UBC Objectives: Palliative Care, Priority Topic: Bad News & Priority Topic: Learning (Patients)8/16/2018 By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Bad News Key Feature 1: When giving bad news, ensure that the setting is appropriate, and ensure patient’s confidentiality. Skill: Patient Centered, Communication Phase: Treatment Key Feature 2: Give bad news:
Phase: Treatment Key Feature 3: Obtain patient consent before involving the family. Skill: Patient Centered, Professionalism Phase: Treatment Key Feature 4: After giving bad news, arrange definitive follow-up opportunities to assess impact and understanding. Skill: Patient Centered, Communication Phase: Follow-up Learning (Patients) Key Feature 5a: To maximize the patient’s understanding and management of their condition: Determine their willingness to receive information. Skill: Patient Centered, Communication Phase: Diagnosis, History Key Feature 5b: To maximize the patient’s understanding and management of their condition: Match the complexity and amount of information provided with the patient’s ability to understand. Skill: Communication, Patient Centered Phase: Treatment Throughout my residency training, I have seen physicians break bad news in wildly different ways. This week, I spent time with a urologist who barged into a room where a patient and his wife appeared to be anxiously awaiting to find out whether or not the data on his prostate suggested an increased risk of prostate cancer. Before even sitting down, he said "Yup, your prostate looks suspicious for cancer." And then as he propped himself into the chair casually he said, "We're gonna need to get a biopsy of it. Just make your way to the front desk and the receptionist will help you with the forms." And out he zipped. He literally spent less then 1 minute in the room. I looked with despair at the patient sitting with his eyes wide open, while his wife's mouth gaped open. As I followed my preceptor out of the room, I watched as the wife turned to her husband and explained what the urologist said but this time in Cantonese. By the time the patient understood what was even said, the urologist was long gone. What the HECK was that. Yes, surgeons are notorious for having poor bedside manners, but earlier this year I witnessed a general surgery resident breaking bad news in the most caring and compassionate way I have ever seen. He explained to the patient what the circumstances were without jargon, he confirmed that the patient understood, and he provided space for questioning. He gave time to ensure comfort of the patient, and obtained legitimate informed consent, something that is not often done well in the hustle and bustle of day-to-day medicine, let alone for the ultra fast pace of surgical medicine. To contrast the two cases, the urologist was a man who I believe is almost ready to retire, while the surgeon-in-training is of a generation being trained to provide patient-centered care. Although there are many exemplary experienced physicians who break bad news with utmost compassion, and many young MDs who lack life experience and the empathy this endows, new physicians are graduating being expected to demonstrate the competency of breaking bad news in a patient centered way. It is an important modifiable factor in creating or curbing harm that can result from devastating news. Certain rules of thumb are pervasive in medicine and the SPIKES mnemonic is the catch-phrase all junior medical doctors are taught to break bad news compassionately and effectively. SPIKES
There are many ways the individual physician can mesh these points with their own practice style to have an authentic approach to breaking bad news. Certainly the urologist didn't, and certainly the general surgery resident went above and beyond. As a physician-in-training, I work with many stellar and occasionally not-so-stellar role models, learning how to provide good care and also witnessing where care falls short, or in this case with the urologist, how it may be the exact opposite of what I am taught to do. While I sometimes cringe at the impact this has on the patients in front of me, it will at least hopefully serve to provide me with reinforcement of the importance of holding high standards of care and not becoming so familiar with disease processes that the impact they have on a patient's lived experience is forgotten.
