PALLIATIVE CARE 101DO’S, DON’TS AND

CONSULTS

James Hallenbeck, MDJames Hallenbeck, MD

Director, Palliative Care ServicesDirector, Palliative Care Services

VA Palo AltoVA Palo Alto

Agenda

Palliative and Hospice Care –definitionsPalliative and Hospice Care –definitions Palliative Care in the VAPalliative Care in the VA Do’s and Don’ts of Palliative CareDo’s and Don’ts of Palliative Care Palliative Care ConsultsPalliative Care Consults

Hospice and Palliative Care – not the same thing… HospiceHospice –overtly focused on care for the –overtly focused on care for the

dyingdying A place, an organization, a philosophyA place, an organization, a philosophy

Palliative CarePalliative Care – – Definition: “Care focused on the Definition: “Care focused on the miserymisery

of illness”of illness”

Annual Veteran Deaths

A small percentage of veterans die as inpatients in VA facilities

Palliative Care at VA Palo Alto HCS 1979 – Menlo Park Hospice opens (one of the first 1979 – Menlo Park Hospice opens (one of the first

publicly funded hospice in the country)publicly funded hospice in the country) 1994 –1999 1994 –1999

Expansion from 7 to 25 bedsExpansion from 7 to 25 beds 1999 Moved to 2C, began non-vet admits1999 Moved to 2C, began non-vet admits

2000 Palliative Care fellowship and consult 2000 Palliative Care fellowship and consult service startedservice started

2002 Palliative Medicine Clinic started2002 Palliative Medicine Clinic started

10 DON’TDON’T forget the bowels, when forget the bowels, when

prescribing opioidsprescribing opioids

DO DO use promotility agents such as senna use promotility agents such as senna proactivelyproactively DSS, stool softeners usually inadequateDSS, stool softeners usually inadequate

9

DON’TDON’T use the O2 sat meter to evaluate use the O2 sat meter to evaluate dyspneadyspnea

DO DO ask if patients are short of breath and ask if patients are short of breath and treat accordinglytreat accordingly

8

DON’TDON’T use Phenergan and Compazine use Phenergan and Compazine interchangeablyinterchangeably These agents opposites in action: These agents opposites in action:

Phenergan antihistimine/anticholinergic, Phenergan antihistimine/anticholinergic, Compazine antidopaminergicCompazine antidopaminergic

DODO use Compazine as suppository of use Compazine as suppository of choice in opioid related nausea choice in opioid related nausea

7

DON’TDON’T prescribe opioids (or any drug with prescribe opioids (or any drug with potentially serious side-effects) with wide potentially serious side-effects) with wide dose ranges such as 2-10 mg morphine q 20 dose ranges such as 2-10 mg morphine q 20 minutesminutes

DODO check to see that any drug is safe across check to see that any drug is safe across the dose range you prescribethe dose range you prescribe

6

DON’T prescribe Ativan (lorazepam) as a sole agent for nauseaAtivan only helpful if anticipatory nausea

or anxiety associated with nausea DO try to figure out why the patient is

nauseated, what receptors are involved and treat accordingly

5

DON’T just think about differential diagnosis relative to disease

DO consider that differential diagnosis can apply to symptoms. Why is a particular disease causing this symptom? What is the physiology of the symptom?

4

DON’T use only short-acting agents (opioids) for chronic painSpecial concern re combo drugs –

Vicodin, T&C #3 and Percocet DO use sustained-release or long acting

opioids, if indicated, for chronic pain

3

DON’T just tell patients what is wrong with them

DO elicit patients’ understandings of their illness by asking questions like, “What is your understanding of why you are sick?’

2

DON’T just tell people what you are not going to do.Nobody loves you for what you don’t do

DO tell them what you are going to do (or how you will help them)Especially important when discussing

“treatment withdrawal”

1

DON’T set out to “get the DNR”Resuscitation status is only one of many

“difficult decisions” that should incorporate patient and family goals

DO assess and document patients’ goals of care

Palliative Care Consults

Help with:Help with: Difficult decisionsDifficult decisions CommunicationCommunication Symptom managementSymptom management Identifying appropriate venues of care for Identifying appropriate venues of care for

patients with serious, life-limiting patients with serious, life-limiting illnessesillnesses

Palliative Care ConsultsWhat they are not A excuse for ward teams not to talk with A excuse for ward teams not to talk with

patients about difficult subjectspatients about difficult subjects Shock troops to break through Shock troops to break through

patient/family denial, thereby “getting” the patient/family denial, thereby “getting” the DNRDNR

Solely about hospice referral as a Solely about hospice referral as a “placement” issue“placement” issue

How you can help with Palliative Care Consults Be as clear as you can as to what help you Be as clear as you can as to what help you

would likewould like At least try to address patient/family goals At least try to address patient/family goals

of care andof care and document document prior to consult prior to consult If you have special concerns you would If you have special concerns you would

rather not put in the consult request in GUI, rather not put in the consult request in GUI, call the consult fellow, beeper: 21656call the consult fellow, beeper: 21656