These are the notes for quick reference only.  Confirm with your text books and PDR.

We try our best to be as accurate as possible but want you to use your judgement.

Confirm dosing with PDR or free Medscape app.



*** Side heading      *new sentence/pointer          ** very imp point/paragraph.


# Causes                    Rx (*Rx)                              s/s: signs/symptoms



Part I

*** WHAT IS HOSPICE: • the concept of Palliative care introduced in 1960’s which means Holistic approach to patient centered care who are dying.* Hospice is one aspect of Palliative care. *Palliative care starts with the time of diagnosis & continues till death. *Palliative care: curative + holistic patient centered care *Hospice care: terminal + holistic patient centered care.*Dame Cicely Saunders founded first hospice in London, United Kingdom in 1960’s (St Christopher’s hospice).*Hospice Started in US in 1974 •Team work of nurses, doctors, pharmacists, social workers, chaplains, volunteers, caretakers & family members.*Hospice: means Total care of a terminal patient. Hospice helps patients with medical, emotional, spiritual problems toward the end of life. Something can be done all of the time for the comfort of the terminally ill. *principles of symptom management: consider “whole patient”, thoroughly evaluate the patient, correct the correctable, communicate effectively, review regularly, do not forget non pharmacological treatments, discuss with colleagues, keep everybody on your team and family informed of the plans, ask for help as needed, plan in advance. *Represent the best treatment plan for terminal patients. *Palliative rather than curative treatment. *Quality rather than quantity of life. * Dying are comforted.* Symptoms relief is provided *Discuss prognosis/issues surrounding death & dying.*Give anticipatory guidance *Offer realistic goals.*Give honest assessments.*Discuss choices of care early.*Family to take part in the care of the person.*Affirm life & regard dying as a normal life process. *Personalized services.*All need compassionate, respectful Rx even if their life style was not conventional.* Does not hasten the demise, nor prolong the inevitable.*Inform patients regarding the choices of care.* In 1990 WHO defined hospice as “the active total care of patients whose disease is not responsive to curative treatment.” *use teamwork to help patient live actively & help family to cope & go through bereavement. * NIH stated that a specific time frame should not be used to define end of life care until prognostication becomes more reliable.*IDG: interdisciplinary group: the team consists of nurses, doctors, social worker, chaplain, volunteers etc.* They consider the views of others, discuss, negotiate, formulate the best course of treatment plan interdisciplinary but medically directed. * They provide physical, spiritual, emotional, & social help to patients & family.

*** HOSPICE NURSING: The team of nurses will take care of symptoms to make patients comfortable.*asses the pain / other S/S & provide prompt treatment. *Respect the dying.*Prepare patient & family / friends for the terminal event.*Speak to patient directly.*Be courteous.*Good symptom management.*Routine vital signs not required.* Brief history & physical examination are required.*Get records including pathology, labs, procedures & biopsy results, consultation, prior history & physical, medication list. *Conceptualize likely causes. *Formulate a treatment plan.*Discuss treatment options with the team.* Provide ongoing patient, family education & support.*Involve all the members of the interdisciplinary team.* Reassess frequently & change treatment accordingly.*Use “if it were me…” *Continuous pain needs continuous pain meds.

***HOSPICE SERVICES: *Skilled nursing care * hospice provides 24 hours a day, 7 days a week services**they provide pain and symptom management with consultation of Hospice medical director and consulting pharmacist  **Home Health Aides and Homemakers services ** Inpatient care **Provide prescription drugs related to admitting diagnosis **Medical equipment & supplies ** Ambulance services , Physician services , Chaplainry services , Volunteer support , Bereavement counseling & group therapy ** Respite  **Closure letter ** Counseling services **Nurses can visit home **patient is independent & able to go out of the house  **Nurses provide in home care around the clock  for a medical crisis instead of going to hospital **Family Bereavement care **Able to see any physician for a different diagnosis and can use  the insurance coverage at any time for a different medical problem.*Patients do not have to stop seeing their primary care physician

***ELIGIBILITY: *Terminal diagnosis. *Diagnosis by physician that the patient has a limited life expectancy (<6 months). *2 physicians testify to that. *Patient, family, attending physician, and Hospice team consent to the service. *patients requires terminal care

***DYING: • Dying is a unique experience which needs respect • not a disease • patient should be center of attention • follow patients’ preferences • do not impose values • realistic treatment is good symptom control




* PAIN: subjective unpleasant physical & emotional experience.  *pain what patient says “hurts”; * believe the patient

*pain is not: due to old age, a last ditch, wrath of God,. *good pain control will not shorten life.  *Morphine do not hastens death  

***Pain assessment : History / physical exam (80% help), onset, quality, type, location, intensity, duration, onset, relieving / aggravating factors, response to prior treatments, current medications, patients goals. We need to know nature, cause, social, emotional, spiritual factors. Collect information about pathophysiology of pain. *does the pain interfere with ADL (activities of daily living), sleep, relaxation, work, Family time, good time! *pain is often under treated, > 90% of pain in hospice can be controlled.*only 1-2 % may need palliative sedation.*the palliative sedation is excellent supportive care is not to be confused with euthanasia.*In Hospice: 70-90% experience pain; 50% moderate; 30 % severe pain *pain equal to or > 5/10 will affect the quality of life.*almost all patients can have good control of pain.

***Pain description: where, when, how, type, continuous, intermittent, location, radiation, intensity, triggers, relieving factors, aggravating factors, associated s/s, quality of life, medications used, *frequently evaluate & re-evaluate the pain

***Treatment: start low, go slow but keep going up till you achieve patient’s goals.* do not wait for testing, investigations and records to be collected*50 million people in US have chronic pain, *Pain: 70-78% in cancer and MS; 30-79% in AIDS;  *cost 100 billion / year.*pain is fifth vital sign.*unrelieved pain is a major source of fear.*4/10 do not get adequate relieve of pain. *Treat co-morbidities due to unrelieved pain : anxiety, depression, memory, sleep disturbances; affects physical, emotional, social, work related activities, affects practically every aspect of the person’s life

***Barriers to good pain control: both patients / physicians have fear of addiction, dependency; different myths & believes, cost of meds, misuse, regulatory over sight, will  use pain medications later. **Physician’s / nurses barriers to control pain: addiction; dependency; diversion; Regulatory issues; **patient’s related barriers: addiction; dependency; cost; saving pain meds for future use; worsening of disease process.


***Pathophysiology:**nociceptive pain:  can be somatic / visceral, can be controlled by NSAID’s; steroids**visceral pain: involves the viscera, cramp, pressure, due to lung cancer, gallbladder, bowel obstruction **somatic pain: due to soma, localized, trauma, tissue damage, burn, metastasis; *throbbing, aching, gnawing, **neuropathic pain: due to nerve involvement, *sharp, shooting, lancinating, burning *requires TCA’s; anticonvulsants

**Pain increased by: Pain is caused by disease process but increases due to fear, fatigue, frustration, untreated depressionunresolved spiritual, mental, physical and social issues.

** Pain decreased  by: Adequate sleep, Discussing worries and fears, Resolving emotional problems, controlling other symptoms, maintaining contact with family and friends, relaxation, Aroma therapy, Various activities: Yoga, Tai Chi, biofeedback, resolving conflicts, TENS unit,

***Pain can / should be controlled *escalating / acutely increasing pain is an emergency  **addiction is not an issue at this stage (hospice) *the goal: adequate pain control, happy & alert patient depending upon the stage of the disease process. *pain could be due to: disease +/- physical, mental, emotional & spiritual problems.*believe pain reported by patient or care givers.**scale: 0-10; 0= no pain; 10 is maximum; target to bring pain down to < 4. *review the medications with each visit.*Asses the total patient.  Total Pain : physical, emotional, spiritual, mental etc etc. *asses for functional limitations due to pain/

***Nurses: before calling doctor: have all the facts ready; good history, conceptualize the cause, med list, failed meds, your plan of care & your suggestions, be concise.

***Long acting opioids as baseline around the clock, Q 8 or 12 hrs mostly. **PRN: immediate release opioids ; used it as needed, 10-20% of total dose; oral q 1-2 hrs no longer than 4 hrs; SQ / IV PRN is q 30-60 minutes. *adjust baseline meds daily up in the amount equivalent to daily PRN, except Methadone. *oral route better than SQ better than IV. *Renal failure, liver problems, elderly start low and go slow. *Opioids are renally excreted except Methadone. *treatment: start low, go slow, and keep going up till goals are met **prefer PO,

**Routine meds for constant pain, 

**PRN meds for breakthrough meds,

***ANALGESIC LADDER: WHO : World Health Organization ladder

  1. Mild pain: (1-3) Non-Opiod ± Adjuvant
  2. Moderate pain: (4-7) Opioid ± Non-Opioid ± Adjuvant
  3. Severe pain: (8-10) morphine ± Non-Opioid + Adjuvant


***Control “total pain” which require physical, psychological, spiritual & social therapies.  **First line=NSAIDS, Tylenol. **Mild Opioids: Vicodin, Codeine, **MILD TO MODERATE PAIN:  NSAIDS ± Vicodin or Percocet. **Moderate pain: Percocet, Oxycontin. **Strong Opioids:  for strong pain: Morphine, Methadone. **First line=NSAIDS, Tylenol, Mild Opioids: Vicodin, Codeine. *MILD TO MODERATE PAIN:  NSAIDS ± Vicodin or Percocet. **Severe pain: Morphine, Methadone, Dilauded, Duragesic

***ADJUVANT ANALGESICS: Adjuvant analgesics are co-analgesics. They  are not true analgesics but developed for something else. They help to alleviate pain either alone or in combination with pain medications. *Elavil, Trazodone, Paxil, Prozac, Cymbalta,  *Tegretol, Neurontin, Ly,rica  *Calcitonin,  *Capsaicin, *Baclofen,  *Clonidine,  *Dextro-methorphan, *Neuroleptics, *Bisphos-phonates (Fosamax), Miacalcin,  *Scopolamine,  *Nonsteroidal Anti-inflammatory (NSAIDS),  *Local applications (lidoderm patches or 4% local lidocaine),  *Cox-2: Celebrex,  

***ADEQUATE TREATMENT OF PAIN: Chronic pain in hospice: intractable, irreversible, requires special attention & skills. ** Cancer pain: Opioid therapy is the first-line approach for moderate to severe pain. ** > 95% of pain can be controlled. **Severe pain is a medical emergency which should be treated promptly & adequately. **Addiction is very rare when opiates are used for pain relief in hospice. **Don’t use Agonist / Antagonists with morphine: Stadol (Butorphenol), Nubain, Talwin.

