Getting Comfortable With Comfort Care

Mike Aref, MD, PhD, FACP, FHMAssistant Medical Director of Palliative Medicine

Carle Hospital and Physician Group

Everyone Needs To Know How To Provide Comfort Care

Palliative Care• Palliative Care is an approach

that improves the quality of life of patients and their families facing the problem associated with life-threatening 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.

Comfort Care• Comfort Care is an essential

part of medical care at the end of life. It is care that helps or soothes a person who is dying. The goal is to prevent or relieve suffering as much as possible while respecting the dying person’s wishes.

www.who.int/cancer/palliative/definition/en/www.nia.nih.gov/health/publication/end-life-helping-comfort-and-care/providing-comfort-end-life

Admission and Increased Mortality

Cohort Number %

Died in ED 205 / 76,060 0.27

Died within 30 days of discharge from ED 111 / 59,366 0.19

Died within 30 days of being admitted from ED 876 / 16,489 4.6

Emerg Med J. Aug 2006; 23(8): 601–603

Death Does NOT Respect Age

www.medicine.ox.ac.uk/bandolier/booth/Risk/dyingage.html

Identifying the Actively Dying

PatientProfound progressive weaknessBed-bound stateSleeping much of the timeIndifference to food and fluidsDifficulty swallowingDisorientation to time, with increasingly short attention spanLow or lower blood pressure not related to hypovolemiaUrinary incontinence or retention caused by weaknessOliguria (positive LR 15.2, 95% CI 13.4-17.1)Drooping of the nasolabial fold (positive LR 8.3, 95% CI 7.7-8.9)Loss of ability to close eyes (positive LR 13.6, 95% CI 11.7-15.5)Nonreactive pupils (positive LR 16.7, 95% CI 14.9-18.6)Hallucinations involving previously deceased important individualsReferences to going home or similar themesChanges in respiratory rate and pattern

Respiration with mandibular movement (positive LR 10, 95% CI 9.1-10.9)Cheyne-Stoke breathing (positive LR 12.4, 95% CI 10.8-13.9)ApneaHyperextension of the neck (postive LR 7.3, 95% CI 6.7-8)Grunting of the vocal cords (positive LR 11.8, 95% CI 10.3-13.4)

Noisy breathing, pooling of airway secretions — “death rattle” (positive LR 9, 95% CI 8.1-9.8)Mottling and cooling of the skin due to vasomotor instability with venous pooling, particularly tibialDropping blood pressure with rising, weak pulse

Pulselessness of the radial artery (positive LR 15.6, 95% CI 13.7-17.4)Mental status changes (terminal delirium, terminal restlessness, agitation, coma)

Decreased response to verbal stimuli (positive LR 8.3, 95% CI 7.7-9)Decreased response to visual stimuli (positive LR 6.7, 95% CI 6.3-7.1)

Bicanovsky L. Comfort Care: Symptom Control in the Dying. In: Palliative Medicine, Walsh D, Caraceni AT, Fainsinger R, et al (Eds), Saunders, Philadelphia 2009.Oncologist. 2014;19(6):681Cancer. 2015;121(6):960.

