#38 Hospice and palliative care: How to manage end of life symptoms

May 8, 2017 | By Matthew Watto, MD

Recognize and manage end of life symptoms with competence and confidence. In this extensive discussion with Dr. Brooke Worster, Assistant Professor of Medicine at Sydney Kimmel Medical College and Medical Director, of the Palliative Care Service at Thomas Jefferson University Hospital we discuss scripts for having difficult conversations, managing patient/family expectations, what comes in the hospice “E” kit, terminal delirium, the “death rattle”, air hunger, and more.

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Clinical Pearls:

1. Palliative care = symptom management for anyone with a serious illness at any stage.
2. Hospice is a medical benefit and entitlement of insurance for patients with life expectancy of 6 months or less. Unlimited renewals are available if patient outlives their initial 6 months.
3. Hospice philosophy of care = Focus on quality of life and comfort. Ask the patient, “What does a good day look like for you?”
4. Home hospice: Team of providers including a nurse, home health aide, chaplain, social worker, and a physician. Providers are on call, but NOT in the home 24/7. Patient’s family must provide 99% of care.
5. Hospice (“E” or emergency) kit contains: Liquid morphine usually 20 mg/ml, lorazepam 0.5 mg tabs, atropine drops (or scopolamine), promethazine suppository for nausea, haloperidol 0.5mg tab.
6. Medication administration: Drip in back of throat, NOT under tongue unless it formulated as an oral dissolving tab (ODT). Last resort = place whole pills in rectum…seriously!
7. Air hunger: Start with 5mg morphine or 0.5 mg lorazepam. Repeat in 15 minutes if dyspnea not relieved.
8. Terminal delirium: Hypoactive version does not need treatment. For hyperactive version (e.g. restlessness, pulling at sheets/lines), treat with 0.5 to 1mg haloperidol one to three times daily.
9. Death rattle: Saliva pools in back of soft palate and air rumbles through it. Uncomfortable for family NOT patient. Treat with atropine drops one to two drops of 1% ophthalmic solution (0.5 mg/drop) administered SL every two to four hours (or another anticholinergic).
10. Cheyne-Stokes breathing: rapid shallow breathing seen near very end of life. NOT painful. Hard to suppress without high doses of narcotics.
11. Scripts aka questions to ask a patient/family: What are you hoping for? What are you worried about? What is your understanding of this illness? If you had to guess, would mom or dad be happy with this quality of life?

Goal: Listeners will gain comfort in starting difficulty conversations with patients who have a serious or terminal illness and learn to recognize and manage end of life symptoms.

Learning objectives:
By the end of this podcast listeners will:

1. Define and differentiate between hospice and palliative care.
2. Utilize scripts to gain insight into a patient’s values, goals, and expectations when they have a serious or terminal illness
3. List the services provided by home hospice.
4. Recall the items provided in the hospice “E” kit
5. Recognize and treat unique end of life symptoms like air hunger, terminal delirium
6. Realize the primary care manager’s role in the treatment team for a patient on home hospice

Disclosures:
Dr. Worster reports no relevant financial disclosures.

Time Stamps
00:00 Intro
03:10 Rapid fire questions
08:33 Defining hospice and palliative care
11:28 Case discussion
21:28 Gunderson, MI and Respecting Choices
24:25 How to counsel patients about home hospice?
37:10 Hospice “E” kit and how to use it
42:09 Air hunger, terminal delirium, death rattle, and Cheyne Stokes breathing
52:48 What is the PCM’s role while patient is on hospice?
58:19 Cancer survivorship and palliative care
60:33 Take home points
62:20 Outro

Links from the show:

1. When Breath Becomes Air by Paul Kalanithi
2. Gundersen Health and Respecting Choices *
3. JAMA. 2016 Nov 22;316(20):2104-2114. doi: 10.1001/jama.2016.16840. Association Between Palliative Care and Patient and Caregiver Outcomes: A Systematic Review and Meta-analysis. Kavalieratos D et al.
4. N Engl J Med. 2015 Aug 20;373(8):747-55. doi: 10.1056/NEJMra1404684. Palliative Care for the Seriously Ill. Kelley AS, Morrison RS.
5. Cochrane Database Syst Rev. 2016 Feb 18;2:CD009231. doi: 10.1002/14651858.CD009231.pub2. Hospital at home: home-based end-of-life care. Shepperd S1, Gonçalves-Bradley DC, Straus SE, Wee B.
6. Cochrane Database Syst Rev. 2013 Jun 6;(6):CD007760. doi: 10.1002/14651858.CD007760.pub2. Effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. Gomes B1, Calanzani N, Curiale V, McCrone P, Higginson IJ.

*Correction: La Crosse, Wisconsin is where Gundersen Lutheran health care system implemented the Respecting Choices program.