***No to Stadol (Butorphanol), Nubain (Nalbuphine) , & Talwin, (Pentazocine), Demerol (Meperidine)

**No Demerol: breakdown products are epileptogenic.

** Radiation therapy: reduces a tumor’s mass, pathological fracture, painful localized bony metastases, Epidural met, Spinal Cord compression

** Debulking a soft tissue tumor may not relieve pain.** Immobilize fracture or joint. **Estrogens or Lupron (gonadotropin inhibitor) in metastatic prostate cancer

**Co-analgesics: NSAIDS, Adjuvant analgesics, Anti-depressants, Muscle relaxers, Anti-epileptics

**Physician’s / nurses barriers to control pain: addiction; dependency; diversion; Regulatory issues; **patient’s related barriers: addiction; dependency; cost; saving pain meds for future use; worsening of disease process.elaxants, Hypnotic, Anxiolytic, Neuroleptics, Corticosteroids.

**Explanation, Education, Counseling, Relaxation therapy, Imagery, family support. ** Adequate analgesia.** Control insomnia

**Physical Dependence: Withdrawal symptoms on abrupt dose reduction. *withdrawal S/S : for short acting meds starts in 6-12 hrs; peak in 48-72 hours; remember DT’s : irritability, severe anxiety, rhinorrhea, nausea, vomiting, diarrhea, lacrimation, HTN, tachycardia, hypervigilence, insomnia,

**Tolerance: Diminish drug effects

**Substance abuse: Use of a drug illegally
**Addiction :  craving, primary chronic neuro-psych & behavioral disorder, *continuousCompulsive use of drug despite harm, SO compulsive use of drug with loss of control despite harm

*** Tylenol: Acetaminophen: step 1 analgesic, coanalgesic, > 4 g / day, ceiling effect, increased risk with alcohol abuse / hepatic disease

***NSAIDs: step 1, coanalgesic, ceiling effect, used: bony pain, bony mets, inflammation,

***Vicodin 5/500 = morphine 5 mg (1:1)


***NON-OPIOID-ANALGESICS: NSAIDS, Prostaglandin-synthesis inhibitor, no central effect **Side effects: bleeding under the skin, GI blood loss, renal dysfunction, liver (rare) **all have ceiling effect **GI side effects seem to be quite low with Tylenol, Arthrotec, Relafen, Lodine, Trillisate, Dolobid, Disalcid, Celebrex, Mobic

**1st line: Ibuprofen or Naprosyn or Indocin with or without Cytotec (misoprostol) protect GI side effects **Avoid Tylenol in liver failure

**uses of non- Opioids: bony mets, pancreatic ca, head & neck tumor, tissue damage, joint inflammation, arthralgia


For severe chronic intractable pain drug of choice is Morphine sulfate,

**morphine has Mu1 & Mu2 receptors

** Opioids are Safe & Effective

**Pain should be anticipated, and treated with regular dosing not PRN

**good dose: alert but pain free patient

**no ceiling dose of effectiveness

**Anticipate constipation & Rx

**Rx Nausea: Reglan, Haldol, Scopolamine **tolerance & addiction is rare

**Morphine does not shorten life

**Dilaudid (hydromorphone): use in morphine intolerance, potency X 4 morphine.   4 times more stronger than Morphine.

**Methadone (dolophine): use in Morphine allergy, drug accumulation, sedation, constipation

** 1% of patients are intolerant to morphine (severe, persistent nausea, vomiting) then use Hydromorphone ( Dilauded), if fails use Methadone (different chemically),  Fentanyl  (Duragesic)

** Demerol, short acting, breakdown product that causes seizures (not to be æused in hospice)

** Duragesic (fentanyl) patch or lollipop, nasal spray

** use same type opioids for long and short acting (MS Contin & MS IR)

***Morphine Sulphate (MS)

Morphine sulphate: can be used in tab/Elixir/SQ/IM/IV/Rectal forms

** Long acting morphine was introduced in 1985

**most commonly used in hospice

**Poor pain control:  increased MS by 50% & add TCA or adjuvant meds (may enhance MS effect) **still in pain: Re-evaluate, consider: Neuropathic pain, neuralgia, infection, muscle spasm, bony pain, vascular disorders, Stress, depression; Still no help: Radiation, hormonal therapy, counseling / psychotherapy, Co-analgesics, non-drug measures, Antidepressants, Chemotherapy

**SE: drowsiness, confusion, nausea, vomiting, constipation, bowel obstruction, urinary retention

** Drowsiness for > 2-3 days, then decrease narcotics 10-25% &/or decrease sedatives; switch meds, use long acting Opioids *Consider: Ritalin, Dexamphetamine **Nausea: Antiemetic: Compazine, Haldol

**Constipation: Docusate; Senakot; Pericolace, Enema

**Narcotic excess: miosis, sedation, hypo-ventilation, prolong confusion: lower the dose by 50% or more

**Morphine-intolerance change to Dilaudid

**Allergic to Morphine: use Methadone (chemically different); Fentnyl

**used in appropriate patients, Morphine does not cause addiction, or tolerance

**when patient is on higher dosage the increments should be larger

**Prior to death, do not stop; use 25-50% of the usual morphine dose to avoid withdrawal symptoms

(restlessness, sweating, and tremulousness)

**If pain lessened lower Opioids

** > 40% receive poor pain control (fear of addiction, lack of experience & knowledge)

**No addiction to Morphine in chronic pain in hospice

**Dosing Schedule: Fixed Schedule Dosing has replace PRN dosing in hospice

**PRN= rescue dose in Hospice= 10% to 20% of the total daily dose

**Otherwise PRN means pain relieve not enough

**Do not wait for days to control the pain

**Methadone: long-half life, pain relieve lasts for few hours, 5-6 hrs.

**The myths of tolerance, addiction, and respiratory depression led to the poor management of cancer pain

**Start with a low dose and adjust according to the response & goals

** Tolerance: does not occur & Respiratory depression does not occur when morphine is correctly to control pain

**Try to achieve full pain control

**TCA & Adjuvant or Co-analgesics may potentate morphine



*increasingly used in the last 6  (few ) years due to the price and found to be effective even in Neuropathic pain, **methadone accumulate with chronic dosing,

**Inhibits reuptake of nor epinephrine & serotonin, binds to NMDA receptors (NMDA receptor antagonist): prevention of opioid tolerance, potentiation of opioid effects, and efficacy for neuropathic pain syndromes,

**increase deaths due to: accidental overdose, improper prescribing, recreational use, improper use, increasing the dose without being recommended;

**QT interval prolongation

**A potent opioid agonist, useful when continuous opioid analgesia is needed **special license is required to prescribe methadone for the treatment of addiction.

**highly lipophilic with rapid GI absorption and onset of action. It has a large initial volume of distribution with slow tissue release.  Unlike morphine there are no active metabolites, can be use in renal failure Metabolized in the liver with significant fecal excretion; renal excretion can be enhanced by urine acidification (pH <6.0). Available in tablet, liquid and injectable forms; oral preparations can be used rectally.

**half-life 190 hrs. but pain relief lasts for 6-12 hrs. once steady state is reached

**rapid dose adjustment could be dangerous

** Morphine to Methadone conversion: 

                           < 90 mg/ d morphine = 1:4
90-300 mg / d morphine= 1:8
> 300 mg/ d morphine to 800 = 1:12
801-1000 mg – 15:1

>1001 mg – 20:1
Due to incomplete cross-tolerance, it is recommended that the initial dose is 50-75% of the equianalgesic dose.

**Methadone is not indicated in poorly controlled pain where rapid dose adjustments are needed; do not increase oral methadone more frequently than every 4 days.

*Dose conversion to: from other opioids and methadone is complex; consultation with pain management specialists familiar with methadone use is recommended.

Patient and family education is essential as they may misinterpret prescription of methadone to mean that their physician believes that they already are an addict

Types of pain

** NEUROPATHIC PAIN: Sharp, shooting, burning, due to nerve involvement **Rx: *TCA *SNRIs: Effexor Cymbalta *Tegretol * Neurontin *Depakote * Dilantin    

***BONY PAIN: = Severe, constant, worse pain with movement, poorly correlate with site **80% by breast, lungs, and prostate, others 20% **w/u: X-rays, Bone Scan (2mm lesion); CT; MRI; Bone Biopsy

***Metastases (most common axial mainly lumbar or lower extremities), compression or pathological fractures ** NSAID’s  **corticosteroids **Bisphos-phonates **Calcitonin  **radiation **Tamoxifen  **Opioids **chemotherapy  **RADIATION: treatment of choice in uncontrolled bony pain,hemoptysis,Tumor (pleura or chest wall), bleeding, Pleural effusion, bony mets = Pre-med: Steroids Hydrocortisone 100 mg & Antiemetic Reglan 10-20 mg IV= 4 800 RADS single dose 4 3000 RADS in ten divided doses as 300 RADS X 104 800 RADS upper body & 1-2 months later lower body

**Radiopharmaceuticals: Strontium  89 (89 SR);  Samarium 153  ( 153 Sm) and Phosphorus  (32 P) : high affinity binding to Hydroxyapatite in rapid bone turnover near the osteoblastic  metastases, * given in single IV without any special preparation, *eligibility: prostate, breast mets, if life expectancy is > 3 months, transient increase in pain around the first week (good response)*no one agent is superior *do not use: cord compression, pathological fracture, WBC < 3, platelets < 60-100 K


***Naloxone: only to be used in dire emergency: dilute 0.4 mg with 9 ml NS, give -2 ml q 15 minutes until effective; repeat 30-60 min