Physical Findings

Death Rattle Cheyne-Stoke Breathing

Palliative Performance Scale (PPS)PPS Level Ambulation Activity & Evidence of

Disease Self-Care Intake Conscious Level Life Expectancy

100% Full Normal activity & work No evidence of disease Full Normal Full

90% Full Normal activity & work Some evidence of disease

Full Normal Full

80% Full Normal activity with Effort Some evidence of disease

Full Normal or reduced Full

70% Reduced Unable Normal Job/Work Significant disease

Full Normal or reduced Full Months

60% Reduced Unable hobby/house work Significant disease

Occasional assistance necessary Normal or reduced Fullor Confusion Weeks-Months

50% Mainly Sit/Lie Unable to do any work Extensive disease

Considerable assistance required Normal or reduced Fullor Confusion Weeks

40% Mainly in Bed Unable to do most activity Extensive disease

Mainly assistance Normal or reduced Full or Drowsy +/- Confusion Weeks

30% Totally Bed Bound Unable to do any activity Extensive disease

Total Care Normal or reduced Full or Drowsy +/- Confusion Days-Weeks

20% Totally Bed Bound Unable to do any activity Extensive disease

Total Care Minimal to sips Full or Drowsy +/- Confusion Days

10% Totally Bed Bound Unable to do any activity Extensive disease

Total Care Mouth care only Drowsy or Coma +/- Confusion Days

0% Death - - -

Victoria Hospice Society

3-Day Mortality Rate Estimates

PPSDrooping of nasolabial fold, present/absent

3-day mortality rate (%)

≤ 20% present 94≤ 20% absent 4230 to 60%   16≥70%   3

Cancer 2015; 3914.

REMAP the Plan of CareStep What you say or do

1. Reframe why the status quo isn’t working.

You may need to discuss serious news (eg a scan result) first. “Given this news, it seems like a good time to talk about what to do now.”“We’re in a different place.”

2. Expect emotion & empathize. “It’s hard to deal with all this.”“I can see you are really concerned about [x].”“Tell me more about that—what are you worried about?” “Is it ok for us to talk about what this means?”

3. Map the future. “Given this situation, what’s most important for you?”“When you think about the future, are there things you want to do?” “As you think towards the future, what concerns you?”

4. Align with the patient’s values. As I listen to you, it sounds the most important things are [x,y,z].

5. Plan medical treatments that match patient values.

Here’s what I can do now that will help you do those important things. What do you think about it?

Expect questions about more anticancer treatment.

Here are the pros and cons of what you are asking about. Overall, my experience tells me that more chemo would do more harm than good at this point. It’s hard to say that though.

Talk about services that would help before introducing hospice

We’ve talked about wanting to conserve your energy for important things. One thing that can help us is having a nurse come to your house to can help us adjust your medicines so you don’t have to come in to clinic so often.

The best way I have to do that is to call hospice, because they can provide this service for us, and more.

vitaltalk.org

Guidelines for Physicians Providing Comfort Care for Hospitalized Patients Who Are Near the End of Life

Blinderman CD, Billings JA. N Engl J Med 2015;373:2549-2561

National Cancer Institute: Last Days of Life (PDQ®)

• “Many patients fear uncontrolled pain during the final hours of life, while others (including family members and some health care professionals) express concern that opioid use may hasten death. Experience suggests that most patients can obtain pain relief during the final hours of life and that very high doses of opioids are rarely indicated. Several studies refute the fear of hastened death associated with opioid use. In several surveys of high-dose opioid use in hospice and palliative care settings, no relationship between opioid dose and survival was found.”

• The goal is to provide symptom management, specifically of pain and dyspnea, not to cause death.

www.cancer.gov/cancertopics/pdq/supportivecare/lasthours/healthprofessional/page2

Basics: Pain and Dyspnea

• First line for alleviation of pain and dyspnea is opiates:– Morphine IV 4-8 mg Q15MIN PRN– Hydromorphone IV 0.6-1 mg Q15MIN PRN– Fentanyl IV 50-100 mcg Q10MIN PRN

• Second line for alleviation of anxiety due to total pain:– Lorazepam 0.5-2 mg IV Q2H PRN

• Delirium should be managed with haloperidol 0.5 mg IV Q30MIN PRN

Continuous Opioid Infusions

• If the patient has been receiving opiates calculate rate based on total dosage in the past 24 hours.

• If this is an acute change, consider one of the following:– Fentanyl start at 25 mcg/hr– Hydromorphone start at 0.3 mg/hr– Morphine start at 2 mg/hr

• Titrate a continuous infusion rate every 8 hours by the dosage of PRN pushes given in the past 8 hours, divided by 8.