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By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Disability Key Feature 2: Screen elderly patients for disability risks (ex: falls, cognitive impairment, immobilization, decreased vision) on an ongoing basis. Skill: Clinical Reasoning Phase: History, Hypothesis generation Elderly Key Feature 1: In the elderly patient taking multiple medications, avoid polypharmacy by:
Phase: Treatment, Follow-up Key Feature 3: In the elderly patient, screen for modifiable risk factors (ex: visual disturbance, impaired hearing) to promote safety and prolong independence. Skill: Clinical Reasoning Phase: History, Hypothesis generation Key Feature 4: In the elderly patient, assess functional status to:
Phase: Treatment, History Tomorrow I start my first day caring for elderly patients in a residential care home, which I will continue to do intermittently throughout the year as part of my program requirements and vocational interests. One of the most important skills in geriatric medicine is appropriate prescribing practices; frail elderly patients can be at significantly more risk of harm compared to the general fit patient with negligent prescribing. While it is always important to prescribe thoughtfully (as indicated, where benefits outweigh the harm for the individual patient, with thought given to potential drug interactions, and with monitoring for side effects), the frail elderly patient has less reserve to cope with complications from errors with medication prescribing. As well, decreased kidney and liver functioning become much more common with age, so if the body is unable to clear the medications from the system as effectively, we need to consider the effect that the drug may have if it lingers for longer or builds up to higher levels than it otherwise would. Depending on the drug, and the patient's kidney and liver function profile, doses may need to be reduced in quantity or frequency. UpToDate provides a table that summarizes an approach to performing a geriatric medication review: Medication review in the frail elderly should be part of all routine comprehensive medical care, just like screening is done as part of a periodic health examination. Specific screening interventions that may be particularly indicated in elderly patients include vision screening, hearing screening, and screening for osteoporosis. Impaired vision and hearing increase risk of functional limitation, falls, and if there is comorbid osteoporosis, increase the risk that a patient may sustain a significant fracture such as of the hip, associated with significant increase in morbidity and mortality. A defining feature of the frail elderly patient is having limitations on functional abilities. It is also something that occurs along a continuum, with different supports indicated depending on the degree of functional limitation. It is important to incorporate monitoring frailty severity into routine clinical practice of all elderly patients. The Clinical Frailty Scale is one tool that is validated and easy to use clinically. A comprehensive assessment of a patients overall functional status but also specific functional needs is important to be able to offer beneficial targeted interventions and supports. This also involves considering what supports the patient currently has, their personal values and goals (including Advance Care Planning), and the supports available in their community. An interdisciplinary approach to supporting the frail elderly patient is standard of care, including involving family members or other loved ones as valued and active members of the care team, as the patient wishes, and referring patients for a comprehensive geriatric assessment may be the best place to initiate an assimilation of key members for an individualized support team. In a patient who has chronic mobility or disease that is not reversible, and who is having quality-of-life reducing symptoms on a regular basis, it's never too early to consider palliative care interventions, which are not just for those who are facing life-threatening illness. For those who are approaching end of life or who have symptoms affecting quality of life that can no longer be cured, palliative care interventions are necessary. Having frequent discussions with the patient and all members of the care team helps to keep people on the same page, to optimize care and to anticipate how care can best be optimised as symptoms progress. The Palliative Performance Scale is a tool used by many palliative care physicians to help in the conversation and understanding of the trajectory of palliative care needs.
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 3b: In patients approaching the end of life: Attempt to address the issues identified as important to the patient. Skill: Patient Centered, Clinical Reasoning Phase: Treatment In a recent post I reviewed the domains (physical, emotional, social, and spiritual) from which concerns arise in patients who are approaching end of life. In this post I will provide an overview of the management of some of the more common issues that arise out of these domains in the patient receiving palliative care. There are many potential options to treat these common problems, but here I will list some preferred first-line choices. PHYSICAL HEALTH
EMOTIONAL HEALTH
SOCIAL HEALTH
SPIRITUAL HEALTH
Assessing and treating each symptom that arises is important in its own right. It's also important to have a sense of the global health status of each patient in allowing for conversations that guide care moving forward. The Palliative Performance Scale (PPS) is a tool used by many palliative care physicians to anticipate and communicate with the care team to be able to optimize palliative care for the whole person. Key Feature 3a: In patients with chronic disease: Actively inquire about pain. Skill: Clinical Reasoning Phase: History Key Feature 3b: In patients with chronic disease: Treat appropriately by:
Phase: Treatment, Hypothesis generation Palliative Care Key Feature 4: In patients with pain, manage it (ex: adjust dosages, change analgesics) proactively through frequent reassessments and monitoring of drug side effects (ex: nausea, constipation, cognitive impairment). Skill: Clinical Reasoning Phase: Treatment, Follow-up The standard general approach to pain control is based on the World Health Organization's Pain Ladder, with the diagram and information below coming from "Palliative medicine: A case-based manual" by Doreen Oneschuk, Neil Hagen, and Neil MacDonald. The "ladder" was designed with cancer pain in mind, but it tends to provide the framework for pain management for people with all sorts of acute and chronic sources of pain. The basic idea is that for mild pain you start with non-opioid medications, with specific choice depending on the type of pain and patient characteristics. It is important to actively inquire not just about the presence of pain, but also about the quality of the pain in patients in order to treat it most effectively. Not illustrated as part of the pain ladder but equally important are also nonpharmacological interventions that can be useful in alleviating pain. As pain increases in severity, the choice of pain medication and/or dose ought to increase accordingly. Adjuvants (medications originally developed for reasons other than to improve pain, but that can also alleviate pain as a secondary effect, depending on the type of pain) can also be very useful when indicated. Poor pain control can have a significant negative impact on quality of life, and we have lots of tools in the box to work to mitigate this source of distress. It is important to continue to reassess patients experiencing pain or receiving therapy for it, to ensure that pain is in fact controlled, as well as to monitor for side and adverse effects. Nonpharmacological therapies to consider starting, in the context of mild pain and patients who are motivated to try them, or to consider adding on to pharmacological treatments for added pain relief, could include:
Common non-opioid medications for mild pain include acetaminophen and NSAIDs (ex: naproxen, ibuprofen, diclofenac, ketorolac).