**Morphine gel nor mouthwash works well (avoid)

** Pseudo addiction: 1989, due to poorly treated pain, Improves with adequate Rx, aggressive dose escalation, establish trust & confidence,

**Addiction: (psychological dependency)  lies and play tricks to get more medications,  clock watching, excessive complaints, use of meds despite harm, family/ friends have substance abuse, avoid referral and non-drug treatments, drug seeking (reports his are stolen),  loss of control over drug use, frequently takes extra doses, overwhelming involvement with acquisition of drugs, compulsive drug use,  **Tolerance: increasing dosage to achieve the same effect, uncommon, not diagnostic of addiction

**Physical dependence: withdrawal when drug is suddenly stopped, most pain patient could have this,

**Pain in impaired patients: try history taking, interview caregivers & family &

friends, watch facial expressions, vocalizations, posture, irritability, interaction, appetite,

**Pain in Assisted living or nursing home: Discuss with all involve. supervisors,  educate them, ask nurses to do complete pain assessment frequently,  use non- pharmacologic therapies, schedule pain meds, PRN pain meds, bowel regimen, prn pain med before activities or therapies,

***Monitoring patient with pain: detail pain history, evaluation, impression and formulate a treatment plan, then reassess frequently, adjust the dosing and control the symptoms, most of the Opioids agonist do not have ceiling effect,

** Do not forget non- pharmacologic therapies

**educating: patient, family, caregiver and on- call or cross covering personnel

**ongoing assessment of treatment outcome

**in hospice involve all team members to help the patient

**be flexible

**ask for help when your plans are not fruitful

***acute pain: lasts days to weeks, easily identifiable condition or injury, or event

***chronic pain: cause is not easily identifiable, nociceptic or neuropathic, unknown duration,

***nociceptic pain: due to stimulation of thermal, mechanical, chemical receptor

***unmanaged pain may lead to changes in  the nervous system that could reduce its responsiveness to treatment (unmanaged pain causes nervous system changes, in turn causes permanent damage which amply the pain)

***unmanaged / poor pain control can have a devastating psycho- social and mental and physical effect on patient and family

***C max for oral opioids is 60 minutes, subcutaneous / IM is 30 minutes, IV is 6 minutes

***90-95%  is excreted through kidneys

*** Plasma concentration reach steady state in 4-5 half lives

***Methadone: even though the half-life is long but analgesia lasts for 4-8 hours, adjust the dose every 4-7 days

*** Corticosteroids: frequently helpful & commonly used, Dexamethasone, with its long half-life (>36 hours) & less mineralocorticoid effect, is the adjuvant steroid of choice. It can be administered once a day.

***chronic pain never ends in hospice

***neuropathic pain: BENTSS = burning, electrical, numbness, shooting, stabbing,

*** Breakthrough meds: used: end of dose failure of long acting opioids, incidental pain, spontaneous pain

***Duragesic: Fentanyl: 72 hours half-life, requires slow titration, incomplete cross tolerance, skin acts as reservoir so  patch is removed may not stop the absorption,

***Adjuvant Analgesics: Antidepressants, anticonvulsants, muscle relaxants, steroids, antiarrythmics

***Anticipate, Prevent, & Manage effects & side effects, including constipation

***Incomplete cross tolerance is most likely due to subtle differences in each opioids, start with 50-75% of published equianalgesic dosing, may need to reduce the dose as much if pain is poorly control

PO/PRMg/24 hrs. Duration hours Opioid equianalgesic dosingverticalDiff med & horizontal route for same Parental     mg Duration   hours
   150   4 Codeine
   30   4 Hydrocodone (Vicodin)   —   4
   7.5   4 Hydromorphone (dilauded)   1.5   4
   2-4   6-8 Methadone (dolophine) cumulate Chronic use   5   6-8
   30   4 Morphine   10   4
   20   4 Oxycodone (Roxicodone)   —
   20   12 Oxycontin (oxycodone LA)   —   —
   7 mcg/hr.   72 Duragesic (Fentanyl) patch    —  —



My formula to calculate the Opioid dose is:


                                         X =      …………..       multiply by  OD 24 hrs. dose

N=equivalent dose of new drug from chart above


O=equivalent of old drug from the chart above


OD 24 hrs. dose=24hrs dose of old drug.


X=24 hrs dose of new drug po


After the calculation: 25% reduction for incomplete tolerance






Common Opioids Used to Palliate Pain in Terminally Patients:


Generic.                    Brand name.


Hydrocodone             Vicodin


Morphine                      MSC, OSR, Roxanol™


Oxycodone              Roxicodone™, OxyContin™


Hydromorphone.         Dilaudid™


Fentanyl                    Duragesic.     1 patch q 3 days (12.5, 25, 50, 75, 100 mcg)


Methadone               Dolophine™






image image image



*** DELIRIUM: S/S: Mental status fluctuation, poor attention, hypervigilence, agitation, rage, visual / auditory hallucination, confusion, delusions, paranoia, disorganized thinking, disoriented to time/place/person, worse with darkness, marked startle response, apathy, depression, fear, tremors, anxiety # CAUSES: advanced disease & old age are high risk factors, CNS Metastases, metabolic, vital organ failure, Heart / Hepatic failure, electrolyte abnormalities, hypocalcemia, nutritional, infection, sepsis, drugs, fecal impaction, Urinary retention, Opiates, steroids toxicity, sedatives / alcohol withdrawal, anti-nauseant, anticholinergics *Rx: *stop responsible meds ** adjust narcotics ** correct the fluid & electrolyte balance** Quiet, well lit surroundings ** frequent reassurance/reorientation ** treat the cause ** Haldol 1-2 mg PO TID, for severe 1-2 mg IM q ½ to 1 hr. X4 max 20 mg/d but up to 100 mg /d have been used  **+ Benadryl or Cogentin po or i/m to prevent extra pyramidal S/S ** Benzodiazepine may worsen the condition, use only for sedation, Ativan, Valium suppository or Versed SQ ; *Ativan 0.5 -1 mg po q 1-4 hrs. prn can be given alternating with Haldol  ** Mellaril **Thorazine ** Magnesium ** Clonidine-PO/Patch ** Neurontin ** Change narcotic agent *adjust pain meds but do not stop them all of a sudden *in hospice we use Haldol & Ativan via least invasive route, oral, buccal, cutaneous are most often used. Leases frequently is SQ * consider Risperidone, Quetiapine, etc


*** ANXIETY (generalized): # S/S: unable to relax, persistent motor hyperactivity, irritable, shaky, autonomic hyperactivity (sweating, epigastric discomfort, palpitations, shortness of breath); Numbness, Apprehension, Worry, Vigilance, Trouble concentrating, Hyper-attentiveness, Insomnia, easily distractible # Causes: Unrealistic goals, fear, Impending death, Electrolyte imbalance, medical (hyperthyroidism, sympathomimetics, weight loss meds, decongestants, caffeine), withdrawal of sedatives, Medications, Fear *Rx: ** Treat the cause ** counselling ** use ancillary hospice services: social, chaplainry **SSRIs are the first line, takes 2-4 weeks of lag time** Buspar ** Benzodiazepines: Ativan, Valium ** Beta blockers: Inderal, Tenormin **if SSRI failed then try Tricyclics antidepressants **Clomipramine approved for OCD **consider Phenobarbital, Nembutal, **consider Risperidone, Quetiapine, Risperidone, and Mellaril, can try these meds with SSRIs


*** PHOBIA: excessive irrational fear which requires avoidance of the situations, person or place, Type:  Social phobias (social functions), simple phobia (claustrophobia), agoraphobia (public places) *Rx: ** Imipramine ** SSRI s (Paxil, Zoloft, Prozac), **Xanax or Benzodiazepines


*** PANIC ATTACK: 1-2%, F>M, afraid to go out because of the fear of attacks, sudden paroxysmal terror, somatization (chest pain, dyspnea), *Rx *TCA *SSRI’s (Paxil, Zoloft, Celexa, Prozac) *Benzodiazepine: Valium, Xanax (Xanax or Klonopin can be given SL) ** Haldol


*** OCD: Obsessive compulsive disorder: ** SSRI’s: Paxil, Zoloft ** Anafranil (Clomipramine)


*** Depression: 20% • High suicide rate *S/S: Persistent sadness; worthlessness; guilty; excessive self-blame; loss of pleasure in any activity whatsoever; lack of energy; sleep disturbances; weight & appetite changes; crying; suicidal thoughts; # multiple risk factors, pancreatic cancer, steroids, beta-blocker, Tagamet, pain, disability, fear, frustrations, personal or social problems  *Rx: *use support system *active listening ** relaxation ** chaplain services ** guided imagery ** TCA antidepressants: takes 3 weeks, Elavil (sedative); Pamelor (if no sleep disturbance) ** SSRI: takes 2 weeks to work, Celexa, Zoloft, Paxil, Prozac ** Remeron: weight gain & sleep with smaller doses 15 mg 1/2 tab in evening increase to 45 mg/d; Adjust the dose • other antidepressants:  Trazodone (Deseryl) sedative ** if patient is drowsy, less alert, lack of energy, have apathy use stimulants works within a day : Ritalin; Dexedrine,


*** Suicide: • Assess all depressed patients for risk • Discussion of thoughts of suicide may reduce the risk • Suicidal thoughts are a sign of depression • High risk if recurrent thoughts / plans • utilize all members of the team  *consider psychologist/psychiatric consultation • listen & encourage patient to talk about his worries & treat appropriately • *Rx depression, pain & other s/s aggressively • advise caretakers to take weapons out of the house • Psychiatric consultation • Social worker • Psychologist • chaplain *visit more frequently


*** Stress of dying: # Death, interpersonal conflicts, guilt, unfinished work, religion, leaving survivors: spouse / children / friends ** utilize the team members ** occasionally use anxiolytics, antidepressants


