PALLIATIVE END-OF-LIFE CARE
PAIN CONTROL AND SYMPTOM MANAGEMENT
IN THE NURSING HOME 

CLINICAL PRACTICE GUIDELINE

 

DISEASE RECOGNITION

  • Admitted with " terminal" diagnosis established
  • Gradual or sudden change in status of resident with medical instability
  • Resident and/or health care agent asks to stop aggressive work-up, treatment or hospitalizations
  • Activated HCP in place with advance directive for " comfort care" when further treatment is medically futile

 

CONTEXT / / COMMUNICATION

Palliative care is always appropriate when a resident is in the end stage of life whether from a malignant or non-malignant cause. 

As the focus of the resident' s disease shifts from curative to palliative, the MD (or NP if MD unavailable), should communicate with the resident and/or health care agent. An honest discussion of the disease process, prognosis and risks and benefits of treatment options is imperative to establish a plan of care, to assure pain and symptom management and to allow time to deal with practical, legal and emotional matters. If a HCP has been appointed or other advance directives exist they should guide the discussion. If none exist, and time permits, the opportunity should be given to the responsible party (when the resident cannot make health care decisions) to provide an affidavit expressing the known wishes of the resident.

 

ASSOCIATED RISKS

  • Malignant and non-malignant comorbidities
  • Treatment failures, limited treatment options
  • Failure to thrive, compromised nutritional status

Consideration for discussing change of focus to palliative care should
be given when any of the following are present:

  • Dementia with dependence in ADLs and inability to communicate
  • Dementia with history of aspiration pneumonia, upper UTI, septicemia, pressure ulcer, recurrent fevers after antibiotic treatment
  • NYHA Class IV CHF and/or Ejection fraction < or = 20%
  • Pulmonary disease with dyspnea at rest
  • COPD with resting pulse > 100 BPM in absence of treatable causes
  • Liver disease with PT prolonged more than 5 seconds > control and albumin < 2.5 gm/dL
  • Ascites refractory to sodium restriction and diuretics
  • Hepatic encephalopathy refractory to protein restriction, lactulose or neomycin
  • Renal disease with creatinine clearance <10 cc/min and creatinine > 8 mg/dl (without dialysis)
  • Oliguria (<400 cc/24 hrs), intractable hyperkalemia
  • New CVA with decreased verbal and tactile response > 3 days
  • Dysphagia leading to inadequate nutrition
  • Rapidly progressing ALS (< 12 months) with critically impaired ventilatory capacity and nutritional impairment

 

PHYSICAL EXAMINATION

  • Pertinent to assess overall physical, emotional, functional and cognitive status with specific attention to specific symptoms and pain

 

DIAGNOSTIC WORK-UP

  • Only as needed to accomplish " comfort care" plan in keeping with the plan of care already established with resident and/or health care agent
  • No unnecessary diagnostic tests unless important to plan of care or to alter course of palliation

 

TREATMENT OPTIONS

DRUG/DOSE

RECOMMENDATIONS/PRECAUTIONS

Mild: Tylenol 1000mg Q6 hr

Do not exceed 4 gm in 24 hours

Ibuprofen 600mg Q6-8 hr or Celebrex 100mg BID or Bextra 10mg QD

Avoid if history gastritis or GI bleed, affects renal function

Better to avoid NSAIDs because of increased risk of CHF exacerbation. Weak narcotic preferrable

Trilisate 1000mg Q8-12 hr

Same as NSAIDs and COX-2 Inhibitors

Moderate:Indocin 25mg Q8 hr

Do not exceed 10 day dose, similar toxicity to NSAIDs

Lortab 5-7.5 mg Q4 hr or T&C #3 Q4 hr

Anticipate constipation and possibly nausea

Titrate the above meds to effective and tolerated dose. If inadequate analgesia consider adjuvant drug* before proceeding to meds for severe pain. This approach would not likely be effective is death is imminent.

Severe: Ultram 50mg Q6 hrs (decrease to 50mg Q12 hrs for cr cl <30ml/min or cirrhosis)

If depression a component and not on antidepressant

Lowers seizure threshold.

Morphine sulfate 15mg p.o. or 10mg supp. p.r. or oral solution (Roxanal) 10mg p.o./s.l. or s.c Q 4 hrs

Short acting. Impacts on respiratory distress and function. When oral intake is likely to become impossible quickly, order suppository or subcutaneous form.

