Harrisons Manual of Medicine, 18th Ed.

CHAPTER 10. Palliative and End-of-Life Care

In 2008, 2,473,000 people died in the United States; death rates are declining. Heart disease and cancer are the two leading causes of death and together account for nearly half of all deaths. About 70% of deaths occur in people who have a condition that is known to be leading to their death; thus, planning for terminal care is relevant and important. An increasing fraction of deaths are occurring in hospices or at home rather than in the hospital.

Optimal care depends on a comprehensive assessment of pt needs in all four domains affected by illness: physical, psychological, social, and spiritual. A variety of assessment tools are available to assist in the process.

Communication and continuous assessment of management goals are key components to addressing end-of-life care. Physicians must be clear about the likely outcome of the illness(es) and provide an anticipated schedule with goals and landmarks in the care process. When the goals of care have changed from cure to palliation, that transition must be clearly explained and defended. Seven steps are involved in establishing goals:

1. Ensure that the medical information is as complete as possible and understood by all relevant parties.

2. Explore the pt’s goals while making sure the goals are achievable.

3. Explain the options.

4. Show empathy as the pt and the family adjust to changing expectations.

5. Make a plan with realistic goals.

6. Follow through with the plan.

7. Review and revise the plan periodically as the pt’s situation changes.

ADVANCE DIRECTIVES

About 70% of pts lack decision-making capacity in their final days. Advance directives define ahead of time the level of intervention the pt is willing to accept. Two types of legal documents can be used: the advance directive, in which specific instructions from the pt may be made known; and the durable attorney for health care, in which a person is designated as having the pt’s authority to make health decisions on the pt’s behalf. Forms are available free of charge from the National Hospice and Palliative Care Organization (www.nhpco.org). Physicians also should complete these forms for themselves.

PHYSICAL SYMPTOMS AND THEIR MANAGEMENT

The most common physical and psychological symptoms among terminally ill pts are shown in Table 10-1. Studies of pts with advanced cancer have shown that pts experience an average of 11.5 symptoms.

TABLE 10-1 COMMON PHYSICAL AND PSYCHOLOGICAL SYMPTOMS OF TERMINALLY ILL PATIENTS

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Pain

Pain is noted in 36–90% of terminally ill pts. The various types of pain and their management are discussed in Chap. 6.

Constipation

Constipation is noted in up to 87% of terminally ill pts. Medications that commonly contribute to constipation include opioids used to manage pain and dyspnea and tricyclic antidepressants with their anticholinergic effects. Inactivity, poor diet, and hypercalcemia may contribute. GI tract obstruction also may play a role in some settings.

Interventions Improved physical activity (if possible), adequate hydration; opioid effects can be antagonized by the μ-opioid receptor blocker methylnaltrexone (8–12 mg SC daily); rule out surgically correctable obstruction; laxatives and stool softeners (Table 10-2).

TABLE 10-2 MEDICATIONS FOR THE MANAGEMENT OF CONSTIPATION

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Nausea

Up to 70% of pts with advanced cancer have nausea. Nausea may result from uremia, liver failure, hypercalcemia, bowel obstruction, severe constipation, infection, gastroesophageal reflux disease, vestibular disease, brain metastases, medications (cancer chemotherapy, antibiotics, nonsteroidal anti-inflammatory drugs, opioids, proton pump inhibitors), and radiation therapy.

Interventions Treatment should be tailored to the cause. Offending medications should be stopped. Underlying conditions should be alleviated, if possible. If decreased bowel motility is suspected, metoclopramide may help. Nausea from cancer chemotherapy agents can generally be prevented with glucocorticoids and serotonin receptor blockers like ondansetron or dolasetron. Aprepitant is useful in controlling nausea from highly emetogenic agents like cisplatin. Vestibular nausea may respond to antihistamines (meclizine) or anticholinergics (scopolamine). Anticipatory nausea may be prevented with a benzodiazepine such as lorazepam. Haloperidol is sometimes useful when the nausea does not have a single specific cause.

Dyspnea

Up to 75% of dying pts experience dyspnea. Dyspnea exerts perhaps the greatest adverse effect on the pt, often even more distressing than pain.

It may be caused by parenchymal lung disease, infection, effusions, pulmonary emboli, pulmonary edema, asthma, or compressed airway. While many of the causes may be treated, often the underlying cause cannot be reversed.

Interventions Underlying causes should be reversed, where possible, as long as the intervention is not more unpleasant (e.g., repeated thoracenteses) than the dyspnea. Most often the treatment is symptomatic (Table 10-3).