*** GRIEF: Normal emotional reaction to loss

*** BEREAVEMENT: Reaction to loss of a love one

*** MOURNING: The social expression of grief


*** INSOMNIA: Up to 50% in advanced cancer, get good history, # CAUSES: crisis, fear, pain: not under control or waking patient up, dyspnea, phobias, anxiety, depression, nausea, dyspepsia, restless leg syndrome, cramps, urinary frequency, coffee, heavy smoking, pruritus, meds causing: Prozac, Wellbutrin, steroids, diuretics, stimulants if they are given in the evening, inadequate symptom control, mental distress *RX: ** Rx the cause ** restore sleep cycle ** sleep hygiene **Analgesics for pain, use more at night or use long acting pain meds ** Antidepressants(if depressed): Doxepin, amitriptyline or Trazodone are the most sedating agents ** Mellaril ** Thorazine ** Valium (very long acting) ** Nembutal suppository/PO/IV/IM ** Phenobarbital po hs ** Restoril (8-25 hrs half-life) ** Dalmane, rapid absorption, sleep, but long acting ** Ambien ** Sonata ** insomnia with anxiety: Ativan, Klonopin  ** insomnia with pruritus: Hydroxyzine (Vistaril), *local applications,*soothing skin prep ** Combination of different classes (Benzo + Opioids + adjuvant analgesics+antipsychotics) in adequate doses should help anybody sleep


*** TERMINAL RESTLESSNESS: patient is transitioning.#causes: Terminal event, Pain, fecal impaction, Urinary retention, Anxiety, severeDyspnea, steroids, itching and uncomfortable position # S/S: respiratory difficulties (dyspnea, death rattle, increase secretions); CNS (restless & agitation 40%, decrease level of consciousness, myoclonus); in pain: but pain just does not come on all of sudden whereas patient was not in pain before, bladder distention s/s*Rx: • prepare the family, make patient comfortable, do not prolong nor hasten the process ** stop all meds except one for pain (reduce or increase), vomiting, seizures, agitation ** keep the patient dry ** stop IV, tube feeding n ** morphine: don’t stop, increase or Decrease the dose depending on discomfort, change oral to Buccal or suppository or SQ ** use 50% of previous 24 hrs. dose of morphine ** to avoid morphine withdraws use 10-25% of the usual dose ** if not on Morphine: Start 10mg SQ / buccal / PR and titrate up fast ** If already on morphine £ the dose by 25-50% ** Valium per rectum ** Lorazepam SL / IM / PO ** Scopolamine patch ** Atropine SC / IM / SL  If restlessness persists use: ** Thorazine PR/IM ** Haldol po/skin paste/buccal / IM ** Versed (midazolam) SQ/IM Phenorbital or Nembutal IM / PR ** Catheterize for retention ** Inapsine (for nausea) Death rattles: A raise HOB 30 degrees A reassure family that patient not aware A to dry secretions use Atropine SL/IM or Scopolamine SL/ up to 3 patches at one given time A Lasix

**Tammy’s cocktail (HAM = Haldol, Ativan, Morphine) 511 = 5 mg of morphine, 1 mg of Haldol & Ativan.  HAM -2 : 522: 5 mg Morphine, 2 mg of Ativan & Haldol. can be given q 15 minutes or q 1 hour.




***BAD TASTE:  *Less meat *dairy ok * increased fluids *Zinc sulphate *vit C chewable

***HALITOSIS: *Poor oral hygiene, *infection, *Lung abscess, *ENT cancers *Rx: Routine oral hygiene, gentle mouth washes, Sodium bicarbonate *hydrogen peroxide *antibiotics

***SORE MOUTH: *Thrush *Dentures *coated tongue • thrush use Nystatin •Gingivitis use Flagyl • Ulcers: Vit C, Fresh pineapple, Mouthwash

***ANOREXIA: *Decrease appetite, weight loss, emaciated, generalized weakness, fatigue # nausea due to Cancer meds, depression, practically any disease *not rejecting love *cancer cell may use most of the nutrients;*Rx: sit up & rest before meals •Breakfast better tolerated • Alcohol & caffeine stimulates appetite • Small portion of attractive palatable meals • patients’ preference •Reglan • Decadron • Megace • Vit C


*** DYSPEPSIA: # Heart burn, indigestion, burning epigastria discomfort, acid reflux, nausea *Rx: ** eliminate predisposing factors ** stop smoking ** no spicy foods ** frequent small meals ** Antacids: magnesium containing antacids causes loose BM, aluminium causes constipation ** H2 blockers ** Carafate ** stop corticosteroids & NSAIDS ** Reglan to increase motility ** Prilosec


*** DYSPHAGIA: # Difficulty in swallowing, regurgitation, aspiration, retrosternal pain # cancer of esophagus / nasopharynx, ALS, Parkinson’s, CVA, MS, candida (esophagitis) • if needs w/u: Barium swallow; endoscopy *Rx: ** oral hygiene ** liquid / soft food, ** carbonated drinks with meals ** Nitroglycerine or Isosorbide dinitrate 10-20 mg or Procardia 10 mg ½ hour before meals ** feeding in sitting or Fowler’s position **Candidiasis: no lesions but burning consider *Rx with Nystatin swish & swallow; Nizoral; Diflucan ** edema: neck cold compress ½ hr AC or Decadron 4 mg QD / BID ** no meat tenderizer

*** GERD: Gastroesophageal reflux: # heart-burn, nausea # gastric contents / acid going into esophagus ® mucosal damage, heartburn, retro or substernal discomfort, increase S/S by recumbency after meals or straining, clinical Dx, 50% abnormal endoscopy # ascites, smoking, obesity, alcohol, fatty/heavy meals, heavy caffeine use *Rx: ** Eliminate the cause, ** change lifestyle, ** elevate the HOB, ** antacid, ** H2 blockers, ** Reglan, ** Prilosec


*** NAUSEA: • Sick to stomach with desire to vomit • Vomiting: throwing up # Causes: multifactorial, Opioids, NSAID’s, Chemotherapy, Drugs, Mechanical obstruction, CNS or G.I. Cancer, increase ICP, systemic Infection, Enteritis,

Radiotherapy, Electrolyte abnormalities, Anxiety Disorders, Gastroparesis

*Rx of N/V: correct the correctable ** frequent small palatable meals ** clear liquids ** eliminate the cause ** avoid recumbency after meals, elevate the head of bed ** Antihistamines: Benadryl, Phenergan ** Pro-kinetics: Reglan : use in gastric stasis, partial bowel obstruction, dysmotility  ** Corticosteroids: Prednisone, Decadron : use in raised intracranial pressure, tumors, ** Phenothiazines: Compazine, Thorazine ** Anticholinergic drugs: scopolamine, atropine ** Cannabinoids: Marinol ** Butyrophenones: Haldol: bowel obstruction with colic, uremia, hypercalcemia, nausea due to drugs,*Inapsine ** Benzodiazepines: Ativan ** Opioids ** Discontinue NSAIDS ** Scopolamine ** Chemo / rad: 5-HT3 antagonists: Zofran ** intestinal obstruction: NG tube, SQ or IV fluids, stop Reglan, Levsin, hyocyamine, morphine,


*** CONSTIPATION: • Anticipate in hospice patients • 1 hard BM > 3 days, difficult or no bowel movement

# causes: opiates, poor bowel habits, advanced age, less fiber in diet, inactivity, impaction; structural, colon ca abnormalities, hypercalcemia, anticholinergic, Phenothiazines, tricyclics, iron, calcium, aluminum containing antacids, calcium channel blockers & other pain meds *Rx ** remove the cause **stool softener and & stimulants combo may be needed** Initiate bowel program ** stool softeners: docusate, Lactulose (bloating/gas), magnesium salts ** laxatives: Bulk agents, Softeners (Docusate Sodium), Colonic stimulants (Senna, bisacodyl) ** Sorbitol, lactulose, magnesium sulfate for severe constipation ** mobilize the patient ** Diet: roughage, fluids & fiber ** Senna ** PeriColace ** Dulcolax suppositories ** Senakot ** Prune Juice ** white grape juice & cranberry juice ½ oz each/day ** Reglan (not in Parkinson’s) • If no BM for > 3 days: intermittent use of mag citrate or phosphosoda, lubricants, Caster Oil, Milk of Magnesia,** Lactulose: not absorbed, side effects: cramping / flatulence (we prefer Sorbitol) ** Dulcolax supp ** Enemas ** Disimpaction **avoid stimulants if colic is present


*** HICCUPS: • Phrenic nerve irritation, CVA, post-operative, Irritation of nerves, psychiatric, Gastric distension, metabolic problems, Uremia • *Rx: ** keeping the tongue out for few seconds ** supraorbital pressure ** teaspoon of sugar on outstretched tongue ** avoid recumbency immediately after meals ** hold breath for few seconds ** Mylanta ** Reglan PO / IV ** Baclofen ** Tegretol ** Haldol ** charcoal-tab ** Adalat ** IV-Lidocaine ** Chlorpromazine (Thorazine) O / IM, 80% improvement ** Peppermint water ** lastly Phrenic nerve block


*** FECAL IMPACTION: # Prolong narcotic use; chronic Constipation, debility, prolong bed rest # Overflow diarrhea, firm mass in rectum, leakage around impaction, abdominal pain, Nausea / vomiting / anorexia, abdominal distension *Rx: ** Dulcolax or Glycerin suppository ** warm water or mineral oil retention enema ** soap suds or Fleets enema ** Reglan 60mg/day SQ continuously for 1 day followed by oral once symptoms improve ** long term care: diet, regular BM, stool softener ** Vaseline balls


