naïve patient where the dictum “start low and go slow” is advisable. The suggested starting dose of oral morphine is 2–5 mg every 3–4 h or the equianalgesic dose of another opioid. The use of a fentanyl patch when initiating opioid treatment in the frail elderly opioid-naïve patient is not advisable as the lower strength patches of 12 μg/h and 25 μg/h provide an OME approximate dose of 25 mg and 50 mg, respectively, every 24 h. Such doses can cause excess fatigue or sedation especially in these opioid-naïve patients. Though expensive, the fentanyl patch has an ease of administration and can provide excellent analgesia in some patients, but is likely ineffective in thin patients and those who weigh less than 105 lbs due to inadequate subcutaneous fat necessary for fentanyl absorption through the skin.

Morphine, oxycodone, and hydromorphone should be used cautiously in patients with moderate to severe renal failure (GFR 30–50 ml/min or less) because of the risk of metabolite accumulation. Methadone and fentanyl are safe to use for patients with advanced renal failure and on dialysis, though neither is dialyzable. Nonopioid medications that are safe to use for patients with renal failure include acetaminophen and tramadol, though the maximal daily dose of tramadol should be reduced from 300 mg a day to no more 100–200 mg, divided twice a day. Morphine and codeine doses may need to be reduced in patients with liver disease, especially those with cirrhosis. Fentanyl may be easier to use in such patients, unless there is inadequate subcutaneous tissue.

Methadone is gaining popularity in the treatment of chronic musculoskeletal pain and clinicians are more frequently prescribing it for the treatment of cancer pain and neuropathic pain. Other indications for its use include refractory pain, intolerance to other opioids, or clinician concern about patient diversion of opioids. Methadone has several mechanisms of action, is extensively metabolized in the liver, and is minimally renally excreted and cheap. However, its prolonged and variable metabolism (half-life may vary from 45 to 180 h) is such that its steady-state plasma concentration is not reached for up to 10 days. It has complex medication interactions and has been associated with prolongation of the QT interval and an increasingly higher cause of opioid-related deaths. Thus, methadone should only be used by (or in consultation with) a clinician who is experienced with its use. When treating frail elders prescribing low-dose methadone 2.5–5 mg, 2 or 3 times a day would be prudent. Methadone should never be used for the treatment of acute or breakthrough pain, as the risk of respiratory depression is too high. For more complete information on methadone use in long-term care, refer to Appendix 6 of the AMDA Clinical Practice Guideline on Pain Management [12].

For guidelines on the use of patient-controlled analgesia, refer to references [8] (UNIPAC Three) and [15].

Eligibility Guidelines for Hospice

Practitioners in LTC medicine must consider, offer, and facilitate resident access to hospice care as residents transition into the terminal phase of advanced illness. Hospice is an underutilized benefit with many patients referred too late in their illness and thereby unable to fully benefit from its services. Studies have shown that hospice stays of 7 days or less have increased to 34% of hospice admissions, while long stays greater than 180 days are less than 10% of admissions.

Practitioner awareness of the general eligibility guidelines and disease-specific guidelines (see Table 8.13) for hospice can help prognosticate whether a resident with advanced illness may have less than 6 months to live. Such a determination can provide the opportunity to open a frank discussion with the resident and family on advance care planning in order to decide upon a more palliative approach to care whether or not the resident and family opt for life-sustaining treatment.

Table 8.13. Disease-specific eligibility criteria/guidelines for hospice

General indicators (i.e., general eligibility guidelines for hospice) that any advanced illness has progressed to its terminal phase include the following:

• Frequent transfers to the ER

• More frequent hospitalizations

• Significant weight loss (5% in 1 month; 10% in the past 6 months)

• Multiple stage 3 or 4 decubitus ulcers

• Serum albumin less than 2.5 g/dl

• Recurrent life-threatening infections such as pneumonia, pyelonephritis, or sepsis

• Declining functional status as determined by either a Karnofsky Performance score of <50% or increasing dependency in 3 of 6 Basic Activities of Daily Living

When the guidelines for disease-specific eligibility for hospice are not met, the presence and severity of comorbid medical condition(s) and/or psychosocial factors can support eligibility for hospice. For example, advanced COPD or dementia may support eligibility for hospice in a resident with late stage heart failure. Or the recent death of a resident’s spouse or a life-threatening illness in a resident’s family member may support the resident’s eligibility for hospice.

Certification for hospice requires that two physicians, the hospice medical director and the attending or referring physician, sign a statement certifying that the patient’s medical prognosis suggests a life expectancy of 6 months or less if the individual’s illness follows its normal course. Once on hospice, a patient must be recertified for each benefit period. Recertification only requires a statement as to continued eligibility by the hospice medical director. The first two hospice certification periods are 90 days each and all subsequent periods are 60 days (with no limit as to the number of 60 day periods). However, continued eligibility for hospice requires that the eligibility parameters present on admission to hospice continue to be met and that physical, functional, and/or nutritional decline continues and suggests that life expectancy is 6 months or less if the individual’s illness follows its normal course. Every patient on hospice has the right to revoke their hospice benefit at any time in order to seek life-sustaining or curative treatment. In such circumstances, if these treatments are of no benefit, patients can be readmitted to hospice if still eligible.

Billing by practitioners for services rendered to patients on hospice can be confusing and dependent upon the Local Medicare Intermediary (now called Medicare Administrative Contractors). It is recommended that practitioners clarify hospice-billing practices with their Medicare Administrative Contractor and refer to Chapter 14 of this text.

