Refractory or intractable symptoms are those that cannot be managed, even with agressive treatment. Often, for symptoms that multiple approaches have been used to manage symptoms and have failed, may require transferring the patient to an inpatient hospice facility.
Pain management in cancer patients is an important goal of care. Pain presents differently depending on the type of cancer. Usually, as the disease progresses, the patient increases, requiring more opioid management, as well as rotations to different opioids. Tumors can compress or stretch various organs, invade bone, or press on nerves. All of these require a different approach for pain management and should be investigated if the patient has a diagnosis of cancer.
Signs of pain in the cognitively impaired is demonstrated by facial expressions such as frowning or grimacing, vocalizations such as moaning, body movements such as guarding or rocking, changes in interpersonal interactions such as resisting care, becoming aggressive or withdrawn, and changes in activity patterns such as appetite or sleep changes. The combination of symptoms is more suggestive of pain, than depression or anxiety.
The PAINAD scale is used in advanced dementia by rating breathing, negative vocalization, facial expression, body language, and consolability.
Palliative sedation is only used in patients who are imminently dying, have a signed consent by their healthcare surrogate, and have a DNR. Palliative sedation is used to relieve refractory symptoms such as dyspnea, agitation, and pain in the imminently dying. Palliative sedation typically does not use opioids. Benzodiazepines, barbiturates, and mild general anesthesia are typically used for palliative sedation.
You must always first review the goal of care for each patient prior to making decisions, because the paln of care is individualized according to there wishes. Some patients do not want to die in their home and prefer to be transferred to an inpatient unit, while others want more aggressive intervention such as bipap or a high-flow nasal cannula. These other choices may not be in line with the patient’s goals of care.
Studies have shown that 70% of people tell someone they intend to commit suicide, although very few people tell their healthcare provider. When a patient mentions anything about taking their own life, it is important to further address the topic in order to fully assess their actual intent and need for intervention. It is escpecially important for the health care provider to ask about the paitent’s plan. Explicit warning signs include a well thought out plan, and often include making a will, getting their affairs in order, suddenly writting letters to loved ones, and a sudden change in mood. At this point, the person has most likely devised a means of ending their life. This person should not be left alone, and the provider should call a social worker to help with assessment and intervention.
Myoclonus (spasmodic jerky contraction of groups of muscles) is a side effect of opioid use and caused by metabolite accumulation evidence by involuntary twitching of muscle groups. Benzodiazepines are first-line drugs given for this condition.
Pseudobulbar Affect (PBA) is seen in ALS patients, and is a neurological condition in which the patient is unable to control their emotional responses. An example is when a patient starts crying or laughing for no reason, and then cannot stop.
There comes a time when tube feeding does more harm than good. Stopping the tube feeding and educating the family is an appropriate step in addressing quality of life issues. Goals of care for hospice patients typically addresses comfort and quality of life. Transferring hospice patients back and forth to the ER for life-sustaining measures or aggressive medical therapy would not be in line with typical hospice goals of care. If a patient changes their mind and would like aggressive therapy or life sustaining support, such as mechanical ventilation, the patient would have to revoke their hospice benefit.
Deactivation of AICDs is recommended due to cardiac arrhythmias in dying patients and prevents the patient from sustaining painful shocks a the end of life. AICDs at the end of life are shown to decrease quality of life. Deactivation is done by a medical professional, and magnets do not replace the preferred method of deactivation. Surgical removal is not necessary for deactivation.
Methadone and Fentanyl are opioids that typically given to patient with end-stage renal failure. Methadone’s metabolites have been found to be inactive and are excreted via the gut. Fentanyl metabolites are inactive and considered safe to use in renal impairement. Morphine and condeine have active metabolites that can accumulate in the presence of renal failure. OxyContin is a trade name for oxycodone, which is synthesized in structure to morphine. MS Contin is long-acting morphine. Hydromorphone, also known as Dilaudid, is a derivative of morphine.