*** DIARRHEA: Increase frequency > 3 stools/d, decrease consistency, Ÿ watery stool # laxative overuse, maldigestion, malabsorption, Partial bowel obstruction, GI Tumor, Magnesium, antibiotics, Clostridium difficile and pseudo membranous-colitis, chemotherapy, NSAIDS, Caffeine, Estrogens, Sulfonylureas, Reglan, Radiation, Infection (particularly in AIDS), bacterial, Viral, parasitic: giardia, AIDS, Colitis, irritable bowel syndrome, Malabsorption, Pancreatic insufficiency, sorbitol, Lactose, diet, tube feedings n Treatment: ** avoid offending agent ** Disimpaction ** bland low residue diet ** watch dairy products ** less carbohydrates ** Gatorade ** Stop offending meds if possible ** Kaopectate ** Pepto-Bismol ** Imodium (Loperamide) ** Lomotil (Diphenoxylate / Atropine) ** Anticholinergic ** Tricyclics ** codeine ** Morphine sulphate ** Pancreatin for pancreatic insufficiency ** Questran provided no biliary obstruction **Steroid enemas for Colitis, infiltrating tumor or Inflammatory ** Infection: Cipro + Flagyl ** Clostridium difficile: Flagyl or Vancomycin ** Desitin or A&D or Vaseline for local irritation ** discontinue Penicillin, Cephalosporin; Sulpha ** Steroids: Ulcerative colitis ** Sandostatin (octreotide) in AIDS diarrhea

*** TO INDUCE CONSTIPATION: ** Codeine phosphate ** Opioids ** Tricyclic antidepressants

*** BOWEL-OBSTRUCTION: • Abdominal pain / tenderness, abdominal distension, Overflow diarrhea, Air-fluid levels on x-ray # colon ca, fecal impaction, ileus, meds *Rx: ** IV fluids, ** NG suction for 7-10 days ** Small meals preferably liquid/low residue ** all meals timed long before bedtime ** don’t force feed ** Vaseline ball-for-high impaction ** Benadryl-PO-BID/QID ** Haloperidol ** Scopolamine (antispasmodic) ** Robinul po TID or SQ / IV ** Atropine (antispasmodic) SC / PO / sublingual • Droperidol (Inapsine) IM-TID ** Opiates for severe pain SL/PR ** Probanthine POQID ** Phosphate enema ** Dulcolax or Senakot for small bowel obstruction  avoid if possible ** Trial Decadron 4mg po QID or Prednisone 30mg po QID for 5-7 days ** Solumedrol 50mg IM TID x 3 days (50% response) ** Thorazine ** NG p.r.n.; ** sedation, ** control pain ** needle decompression for severe gaseous distension ** steroid retention enema ** Pepcid 20 mg POBID ** 1 wk. to allow spontaneous resolution before surgery, avoid surgery, 30% perioperative mortality with surgery • Avoid Tubes

*** Abdominal DISTENTION: # Tumor, ascites, Perforation, Intestinal Obstruction, Gaseous Distension (Lactulose) *Rx: ** Treat the Cause ** No NG Tube or No flatus tube in Perforation ** Treat symptoms ** Control Pain ** Needle decompression!

*** Ascites: Fluid in the abdominal cavity # Abdominal distension, pain, discomfort, fluid thrills, Dyspnea, orthopnea, nausea, Lower Extremity edema # Any cancer primary or metastatic, cirrhosis, CHF, infection, nephrotic synd.  *Rx: ** Elevate HOB 30º ** sodium restriction ** Pain Control ** Diuretics ** Para-centesis ** Peritoneovenous Shunt ** treat the cause ** symptomatic


*** RETROPERITONEAL METASTASES: • Cancer of Pancreas, breast, cervix, endometrium, kidney, colon, or prostate • Retroperitoneal: sarcomas, germ cell tumors, lymphomas S/S: • Backache, palpable abdominal mass, urinary frequency, venous thrombosis, pain, impotence, lymphedema *Rx: symptomatically, radiation



***URINARY-FREQUENCY/INCONTINENCE: (urge incontinence) # >7 daytime, > 2-3 times/night # Ÿ with age, Diuretics & Hypercalcemia (large volume, urine), Infection (cystitis, prostatitis), Diabetes, tumor, debility, Diabetes, Bladder spasm / cancer, Fecal impaction, Retention with overflow, ** Anxiety, Detrusor weakness, coffee *Rx: ** Ditropan (oxybutynin)  Detrol ** Elavil ** Catheter ** Bladder Training ** Flomax • Dysuria ** Phenazopyridine (Pyridium): for dysuria ** Septra DS bid if not allergic ** antispasmodics: Levsin SL, Scopolamine ** TCA: Elavil, Tofranil

*** HESITANCY/RETENTION: # Frequent small volume, large post void, overflow incontinence, Urinary Retention *Rx: bedpan, schedule urination ** Minipress ** Hytrin ** Urecholine (bethanechol), ** Flomax, ** Cardura A stop anticholinergics A catheter ** suprapubic catheter **high dose Lasix 40-80 mg bid, bumex 2 mg -3 mg bid , Zaroxyline 5 mg   (1 mg of Bumex = 40 mg of Lasix)

*** BLADDER SPASM: # Infection, tumor, radiation, fecal impaction *Rx: ** Ditropan (OXYBUTININ); Flavoxate (Urispas)100-200mgq 6-8 hers.; Hyoscyamine (Cytospaz) 0.125-0.5 mg quid.; Dicyclomine (Bentyl) 10-20mg quid; Tolterodine (Detail) 1-2 mg bid** Urispas ** Probanthine ** Tofranil ** Flomax ** Benzodiazepines ** Levsin SL ** Scopolamine ** Atropine ** Naprosyn ** TCA: Elavil, Tofranil ** Belladonna

*** URINARY TRACT INFECTIONS: # Dysuria, fever n treat if symptomatic, not near death, don’t treat if asymptomatic bacteriuria ** Pyridium (pink urine) ** Septra ** Floxin ** Cipro ** Augmentin **NITROFURONTIN: EXCRETED IN URINE, **PROPHYLACTIC NITROFURONTOIN 50-100 mg /d **VIT C; Hiprex **POST CATHETER HIPUREC, NITROFURONTOIN, HIPREX

*** MESTASTIC PROSTRATE CANCER • Bone pain, anorexia, weakness, malaise, anemia, hematuria, obstructive uropathy ** Lupron (leuprolide) / month (Less side effects than estrogens) ** Antiandrogens – Eulexin (flutamide) (Prevents testosterone receptor binding, less side effects ** Orchiectomy instead of Lupron (less expensive) **Corticosteroids: for painful bony mets ** Radiation ** Didronel ** Calcitonin **HORMONAL AND CHEMOTHERAPY **

*** HEMATURIA: Bloody urine # tumor, infection, chemotherapy, radiation, coagulopathy • *RX: ** Antibiotics ** Continuous irrigation with 1% Alum solution at 5cc/min ** Radiation ** Amicar 5gm po followed by 1 gm po q1-4h as needed ** Transfusion (benefits lasts 2 days) **THROMBIN OVER THE WOUND **WEAK FORMALIN SOLUTION**RX INFECTION, STOP ANTICOAGULANT **RX INFECTION, **THREE WAY CATHETER USE SALINE/ WATER IRRIGATION **

*** URETHAL CATHETER: • Cause: clot, sediment, tumor, infection and Irrigation ** Larger catheter ** Larger balloon ** Emmett catheter – multiple holes, **prefer suprapubic catheter **

*** CATHETER: Catheter better than pads or diapers, drained to gravity, if ambulatory use leg bag, do not culture for few days after placing catheter (about 5 days);  complications: infection, fistula, peri catheter draining of urine,





*** PRESSURE SORES • Turn in bed Q2-4 hrs • Avoid pressure/friction except in last few days • Use skin prep (Sween, Hollister, Bard) • Egg crate, thick foam, air-mattress • Do not massage • Clean, rinse, dry & Open wounds: kept moist to heal; Protein supplement, multivitamins, Vit C 500mg TID, and Zinc 220 BID; Foley catheter & BEDSORE with INTACT skin (reddish): Ointments: A&D, Vaseline, zinc oxide, Desitin • (Op-site, Tegaderm), change every 5-7 days or PRN • Granulex spray BID or prn • Blister (skin break partially): Irrigate well with saline • Use saline • Carrington wound gel • Duoderm, Tegasorb, Change each week & Sore with exposed Bone / muscle exposed: Bedside surgical debridement; Travase or Elase; Carrington wound gel; Wet to dry gauze; if granulating & Infected bedsore: Wet to dry; Carrington wound gel; Silvadene; no semi-permeable or occlusive dressing when infected • Granular (clean pinkish): Moisturizing ointments; MVP film; Granulex

*** PERISTOMAL CARE: • Cleanse, rinse and dry • use skin Prep • device fit & sealed • Rapid attention to skin breakdown

*** MALIGNANT ULCERATIONS: A radiation ** Anti-inflammatory ** steroids ** Odor/ drainage: Dakin’s soaked dressings, Benzoyl peroxide 10% solution packing (protect surrounding tissue) ** Air freshener ** Flagyl PO/gel ** Bleeding lesion: Alum in 1% solution; 1:1000 epinephrine soaked gauze; Gel foam

*** SKIN INFECTIONS: • Infected sores, Erythema, purulence, foul odor, pain • Culture *Rx ** Dakin’s dressings ** use Acetic acid if green (Pseudomonas) ** Metrogel topical BID ** Flagyl po QID ** Silvadene ** Cipro. Impetigo-superficial-infections: Bactroban (mupirocin) topical, Erythromycin, Dicloxacillin, Velosef, & Cellulitis: Penicillin, Erythromycin, Velosef or cipro & Candidiasis: Nizoral, Lotrisone, or Mycolog topically, Nizoral for 2 weeks

*** DRY SKIN: • After bathing apply Lanolin, Vaseline Intensive Care, Vaseline, Bag balm ** Atarax (hydroxyzine) ** Steroids: 1% hydro-cortisone ointment 0.1% Triamcinolone oint / Prednisone 20-40 mg po daily ** Phenergan only if allergies ** Benzodiazepines

*** WET SKIN: ** Wash & dry ** Special cleansers ** Zinc oxide ** No ointments or creams ** Calamine lotion ** Starch ** zinc oxide ** talc ** Lotrimin ** Burrow’s solution