For pain that is sufficiently severe and that cannot otherwise be controlled (with non-opioids, adjuncts, and nonpharmacological modalities), treatment with an opioid may be indicated. Opioids exert their analgesic effect mostly by agonising mu opioid receptors in the brain. Commonly prescribed weak opioids include codeine and tramadol, and commonly prescribed strong opioids include morphine, hydromorphone, oxycodone, fentanyl, and methadone. General principles of opioid initiation and titration include having a regular dosing schedule (initially starting with a short-acting preparation until the baseline pain is controlled) with a prescribed breakthrough dose for pain to be taken as needed for acute exacerbations (generally prescribed to be taken as much as every 1 hour, or in the setting of opioids with a very rapid half life, up to every 30 minutes or so). The degree of pain control as reported by the patient along with the number of needed breakthrough doses in a given 24 hour period indicates whether or not there is a need to adjust the baseline opioid dose. As a general rule of thumb, if greater than 3 breakthrough doses in a 24 hour period are needed, unless this is attributed to being incident pain (aggravated by a specific event such as movement that would not otherwise be present at baseline), then an increase in the baseline opioid dose is warranted. The amount to up-titrate can be calculated by adding up the total quantity of opioid needed in the last 24 hour period (baseline and amount of breakthrough used), calculating the conversion to the new choice of opioid based on number of morphine equivalents, and dividing this quantity so that it is given over the next 24 hour period as the scheduled dose. And then a new quantity of breakthrough pain medication is prescribed, and a rule of thumb for this is dosing it at about 10% of the total daily scheduled amount of opioid to be given over the next 24 hour period. On the flip side, when patients report good pain control, with minimal to no use of doses required for breakthrough pain, the patient can be gradually weaned down as tolerated. Side effects of all opioids are generally the same (though they may occur to different degrees depending on the formulation, dose, and patient factors), and they most commonly include transient nausea, transient drowsiness, and constipation that is not transient and that lasts as long as the opioid is being taken. If they are given in a high dose too quickly, they can cause respiratory depression, but when prescribed responsibly in small doses with gradual up-titration, this concern is mitigated. For the nausea, an antiemetic can be prescribed either to be taken routinely or as needed, and for the constipation the patient will likely need to be on a regular dose of laxative medication. See my next post for more detail on these options. Besides the above side effects that can occur when any opioid is used, there is also the phenomenon of opioid neurotoxicity that can occur. Briefly, this is a situation in which patients can develop altered mental status (ex: delirium, agitation, somnolence), vivid or unpleasant dreams, delusions/hallucinations (usually visual), and increased pain perception (ex: allodynia or hyperalgesia). Myoclonic jerks and seizures can also occur. In the setting of suspected opioid neurotoxicity, rotating to a different opioid is warranted (other options include simply changing the route by which the current opioid is delivered, decreasing the dose of the current opioid and adding an adjuvant, or just treating the toxic symptoms themselves; rotating the opioid is generally the preferred option). This is done by adding up the total number of morphine equivalents a patient has on board in a given 24 hour period, calculating the equivalent dose in the opioid to which the patient is being rotated to, reducing this dose by 25%, and dividing the dose to be scheduled throughout the day as the half-life of the new opioid indicates. Opioid options include:
Some adjuvants that may be useful in pain management, particularly in the palliative care setting:
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 3a: In patients approaching the end of life: Identify the individual issues important to the patient, including physical issues (ex: dyspnea, pain, constipation, nausea), emotional issues, social issues (ex: guardianship, wills, finances), and spiritual issues. Skills: Patient Centered, Clinical Reasoning Phase: History As expressed in my previous post, palliative care aims to alleviate total suffering, including sources of physical pain or discomfort, along with emotional, social, and spiritual concerns. In patients who are approaching end of life, it is important to explicitly screen for concerns in these various domains, as some patients may not be as forthcoming about certain types of distress. Common physical issues that affect patients approaching the end of their life include pain, dyspnea, constipation, and nausea, and these are so common they are worth screening for specifically. Asking how a patient is feeling emotionally can open up a conversation about mood and anxious distress, and gathering a good social history can provide a framework for exploring social issues and revealing the extent to which advance care planning has been explored. Spiritual issues can often distress patients, consciously or unconsciously, as many patients are faced with difficult existential issues as they approach end of life. Taking a spiritual history is not something clinicians are trained to do very often, but it is essential in providing care that truly seeks to alleviate all sources of suffering. The approach I've adopted to taking a spiritual history comes from "Palliative Medicine: A case-based manual" by Doreen Oneschuk, Neil Hagen, and Neil MacDonald. It is summarised by the acronym "FICA" and is demonstrated in the following table as published in the book: It's worth mentioning that the overall approach to pediatric palliative care is much the same, considering many of the same issues as for the adult patient. However, according to UpToDate, "Although the goals of palliative care in children are the same as those in adults, implementation of care is different because of the need for age-based care, differences in the underlying illnesses, the emotional and psychological issues in dealing with a poor outcome in a child, and the necessity of dealing with the child, parents, and in some families, siblings." The need for a strong team-based strategy with pediatric expertise cannot be stressed enough, and meetings that include the family are important to put together the most understanding and resources to maximize care. It's also important to consider how the patient's family and other loved ones may be impacted by anticipatory grief and eventually loss and bereavement of their loved one. Ensuring these support people are themselves supported promotes the capacity for the patient to be better cared for, and can help promote healthy adaption to life after loss. It helps to know the resources available within your community, as well as resources online or in print. These principles of integrating and caring for a family network are also esteemed for the care of adult palliative care patients.