OxyContin 10mg Q 12 hrs

Titrate slowly and use short acting opiods for breakthrough pain

Nubain 10mg sc/IM Q3-4 hrs

Fast acting - short term use only- do not use if on opiod

Methadone 5 mg Q12 hours & 5 mg Q4 hours PRN for breakthrough

Review every 6-7 days and increased - no ceiling dose

Duragesic 25mcg patch Q 3 days

Titrate slowly (Q 6 days) and use short acting opiods for breakthrough pain. This approach would not likely be effective is death is imminent.

ADJUVANT DRUGS*

Tegretol 100mg QD X 7 then BID

Lancinating pain (neuropathic or Trigeminal neuralgia) - check LFTs, CBC, BMP at baseline & Q4 weeks with Tegretol level

Neurontin 100mg QD

Neuropathic -Increase Q5 days until 100mg Q 8 hrs up to 1500mg/day

Doxepin or Pamelor (TCA) 10mg Qhs or Desyrel 25mg hs 

Neuropathic pain with sleep disturbance and not on antidepressant

Effexor 25mg BID

Neuropathic pain with depression, least anticholinergic effect

Baclofen 5mg TID or Valium 2mg Q8 hrs

Neuropathic pain with muscle spasms

Miacalcin nasal spray 200 IU QD

Bone pain, new compression fracture

Zostrix 0.025% cream top. QID - Not PRN or Lidocaine Patch, 1-3 patched 12 hours a day

Joint pain, post herpetic neuralgia

 

TREATMENT OPTIONS FOR SYMPTOM CONTROL

Agitation

  • Evaluate and treat known contributors (constipation, retention, etc.)
  • Ativan 0.5 mg Q8 hrs or Haldol 0.5 mg Q12 hrs for delusional component

Anxiety

  • Evaluate as above; Ativan 0.5 mg Q8 hrs or Buspar 5 mg TID

Appetite loss

  • Treat oral candidiasis and constipation, stop nauseating drugs where possible
  • Periactin 4 mg Q12hrs - weigh Q 2 weeks - if no response after 4 weeks (or adverse effect from drug) start Megace 400 mg BID

Ascites

  • Restrict sodium intake and fluids, monitor abdominal girth and weight
  • Aldactone 50 mg QD, titrate to 100 mg QD and (in liver failure) Lactulose 30cc BID, titrate to 2-3 soft stools a day

Bladder spasms

  • Rule out UTI or retention and treat if present
  • Pyridium 100 mg TID, pc X 2 days for transient dysuria; Detrol 1 mg BID or Ditropan 5 mg TID for spasms

Candidiasis-oral

  • Mouth care (teeth and tongue) brushing and rinsing or cleaning with dilute H2O2 or non-alcoholic mouth wash; soft diet for painful swallowing
  • Nystatin suspension 100,000 units/cc - 5cc  QID swish and swallow or Mycelex troches 10 mg 5 x D X 14 days

Constipation

  • Stool softener and laxative with titration per bowel management guideline

Cough

  • Evaluate for worsening of underlying disease and treat where possible
  • For cough suppression - Robitussin AC 10 cc Q 4 hrs PRN or Tessalon Perles 1 TID PRN

Depression

  • Evaluate and treat contributing factors where possible; medicate according to depression guideline

Diarrhea

  • Evaluate and treat contributing factors where possible; medicate according to bowel management guideline

Dyspnea

  • Evaluate and treat underlying cause where possible; symptomatic relief with oxygen
  • Morphine sulfate 10 mg po/pr Q 4 hrs; or T&C #3 1 PO Q4 hrs; if inadequate relief add Ativan 0.5 mg Q 4 hrs or Valium 5 mg po Q 8 hrs

Fever

  • Assess potential sources of infection and evaluate hydration status - treat in accordance with the plan of care; initiate cooling measures; schedule Tylenol, Aspirin or Ibuprofen

Hiccough

  • Assess for contributing and treatable causes; nasopharyngeal stimulation with cotton swabs or NG tube; Thorazine 25 mg Q 6 hrs po/pr or Reglan 10 mg Q 6 hrs. If no relief - Valium 2 mg Q 6 hrs or Baclofen 5 mg TID

Mucositis

  • Assess for and treat oral candidiasis; artificial saliva, lip balm, mouth rinses, brushing teeth
  • Viscous Lidocaine 2% top. to ulcerations