*** MOUTH CARE:  Dry mouth *Rx: ** avoid anticholinergic drugs ** Lip balm ** Frozen tonic water, fruit juices, pineapple chunks ** Sugarless lemon drops ** Chewing gum ** Artificial saliva ** brush ** rinse (H2O2) ** Soda water ** Cepacol n Ulcerations: Herpes: ** Zovirax (acyclovir) 200mg q4 hrs for 5 days • Aphthous ulcers: ** Glyoxide rinse n Periodontal infections: ** Peridex wash, oral Pen VK, Flagyl, Velosef ** Kenalog, Lidex or benzocaine in Orabase & Foul, fungating lesion: ** Flagyl & Yeast ** Mycelex troches 5 x/day are very effective ** Nizoral (Hepatotoxic) ** Nystatin suspension 1 tsp q4h

***Painful mouth: ** Xylocaine 2% viscous solution 1-2 tsp or 10% oral spray q3h **Antacid ** Glyoxide rinse ** Tessalon pearls, 1 or 2 dissolved orally q8h Anesthetized Throat

*** Taste alternation: ** Zinc, Vit C

*** URTICARIA:  *Rx: ** Antihistamine ** H2 blockers (Pepcid) ** TCA (Elavil) **Benzodiazepine ** Local application

*** PRURITIS: Dry skin: ** NO hot baths ** avoid irritants ** lubricants ** cornstarch & baking soda tepid bath ** cotton dressing ** 1%Hydrocortisone cream ** Antihistamine ** Decadron

*** CANDIDIASIS: 70% • Sore mouth • Painful Dysphagia • Ç risk with: Steroids, antibiotics, radiotherapy, chemo, dentures *Rx ** Nystatin oral susp / Popsicle **Ketoconazole ** Diflucan ** prophylactic Mycelex troches






*** SUBCUTANEOUS INFUSION: • Change needle site weekly • use: Intractable pain, Nausea, Bowel obstruction, coma, debility, poor compliance *Rx: ** Fluids 500-1500 ml / 24hrs ** Morphine ** Antiemetics ** Haldol ** Reglan ** Dilaudid • contraindication: severe Thrombocytopenia

*** Eternal tube feeding: Patient, family & team preference, not helpful in last few days *** TPN (Total parenteral nutrition): does not improve nutritional status, may be inappropriate in hospice

*** TRIGGER POINT:  *Rx: ** Local injection of Bupivacaine & Methylprednisolone ** Ethyl chloride spray ** Lidoderm patches 12 hrs on 12 off

*** EPIDURAL OPIOID THERAPY: • Analgesia • less sedation • less side effects • able to use mall doses

*** NERVE BLOCKS: Blocking the nerve • Marcaine + Depomedrol

*** SYMPATHETIC BLOCKS: •+ Local anesthetics + 50% alcohol or phenol 5-10% in water

*** CELIAC PLEXIS BLOCK: • Pancreatic ca • upper abdominal cancers

*** STELLATE GANGLION BLOCK: • For pain in the head, neck and arm,Complications: Pneumothorax, infection, Horner’s syndrome, laryngeal nerve, phrenic nerve & brachial plexus injury

*** NEUROABLATION: • Cordotomy, for severe pain below that level • Partial posterior rhizotomy

*** RADIATION: • Shortest treatment • Bone Pain • Spinal cord compression • Fungating ulcer Control of hemorrhage • Obstruction (SVC, airway, esophagus) • Brain metastases • Reduce tumor bulk • SE: Nausea and vomiting; • skin reactions: starts in 21 days; lasts 1 or 2 weeks after the last treatment





*** ANGINA: • Chest pain, increases on exertion, relieved by rest/nitro • *Rx: ** sublingual nitroglycerin 0.4 mg q 5 min x3 or pain free ** O2 ** rest **nitro before exertion /exercise. *long acting Nitro *Beta blockers *Calcium chanel blockers *Aspirin

*** ACUTE MI: • Chest pain > 30 min, shortness of breath, left arm/neck pain, diaphoresis, hypotension • *Rx: ** O2 • 2-4 L/min ** Nitro-glycerine 0.4 mg SL q 5 min x 3 ** Morphine liq sublingual

*** HYPERTENSIVE CRISIS: • BP > 200/120 • Headache • Epistaxis • Blurred Vision *Rx Catapress (clonidine) 0.1 mg q 1hr until DBP < 115 (total dose 0.8 mg) ** Procardia (Nifedipine) 5-10 mg bite & swallow q 1 hr (x3), no sublingual may drop BP rapidly ** Nitroglycerine SL

*** HYPERTENSION: • Diuretics: elderly, African-American, smokers • Beta-blockers: whites, non-smoker, younger, no asthma/CHF • ACE inhibitors: whites, young, total chol > 240, diabetics • Calcium channel blockers: elderly, African, hypercholesterolemia •Alpha 1 blocker: men with prostatic hypertrophy

*** DYSPNEA: Breathlessness, severe shortness of breath, 70% in cancer # lung-ca, CHF, COPD/Emphysema, CNS metastases, pain, anxiety, Anemia, Infection, terminal event, SVC • superior vena cava synd (edema above neck & upper extremity) • hrs or days ¢ infection • weeks ¢ tumor or chronic diseases  *Rx: ** Treat the cause if possible** Relaxation ** reassurance ** breathing exercises ** fan ** cold humidified air ** Fowler’s position ** pursed lip breathing ** Bronchodilators ** Prednisone, control pain • Asthma / COPD: Albuterol, Atrovent inhaler, Beclovent inhaler, ** Theophylline for COPD, • CHF: raise head of bed, Diuretics, Digoxin, ACE inhibitors • Infections:antibiotics unless near and symptomatic death # Death rattle: ** turn patient on side; Scopolamine Patch; Atropine 1% 1-2 drops SL/PO Q 4 hrs ** Small doses of Ativan or Valium as anxiolytics • Anemia: Transfusion (affects lasts 2 days) • SVC or TUMOR:Radiotherapy +/- Corticosteroids • O2 • Morphine

*** COUGH: # Pneumonia, bronchitis, lung abscess, COPD, Cancer, Smoking, CHF, LVH, ACE inhibitors, GERD  *Rx: ** remove irritants ** oral hydration ** steam ** antibiotics for infections except actively dying ** expectorants • Bronchospasm: Bronchodilator; Atrovent; Proventil inhalers • Post nasal drip: Anti-histamines / decongestants; Pseudoephedrine (Sudafed= decongestant) • CHF: Diuretics, Digoxin, raise head of bed, (ACE inhibitors may induce cough) • Dry cough: ** hydration, humidity and or steam, Bronchodilators, terpin hydrate • Productive cough: ** Antitussive, Dextrometh-orphan, Codeine PO; Scopolamine sublingual / patch ** Atropine PO or SL ** Corticosteroids • Cancer: radiation or chemotherapy • Dying with ineffective cough: ** morphine ** atropine drops ** Scopolamine patch

*** LYMPHEDEMA: Unilateral painless non-pitting edema # post-mastectomy: immediately or yrs. later; radiotherapy; Pelvic malignancy • document limb circumference  *Rx: ** elevate the extremity ** avoid infection ** Compression stockings ** lymphatic compression pump ** light massage ** exercise ** no Diuretics A physical therapy (Home?) pneumatic compression 1 hr/d for 1 month ** TS proximal & distal to the swelling ** short course of decahedron ** if very painful consider infection or tumor invasion

PERIPHERAL EDEMA: Failure of heart, liver & kidney # Fluid retention, Immobility, Hepatomegaly, Low serum albumin, CHF, Pelvic tumors, nephrotic syndrome *Rx: **Elevate extremities ** Exercise ** Ted Hose ** Start Diuretics ** Reduce the dose or D/C Steroids

*** DVT: ** Elevate leg ** moist heat ** Heparin ** Coumadin

*** BRONCHOSPASM:  *Rx:  Albuterol ** aminophyline ** steroids ** Radiotherapy: large carcinoma ** Opioids: the most powerful central cough suppressants ** Nebulized Lidocaine: 2% can bring dramatic relief

*** DIABETES: # Carcinoma of the pancreas, steroids # Thirst, Drowsiness, increasing weakness • keep pre-prandial blood glucose levels below 170 mg/dl • Oral hypoglycemic ** Diet • Warned about hypoglycemia • Insulin requirements in advancing disease may decrease • During the terminal phase, insulin may still be needed • Basal requirement of insulin Novolin 70/30=10 units BID • If unconscious insulin should be stopped but follow blood sugars unless near death

*** SUPERIOR VENA CAVA SYNDROME (SVC): # Right apical lung ca; breast; lymphoma; mets # Headache, swelling of the face & right arm, swollen eyes, pain, dilated neck veins *Rx: ** Decaderon 8-12 mg per day ** Radiation ** Chemotherapy



Part IX: CNS

*** SEIZURES: 1% # CNS tumor & metastases, CVA, electrolyte abnormality, hypocalcema, hypoglycemia, drug, stopping anticonvulsants abruptly, sedative withdrawal, alcohol  *Rx: ** Valium 5-10mg by slow IV/rectal stat ** Dilantin 1,000mg po in first 24 hours in 3-5 doses, followed by 300- po/day ** Dilantin, phenobarbital 100-200 IM ** Phenobarbital 30-60mg po BID-TID ** Dysphagic: Phenobarbital, Ativan, Valium IV/Rectal. ** Versed 0.25-2mg/hr by SQ pump C Diastat: Rectal valium pre-filled syringe • control seizures even in dying patients

*** ALS: • Respite care • Mentally alert until death • Choking is a rare cause of death <1% • Occupational therapy • Aids: walking, talking, eating, etc. • Dysphagia: ice to neck before meals • Suck ice before meals • eat slow • place food at the back of throat • Avoid dehydration • Repeated chocking: PEG • Drooling: ** Atropine, Scopolamine, TCA (Elavil) • NO artificial ventilation • Good symptom management • Rilutek: very expensive, not a cure.