End-of-Life Care

As patients with advanced serious illness enter the last months and weeks of life, practitioners need to both recognize this terminal phase and inform patients and family accordingly. Goals of care need to be reviewed and modified through advanced care planning. Whether the patient and family want to continue to pursue life-prolonging treatments or are amenable to hospice care, palliative care can be integrated into either choice. Irrespective of where the patient resides, interdisciplinary management is essential in maintaining hope, dignity, and the best possible quality of life until the patient dies. Eventually, however, continuing life-sustaining treatments (such as IV fluids, PEG tube feeding, blood transfusions, antibiotics, pacemakers, ICDs, and hemodialysis) during the last weeks and days of life can become overly burdensome and cause more harm, pain, and suffering than benefit to both patient and family.

The physiologic changes of dying, although complex, can be effectively managed if practitioners and the IDT understand the etiologies and underlying pathophysiology of each distressful symptom and use appropriate nonpharmacologic and pharmacologic interventions [16]. Given each patient’s terminal illness and their comorbidities, palliative drugs, equipment, and supplies should be available in anticipation of those symptoms that are most likely to occur at the end of life (EOL).

As death approaches, patients and families should be advised that fatigue and weakness will increase while the desire for food and fluid intake is reduced as manifested by the loss of both appetite and thirst. Reduced cardiac output and intravascular volume depletion result in tachycardia, hypotension, peripheral cooling, cyanosis, and mottling. Urine output will diminish with eventual anuria. Neurologic dysfunction will occur, leading to a decreased level of consciousness and eventual coma. Ten percent of patients may experience an agitated delirium during the last days of life.

Practical interventions to maintain patient comfort include periodic repositioning, decreasing food and fluid intake to prevent choking or aspiration, maintaining a moist oral mucosa, and providing moisture and lubricating agents to the conjunctiva and lips. Family members should be encouraged to participate in this care as it can often provide them with a sense of fulfillment in having helped to comfort their loved one at EOL.

Nonessential drugs (e.g., aspirin, multivitamins, calcium supplements, lipid-lowering agents) should be discontinued. Practitioners should also consider the benefits and risks of continuing drugs such as antidepressants, antihypertensives, warfarin, and thyroid replacement. Other drugs, such as diuretics, ACE inhibitors, and hypoglycemic agents (even insulin), may require a dosage reduction or even discontinuation. Reduced hepatic function and renal perfusion can precipitate an opioid-induced terminal delirium. If this occurs, consider reducing the opioid dosage while ensuring that pain is still adequately controlled.

During the last few days of life, medication reconciliation is essential to avoid polypharmacy and its potential sequelae, especially as “comfort medications” are administered to manage pain and distressful symptoms and suffering.

Remember that a peaceful death is just as important to the family as to the patient, perhaps even more so.

General guidelines on the use of comfort-directed pharmacologic interventions include:

For tachypnea or breathlessness: use low doses of an immediate-release opioid and/or benzodiazepine, administered sublingually or transbuccally.

For excessive respiratory or oral secretions: consider an anticholinergic agent administered sublingually (e.g., hyoscyamine or an ophthalmic solution of atropine) or topically (e.g., transdermal scopolamine).

For pain: use a concentrated oral formulation of either morphine (e.g., Roxanol^R 20 mg/cc) or oxycodone (Oxyfast^R 20 mg/cc). Either can be administered sublingually or transbuccally. Avoid IM or SC injections if possible as these can be painful.

For anxiety, agitation, or restlessness: use a benzodiazepine or an opioid, possibly an antipsychotic. Remember any of these can cause a paradoxical agitation.

For fever: schedule regular doses of acetaminophen administered orally, per rectum or per PEG (if present).

If excessive sweating: consider an opioid dose reduction.

If delirium: perform a careful medication review and rule out rectal fecal impaction or urinary bladder retention; treat accordingly with a benzodiazepine and/or antipsychotic; and ensure adequate pain control.

Compounded formulations applied topically on the skin may be effective for EOL restlessness, for example, ABH gel compound that comprises lorazepam, diphenhydramine, and haloperidol. Review of compounded topicals is beyond the scope of this chapter; practitioners are encouraged to contact their local compounding pharmacies and hospice agencies.

Pearls for the Practitioner

Integrate palliative care into traditional care provided to residents and patients throughout the long-term care continuum, irrespective of whether they choose to continue disease-directed or alternative therapies.

Support informed patient and family decision-making (i.e., advance care planning) that supports their values and preferences for care.

Determine, if possible, the pathophysiologic and clinical factors underlying each pain and nonpain symptom in order to choose the most appropriate interventions.

Treat pain through the use of multiple modalities, both nonpharmacologic and pharmacologic as well as complementary and alternative therapies.

Choose the most appropriate analgesic based on the type of pain, pain severity, potential adverse effects of the medication, and the patient’s individual characteristics.

Always initiate a bowel regimen to prevent constipation when prescribing an opioid and remember to intensify the bowel regimen when the dose of the opioid is increased.

Anticipate which symptoms are most likely to occur during each patient’s illness trajectory, in addition to identifying, assessing, treating, and monitoring distressful symptoms, and if possible, preventing their emergence.

Consider both the general and disease-specific guidelines when evaluating persons for hospice.

Consider palliative sedation to alleviate unbearable pain or suffering that persists despite aggressive palliative care.

Use as resources healthcare professionals in your community who have expertise in palliative care.

Websites

City of Hope Pain and Palliative Care Resource Center www.cityofhope.org/patient_care

American Academy of Hospice and Palliative Medicine www.aahpm.org

Center to Advance Palliative Care www.capc.org

Fast Facts and Concepts www.eperc.mcw.edu

American Pain Society www.ampainsoc.org

Morphine Equivalent Dose Conversion www.hopweb.org