Nausea and vomiting

  • Assess and treat contributing factors where possible; avoid oral intake for 2 hours after vomiting; clear liquids X 24 hrs then small frequent feedings
  • Compazine 10 mg po or IM Q 6 hrs PRN or 25 supp. pr; if related to opiods try Reglan 10 mg po/pr AC or Reglan 10 mg ac meals; if accompanied by motion sickness symptoms try Antivert 12.5 mg Q 8 hrs

Pruritus

  • Identify actual or potential cause; follow skin guidelines for actual problem

Secretions

  • Good oral care; improve hydration where possible; artificial saliva for xerostomia; Robitussin 10 cc Q4 hrs for thick secretions; Levsin gtts 0.125 mg/cc 1 gtt SL QID or Atropine eye drops 1 gtt SL Q 6 hrs for excessive secretions with gurgling

 Seizure

  • Ativan 1mg IM Q 8 hrs

Sleep disturbance

  • Eliminate stimulants; assess and manage contributing factors where possible;
  • Ambien 5 mg, Ativan 0.5 mg, Restoril 15 mg or Desyrel 25 mg - all at HS

 

GENERAL RECOMMENDATIONS

  • Remind nurses to follow "Pain Control for Terminally Ill Nursing Assessment Guideline" and to contact providers accordingly.
  • Underlying (contributing) diseases should be managed optimally to reduce pain
  • Always review dosing schedule of PRNs with nursing before increasing analgesics. Often not given as ordered. Consider scheduling analgesics until acute pain under control and schedule before activities likely to exacerbate pain
  • If a resident has a history of effective pain management on a med not listed in this guideline and if there are no serious side effects or risks for this resident from the med consider using it
  • Consider starting GI protective med if on NSAID (Zantac 150mg BID)
  • If starting long acting analgesic make sure short acting analgesic available for breakthrough pain
  • Monitor bowel status and add or increase bowel meds to prevent constipation or impaction
  • " Start low and go slow" with analgesics but review pain management often until pain and quality of life is at maximum - make sure all nursing and psychosocial supports are in place to enhance effect of analgesics
  • Residents with chronic pain need regular reassessment (with scheduled visits) for improvement, deterioration, or complication attributable to treatment
  • Educate residents and families with realistic pain management possibilities - complete relief for chronic pain unlikely
  • Offer psychosocial and spiritual support services where requested or appropriate - consider alternative medicine when asked (i.e. massage therapy, naturopathic preparations, spiritual healing) - do not create a feeling of hopelessness
  • Referral to a multidisciplinary pain management center should be considered when pain management efforts do not meet the resident or HC agent's goals or when life-altering intractable pain is present

 

 

 

References for Palliative Care

  1. Guidelines for Determining Prognosis in Hospice Care A Physician. s Guide, National Hospice Organization, 1998.
  2. Bruera, E., Byock, I.: End-of-life management of pain and other discomfort in Patient Care, November 15, 2000, 38-72.
  3. Cleary, J, Frederich, M: Palliative Care and Pain Management in Annals of Long-Term Care, Special issue, Vol. 8, July, 2000, 34-36.
  4. King, SA: Chronic Pain Control: What’s Adequate – and Appropriate? in Consultant, Vol. 43, No. 13, November 2003,1558-1573.
  5. Luce, JM, Luce, JA: Management of Dyspnea in Patients With Far-Advanced Lung Disease in JAMA, Vol. 285, No. 10, March 14, 2001, 1331-1337.
  6. Reuben, DB, Grossberg, GT, et al: Osteoporosis in Geriatrics At Your Fingertips, 1998/99 Edition, 36-37.
  7. Thomas, DR, et al: The Management of Chronic Pain in Long-Term Care Settings in Supplement to Annals of Long-Term Care, November 2001. 
  8. Wallach, S., Beier, MT, et al: Innovative Treatment of Osteoporosis in Annals of Long-Term Care, satellite symposium, March 5, 1999, 1-11.
  9. Wrede-Seaman, L.: Symptom Management Algorithms A Handbook for Palliative Care, 2nd Edition, 1999.
  10. Yeh, SS, et al: Improvement in Quality-of-Life Measures and Stimulation of Weight Gain After Treatment with Megestrol Acetate Oral Suspension in Geriatric Cachexia: Results of a Double-Blind, Placebo-Controlled Study in JAGS, 48:485-492, 2000.


MS/10.99
©EMS
Revised 10.04

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