*** RAISED INTRA CRANIAL PRESSURE: # Wakes up with HA, nausea, projectile vomiting, papilloedema, focal neurologic deficit, mental status change (seizure) Tumor, metastasis *Rx: ** High dose Decadron 16mg/d as 4 mg PO QID ** diuretics ** Head of bed elevated to 30-45°

*** BRAIN METS: 10% of Cancers # Focal Neuro deficit, Seizures, ã ICP, wakes up with HA, Vomiting, Papilloedema, Personality changes *Rx: ** High dose Decadron ** Radiation ** Anticonvulsants ** Surgery: Solitary accessible lesion, no other mets, healthier, not dying, good prognosis

*** SIADH: 1% ca of lung small cell, ã water, decreased sodium # HA, fatigue, cramps, confusion, seizures, coma ** Fluid Restriction 500-900 cc/day ** Demeclocycline 300 mg PO BID A Lasix *Rx the cause A monitor electrolytes A consider hypertonic saline infusion but avoid rapid correction

*** ALZHEIMER’S disease : • Most common cause of dementia • Cause: not known • Gradual decline in intellectual functioning, memory, concentration, behavior, language • Early Stages: Treatment is available • Late Stages: Symptomatic Care, control behavior, support caretakers

*** CONFUSION: # Drugs, metabolic & electrolyte abnormalities, Pain, Impaction, Brain Metastases, CVA, Infection, Alcohol, bladder distension j family members are worried more than the patient # confusion, disorientation, agitation  *Rx: ** correct the cause • agitation / hallucination: ** Haloperidol ** Chlorpromazine, Risperdal, Zyprexa **Symptomatic care

*** DROWSINESS: # Morphine, Psychotropic drugs, Hypercalcemia, Uremia, Electrolyte imbalance, Hyponatremia, Infection *Rx: ** Treat cause • pain free but drowsy: A ¤ morphine A Ritalin

*** CAUDA EQUINA SYND: # Involvement b/wL1 to the end • Lumbosacral nerves supply the lower extremities, bladder, rectum. • Interruption of S2, 3, 4 the bladder emptying reflex causes retention # bilateral Sciatica • Perianal numbness (“saddle anesthesia”), Urinary hesitancy or retention, Weak, flaccid legs • *Rx: ** Radio-therapy, ** high dose steroids ** Tricyclic ** phenothiazine ** Pain control ** Urinary Catheter

*** SPINAL CHORD COMPRESSIONS: 5% # pain, weakness / paralysis / decrease sensation / increased DTR below the compression; incontinence of bowel / bladder • W/ U: x-ray, MRI, Myelogram (if needed), CT *Rx: ** immediate *Rx within 48 hours may restore the deficit ** High dose steroids ** Radiation A decompression

*** FECAL INCONTINENCE: # weak to get the bathroom, Diarrhea, Impacted feces, Rectal carcinoma, spinal cord compression *Rx: ** treat the cause

*** TREMORS: ** Myosin ** Beta-Blockers ** Benzo: Klonopin ** Neurontin

*** MUSCULAR SPASMS:  *Rx: ** Diazepam ** Baclofen ** Physical therapy ** Replace magnesium & calcium




*** ANIMEA: • Hemoglobin < 7, or sudden blood loss # Light headedness, dizziness, palpitation, dyspnea, fatigue, generalized weakness • 1 unit of blood raises HG 1 g/dl *Benefits lasts 1-2 days • Transfuse for special occasion or good prognosis!

*** NOT RECOMMENDED: • Mixed agonist-antagonists: Pentazocine (Talwin), Butorphenol (Stadol), Nalbuphine (Nubain), Dezocine (dalgan), compete with agonists à withdrawal • Demoral: breakdown product epileptogenic

*** PRECHEMOTHERAPY TREATMENT: • Vomiting ¢ Central mechanism ** Antiemetic before chemotherapy; Zofran IV, Benadryl, Compazine ** Dexamethasone: 6-10 mg oral / parental starting before therapy then Q 6 hrs x4 ** Reglan 1-2mg / kg IM / IV / 30 minutes before & after ** combination • Reglan + Ativan + Dexamethasone **Dronabinol (tetrahydrocannabinol)

*** HIV: • > 60% experience pain • intense pain is associated with fear, anxiety, depression, poor quality of life • Neuropathy, CNS involvement • Opportunistic infection are common, treat if not terminal • Headache: Cryptococcus, Toxoplasmosis, Lymphoma • Poor Nutrition • Pain • Painful peripheral Neuropathy • Wt. Loss • Fever • Diarrhea • Dementia • Retrosternal discomfort: Esophagitis due to candida, Herpes virus, CMV, GERD • Rectal pain: Herpes until proven otherwise ** Acyclovir 200-800mg 5x/day for 5 days, remain on 200mg 3x/day • Gonorrhea and Chlamydia ** Amoxicillin 3 grams orally and Tetracycline • Herpes Zoster; Acute: ** Acyclovir 800mg 5x/day for 5 days, Tegretol, TCA • Kaposi’s (KS): ** Radiation therapy • FEVER: T cells are under 100, PCP, Mycobacterium Avium lymphoma, include Cryptococcus, CMV, Toxoplasmosis , candidiasis, KS, drug reaction to sulfa. N Octreotide (Sandostatin) in AIDS- related diarrhea 100-500mcg Sq tid • good symptom management • Total care

*** FEVER: # U.T.I, URI, infection, Dehydration, wound *Rx: ** Fluids ** Cooling: ice packs, axial, groin or cooling blanket ** Tylenol ** Aspirin ** Water Sponging **Antibiotics in appropriate patients, avoid close to death

*** HYPERCALCEMIA: > 12 mg/dl = 80% die within one year # Cancer of lung, prostate, breast, head & neck; hypernephroma # presenting S/S in MM = Multiple Myeloma, T cell Lymphoma, Hyperparathyroidism # drowsiness, Confusion, lethargy, fatigue, Polyuria, Polydipsia, anorexia, dry mouth, nausea, vomiting, severe weakness, constipation, coma, S/S resemble OD of morphine & typical worsening hospice pt., hyporeflexia,  alkaline phosphates (not in MM  multiple myeloma)  *Rx: ** increase Fluid intake, mobilize pt ** D/ C Dyazide (Thiazides) ** Decadron ** Lasix ** 1.V.F NS>3L/d ** Calcitonin: 200-400 1 U SQ q 12 hrs. ** Aredia 60 mg / 250 cc 1.V. over 4-8 hrs ** Calcitonin 200 units QD nasal spray ** Oral phosphate ** Oral steroids ** Hormone • Chronic Hypocalcaemia: ** exercise ** Ÿ fluids ** Didronel 200 –400 mg PO / day ** no vit A&D A no extra calcium ** Prednisone • Levels above 14.0 mg/dl require IV re-hydration with 2 to 3 litters normal saline per day with potassium supplements (monitor serum electrolytes) combined with Didronel (Etidronate) 7.5 mg/kg/day in 250 cc over 2 hrs for 3 days or Aredia

*** ODOR: • Wound: Yogurt, Dakin’s Solution chemical or surgical debridement • Ostomy: activated charcoal, Aspirin crushed in bag • Incontinence: *Rx appropriately • ionizer • infection: Antibiotics • Flagyl or Clindamycin • Topical: ** Bacitracin, ** Neosporin ** Bactroban • Topical Antifungal: ** Clotrimazote (Lotrimin), ** Miconazole (Monistat) • Tea Tree Oil

*** PHYSICIAN ASSISTED SUCIDE: NO-NO-NO • no right to PAS by US Supreme Court • Oregon is the only state where PAS is legal (as of 1999) • their intent is to shorten life • Hospice intends to comfort, do not shorten or prolong the inevitable in dying • don’t give license to kill to those who were trained to save & cure

*** ANTI COAGULATION: • May be ok in DVT/PE to control symptoms ** Coumadin: decrease the dose by 50% or stop • to reverse: vit K po/IM effective in 4 hrs.

*** BLEEDING: Local measure • 1:1000 adrenaline soaked dressing • Reverse Coumadin by Vit K, oral/I.M. • No blood transfusion • Heavy Sedation in terminal event • Radiation • 1% alum for hematuria / Skin Bleed / Rectal bleed • nasal pack • ICE • keep towels wet

*** CANDIDIASIS: Sore white plaques, Painful Dysphagia, # following antibiotic or steroids or radiation *Rx: ** Nystatin, ** Ketoconazole

*** TERMINAL DEHYDRATION: benefit • keeps pt dry, No IVF, comfort family, educate, chaplain, involve team

*** EXCESSIVE SWEATING: ** Prednisone 20mg/day QD or divided dosage *Anticholinergic

*** SURGICAL OPTIONS IN HOSPICE: • Paracentesis • colonic tumor resection for obstruction in appropriate • Tracheostomy • PEG tube for feeding • Colostomy • central line • Pick line • Fractures

*** STRENGTH: ** No med will restore ** vitamin may help ** blood: no help ** depressed: anti-depression




*** ANTICHOLINERGIC: Uses: £ secretions, Death Rattle, colic, bladder spasms, sleep, to produce urinary retention, to prevent EPS (extra pyramidal SE) ** Atropine ** Scopolamine ** Benadryl ** Cogentin • SE: dry mouth, confusion, agitation, ataxia, dizziness, delirium, bradycardia, photophobia, constipation, urinary retention

*** HALDOL: non-sedating anti-emetic or anxiolytic • calm a severely agitated person ** Haldol: Uses: psychosis, agitation, combative-ness, pain, nausea, intractable vomiting, pelvic-abdominal radiation induced pain & discomfort • Haldol: available in tabs / concentrated liquid/IM, absorbed sublingually, less sedative, less anticholinergic, minimal cardiac/CNS side effects, long acting

*** CONTICOSTEROID: USE: • Superior vena caval syndrome (Decadron 8mg/d) *Upper Airway obstruction • With radiation or chemo-therapy • Bowel obstruction •Carcinomatous lymphangitis • lymphadema • Malignant effusion • Hemoptysis • Discharge from a rectal tumor • Raised intra cranial pressure secondary to tumor (high dose Decadron 16mg/d) • Painful compressive Neuropathy • Bony metastases • Spinal cord compression • Hepatomegaly • vomiting due to Pyloric stenosis resistance to other meds • to improve appetite • Hypercalcemia • Excessive sweating: Prednisone up to 20mg/day in divided doses • Prednisone 7:1 ratio to Decadron (prednisone 30mg = Decadron 4mg) • If no benefit after 7-10 days, then discontinue • after prolong use decrease steroids slowly (Decadron 2mg/week) • Dysphagia (esophageal cancer) • Dyspnea  SE: • Peptic ulcer disease and hemorrhage rare • Infections • Tuberculosis: no difference in incidence • Oral candidiasis *Rx: ** nystatin, ** Mycelex ** ketoconazole: • Hyper-glycaemia • Euphoria and restlessness • manic depression • increased appetite • insomnia • psychosis: *Rx symptomatically • Avascular necrosis (femoral or humeral head) in 6 months • Adrenocortical atrophy in 16 months • gastric irritation • facial swelling • easy bruising • edema • weakness (potassium depletion, proximal sympathy) • hair growth • acne





Familiar and trade names are used · PO unless mentioned. Just the guidelines. Check before using.