TABLE 10-3 MEDICATIONS FOR THE MANAGEMENT OF DYSPNEA

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Fatigue

Fatigue is nearly a universal symptom in terminally ill pts. It is often a direct consequence of the disease process (and the cytokines produced in response to that process) and may be complicated by inanition, dehydration, anemia, infection, hypothyroidism, and drug effects. Depression may also contribute to fatigue. Functional assessments include the Karnofsky performance status or the Eastern Cooperative Oncology Group system based on how much time the pt spends in bed each day: 0, normal activity; 1, symptomatic without being bedridden; 2, in bed <50% of the day; 3, in bed >50% of the day; 4, bedbound.

Interventions Modest exercise and physical therapy may reduce muscle wasting and depression and improve mood; discontinue medications that worsen fatigue, if possible; glucocorticoids may increase energy and enhance mood; dextroamphetamine (5–10 mg/d) or methylphenidate (2.5–5 mg/d) in the morning may enhance energy levels but should be avoided at night because they may produce insomnia; modafinil and L-carnitine have shown some early promise.

Depression

Up to 75% of terminally ill pts experience depression. The inexperienced physician may feel that depression is an appropriate response to terminal illness; however, in a substantial fraction of pts the depression is more intense and disabling than usual. Pts with a previous history of depression are at greater risk. A number of treatable conditions can cause depression-like symptoms including hypothyroidism, Cushing’s syndrome, electrolyte abnormalities (e.g., hypercalcemia), and drugs including dopamine blockers, interferon, tamoxifen, interleukin 2, vincristine, and glucocorticoids.

Interventions Dextroamphetamine or methylphenidate (see above); serotonin reuptake inhibitors such as fluoxetine, paroxetine, and citalopram; modafinil 100 mg/d; pemoline 18.75 mg in the A.M. and at noon.

Delirium

Delirium is a global cerebral dysfunction associated with altered cognition and consciousness; it is frequently preceded by anxiety. Unlike dementia, it is of sudden onset, is characterized by fluctuating consciousness and inattention, and may be reversible. It is generally manifested in the hours before death. It may be caused by metabolic encephalopathy in renal or liver failure, hypoxemia, infection, hypercalcemia, paraneoplastic syndromes, dehydration, constipation, urinary retention, and central nervous system spread of cancer. It is also a common medication side effect; offending agents include those commonly used in dying pts including opioids, glucocorticoids, anticholinergics, antihistamines, antiemetics, and benzodiazepines. Early recognition is key because the pt should be encouraged to use the periods of lucidity for final communication with loved ones. Day-night reversal with changes in mentation may be an early sign.

Interventions Stop any and all unnecessary medications that may have this side effect; provide a calendar, clock, newspaper, or other orienting signals; gently correct hallucinations or cognitive mistakes; pharmacologic interventions are shown in Table 10-4.

TABLE 10-4 MEDICATIONS FOR THE MANAGEMENT OF DELIRIUM

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CARE DURING THE LAST HOURS

The clinical course of a dying pt may largely be predictable. Figure 10-1 shows common and uncommon changes during the last days of life.

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FIGURE 10-1 Common and uncommon clinical courses in the last days of terminally ill pts. (Adapted from FD Ferris et al: Module 4: Palliative care, in Comprehensive Guide for the Care of Persons with HIV Disease. Toronto: Mt. Sinai Hospital and Casey Hospice, 1995, www.cpsonline.info/content/resources/hivmodule/module4complete.pdf.)

Informing families that these changes might occur can help minimize the distress that they cause. In particular, the physician needs to be sensitive to the sense of guilt and helplessness that family members feel. They should be reassured that the illness is taking its course and their care of the pt is not at fault in any way. The pt stops eating because they are dying; they are not dying because they have stopped eating. Families and caregivers should be encouraged to communicate directly with the dying pt whether or not the pt is unconscious. Holding the pt’s hand may be a source of comfort to both the pt and the family member/caregiver. Table 10-5 provides a listing of some changes in the pt’s condition in the final hours and advice on how to manage the changes.

TABLE 10-5 MANAGING CHANGES IN THE PATIENT’S CONDITION DURING THE FINAL DAYS AND HOURS

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Additional resources for managing terminally ill pts may be found at the following websites: www.epec.netwww.eperc.mcw.eduwww.capc.org, and www.nhpco.org.

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For a more detailed discussion, see Emanuel EJ: Palliative and End-of-Life Care, Chap. 9, p. 67, in HPIM-18.