Once you've asked and begun exploring any sources of discomfort, it's important to be an advocate for the patient in attempting to relieve their burden. Although many patients approaching end of life exude an astonishing degree of energy and capacity for autonomy despite the circumstances, many others may be too exhausted to do so, or not be aware of the possibility that some, if not most, of their physical, social, emotional, and spiritual suffering can be alleviated. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 1: In all patients with terminal illnesses (ex: end-stage congestive heart failure or renal disease), use the principles of palliative care to address symptoms (i.e., do not limit the use of palliative care to cancer patients). Skill: Patient Centered, Clinical Reasoning Phase: Treatment Key Feature 2: In patients requiring palliative care, provide support through self, other related disciplines, or community agencies, depending on patient needs (i.e., use a team approach when necessary). Skill: Patient Centered Phase: Treatment Key Feature 5: In patients diagnosed with a terminal illness, identify and repeatedly clarify wishes about end-of-life issues (ex: wishes for treatment of infections, intubation, dying at home) Skill: Patient Centered, Clinical Reasoning Phase: History, Hypothesis generation Today I began my palliative care rotation at St Paul's Hospital. I met 4 different patients on the ward all receiving palliative care for very different reasons. All patients had incurable but not unmanageable disease states, including end-stage chronic obstructive pulmonary disease, impaired postoperative wound healing in the setting of severe frailty, advanced congestive heart failure, and metastatic esophageal cancer. Although only one of these patients had a diagnosis of cancer, all of them had symptoms that warranted management according to the principles of palliative care. For a succinct overview of what palliative care entails, see the WHO Palliative Care webpage. Central to the palliative care approach is the appreciation of an individual's total suffering, which includes sources of physical pain but also areas of emotional, social, and spiritual pain, among other domains. The benefit of a multidisciplinary team strategy when taking a comprehensive perspective of pain cannot be understated; while the physician is certainly an expert in treating physical sources of pain with analgesia, this is but one method of alleviating pain associated with life-limiting and life-threatening illness. The book, "Palliative medicine: A case-based manual" by Oneschuk, Hagen, and MacDonald (2012) provides examples of the ways in which various health care professionals may contribute to alleviating a patient's total suffering:
There are many methods of mitigating suffering, many of which may or may not be useful or desirable to a specific individual given the context of their circumstances and how it interacts with their beliefs, values, and wishes. As a treating physician, it is important to have conversations that explore these considerations, as indicated by the context. Whenever any medical decision is made, it is always important to ensure the decision is being made with informed consent. Furthermore, it may be important given certain circumstances to begin thinking about the decisions one may want for their health in anticipation of a future time when they may no longer be able to speak for themselves. This is particularly important when a patient is at greater risk of an incapacitating illness or event (although some say it is never too early to start having these conversations because you just never know). Regardless, it is always important to have these conversations with patients diagnosed with a terminal illness, and the sooner the better, when more time can be given to proper reflection. When done well in advance, this is typically the process of Advance Care Planning (ACP), and consists of reflecting on one's values and wishes for future health care decisions, along with identifying a person whom they would want to make decisions for them if/when they cannot make decisions for themselves (aka a substitute decision maker [SDM]), and communicating this verbally or as documented in writing (far preferable). This may include conversations about Goals of Care, which are more focused health care goals given a situation at hand (ex: What a patient's goals are for a given hospital admission and the scope of what they would and would not want to receive in terms of medical management. This would include but is not limited to clarification of the patient's Code Status.) The conversation does not end here of course, and each medical decision should be done with informed consent as given by the patient or the SDM if indicated. And as patients' circumstances and occasionally their beliefs, values, and wishes change, it is important to revisit ACP accordingly. If there has has been no ACP, then urgent decisions will need to be made regardless for medical decisions at hand, but research indicates that the outcomes are far more ideal for patients and care providers if these conversations are begun well in advance. The Pallium Palliative Pocketbook lists benefits of ACP as follows:
For more information on ACP, check out www.advancecareplanning.ca. |
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