  • Familiar and trade names are used · PO unless mentioned
  1. Pain


  • Ansaid: PO 50-100 mg tid (50,100)


  • Codeine: 15-60 mg q4-6h PO/SQ/IM (15, 30, 60)


  • Daypro: 600 mg 1-2 tabs/d PO


  • Dilaudid (hydromorphone) 2-4 mg q4-6h; (tab 2,4,8 mg; supp 3; solution 5mg/5ml; inj 10 mg /ml)


  • Duragesic- 1 patch q3-d (patches 25, 50, 75, 100 mcg/hr)


  • Feldene: up to 20 mg qd (10,20)


  • Fioricet (butal + Tylenol + caf 50/325/40 mg): 1-2 tabs q4h


  • Fiorinal (Butal/ aspirin/caf) 50/325/40 mg 1-2 tabs q4h


  • Indocin: 25-50 mg tid or SR: 75 mg qd/bid.


  • Lodine: 200-400 mg tid/qid (200,300,400,500,600) 1000/d


  • Lorcet (hydrocodone/Tyl 5/500): 1-2 q4-6h


  • Lortab (hydrocodone/ Tylenol) 5, 7.5, 10/ 325,500,750 =1-2 tab, or elixir 7.5/325,500/15 ml


  • Methadone (Dolophine): develop a protocal & follow PO / IM / SC q4h (tabs 5, 10, 40 mg) cumulative effect, read more before using.


  • Motrin: 200-800 mg PO qid. [200, 300, 400, 600, 800]


  • MS-contin: 15, 30, 60, 100, 120 mg q8-12hrs; morphine Elixir 10-30mgPOq4h short act (10, 20,100 mg/5ml)


  • Narcan: 0.01 mg / kg IV / IM / SC / ET; opiod antagonist, avoid in hospice, dilute the dose in 10 ml, use 1/10 of the dose & stop as soon as it is effective


  • Naproxen: 250-mg PO q4-6 hrs, 500 mg bid (250, 275, 375, 500, 550)


  • Orudis: 50-75 mg PO tid. (12. 5, 25, 50, 75) (Oruvail): 200 mg PO qd. [200]


  • Oxycodone: tab 5, 7.5, 15, 30 mg,  5-15 mg PO  q4-6 hrs PRN;  oral solution 5 mg/ 5 ml; concentrate 20mg / ml


  • Oxycontin: 1 tab PO q12h (10, 15, 20, 30, 40, 60, 80 mg)


  • Percocet (oxycodone+Tylenol):tab 2.5/325; 5/325;7.5/500;10/650 mg; 5/325mg/5 ml q6 hrs PRN


  • Percodan (oxycodone 5mg+ASA 325): 1tab PO q6h PRN


  • Pyridium: Dysuria 200 mg po tid x 2d (100,200 mg)



                                                 XIII Futile meds in hospice:

A 2010 survey of more than 10,000 physicians in the United States found respondents divided on the issue of recommending or giving “life-sustaining therapy when [they] judged that it was futile”, with 23.6% saying they would do so, 37% saying they would not, and 39.4% selecting “It depends”

Withholding or withdrawing futile meds or medical care does not speed nor encourage the onset of death.

Hippocratic oath : “under no circumstances will we prescribe a deadly drug nor give advice which may cause death”. Now I add ” do not give any futile treatments”.

FUTILE MEDS: are the meds with
No further benefits using the meds, but may prolong death / dying process,
Desired outcome can not be met,
Anything < 5 % chances of success would be futile,
Poor quality of life to continue the treatment,
No useful purpose
Medications completely ineffective
List of meds you can avoid :

1. Aspirin : risk is more than benefit.

2. Docusate (Colace): Lack of proven efficacy / risks / benefits. Side effects of it. Solution taste very bad for 2-3 hrs after ingestion.

3. Meds for Alzheimer’s: are not effective in terminal patients. Sometimes we continue the meds if they are helping with the behavior.

4. Statins: No good evidence that statins being effective in terminal patients. PROVE IT (study)– excluded patients who were likely to die within 2 years. No evidence that stopping statins in patients with chronic cardiac disease increases mortality except higher LDLs. Side effects: Myalgia, arthralgia, drug-drug interactions, GI problems, etc

5. Multi-Vitamins: are not proven to be effective. Side effects: unpleasant taste, indigestion, constipation, nausea, expense.

6. Beer’s criteria : archives of internal medicine: futile meds in nursing home population: 13 specialist, 30 criterias: sedative-hypnotics, antidepressants, antipsychotics, antihypertensives, nonsteroidal anti-inflammatory agents, oral hypoglycemics, analgesics, dementia treatments, platelet inhibitors, H2 blockers, antibiotics, decongestants, iron supplements, muscle relaxants, GI antispasmodics, and antiemetics.

7. Doctors are able to reduce unneccesory meds by 7.3 to 7.5%

8. NEW ORLEANS – Futile / duplicate medications remain a largest burden among patients at the end of life, according to a blinded, prospective cohort study of 397 consecutive hospice patients. At some point in their end of life care, 39% of patients received futile medications such as statins, and 19% received duplicate medications.

9. Vitamins and minerals including calcium, iron, and fish oil supplements made up the bulk of futile medications (67%), followed by statins (21%), and other medications (12%) including allopurinol (Zyloprim and generics), Imodium, megestrol acetate (Megace), Metamucil, epoetin alfa (Epogen), alendronate sodium (Fosamax), cholestyramine (Questran), and silodosin (Rapaflo), Mr. Munshi reported.

10. Questionable medications were anticoagulants/antiplatelets (36%), Alzheimer’s medications (18%), electrolytes (14%), appetite stimulants (9%), and other (23%) including acetaminophen, ranitidine (Zantac), methylphenidate (Ritalin), amphetamine and dextroamphetamine (Adderall), cetirizine (Zyrtec), Sudafed, etc.

11. Ventilator : can be discontinue

12. CPR: not needed

13. Food, & fluids can be stopped.

14. About 51 articles examined in detail, three studies relating to cancer have been evaluated. In these retrospective and cross-sectional studies, the incidence of PIMs (potentially inappropriate meds) was shown in approximately 20 % of patients, although the studies were inconsistent.

15. Assess the patient with emphasis on GOALS OF CARE. Balance with perspective from everybody involved including primary care, oncologist and other colleague on your team.

16, Surgical intervention in a patient who is terminal is futile.

17. Keeping a brain dead patient on ventilator is futile therapy.

18. No therapies are needed if there is no hope for cure, nor any benefit nor any hope for improvement.

19. Withholding / withdrawing futile therapies neither encourage nor speed up the natural dying process.

20. Always remember ” Do good, Do no harm

21. Percent mortality = age + burn %

**If you come across some meds you believe are futile, then do not hesitate to drop us a note.

Thanks. Kazmi, MD


XIV Last hours of live


Once transitioning process started, discuss the goals of care with family (may be patient if he is able to)
Several patho-physiological changes occur as patient is transitioning
Patient develops multiple signs & symptoms as they are getting closer to death
The S/S are devastating to patients and staff & friends & family.
Control each symptom effectively,
May require contineous care, family / friends needs access to patients 24/7
Aggressive resuscitative measure are fruitless
The degree of family distress seems to be inversely related to the extent to which advance planning & preparation occurred. Spending time in preparation of families is very worthwhile
Physicians, nurses & hospice staff need to have a clear understanding of:
signs & symptoms
pharmacological / non-pharmacological approach
changes encountered surrounding the dying process : Decreasing Appetite/Food Intake, Wasting, Decreasing Blood Perfusion, Renal Failure, Decreasing Level of Consciousness , Terminal Delirium, Loss of Ability to Swallow,Pain, declining in all aspects of life
Weakness/Fatigue : functional decline
Decreasing Fluid Intake, Dehydration
Neurological Dysfunction: An Overview
Loss of Sphincter Control
Changes in Respiration
Loss of Ability to Close Eyes
Manage other s/s
Most common S/S are: functional decline, dependent on all ADLs, anxiety, dyspnea, delirium, death rattle, nausea, worsening of discomfort / pain.

Place of death:

* 59-81% wants to die at home.

* 20% of dying patients are having rough time due to transition between hospital / home/ nursing home/ assisted living facilities.

*Recognize transitioning and help them die peacefully at home

*45% of deaths occur under hospice care in USA

* Place of death of hospice patients : at home 42%, at nursing home 18%, assisted living 7%, hospice in patient were 26%, hospital 7.4%

Weakness/Fatigue :

Increases generalized weakness, more tired, sleepy, may be confused
Falls, injuries
Consider AIDS: cane, walker, wheelchair, bedside commode etc.
Unable to move even in the bed
Pain : joints, muscles, nerves
pressure ulcer,
Trouble eating, drinking
Stop chasing fatigue (irreversible)
Consider AIDS: cane, walker, wheelchair, bedside commode etc.
Passive range of movements Q1-2 hrs
Prevent pressure ulcer : Intermittent massage before and after turning to areas of contact with bed
Do not massage: erythematous areas, skin breakdown, wounds, pressure ulcers.
Turn him from side to side Q 1 to 2 hours
Protect bony prominence with hydrocolloid dressings & special soft supports
Use a draw sheet to minimize pain & shearing forces to the skin
When turning becomes painful: use pressure-reducing surface with soft pillows, air mattress / soft bed.

Decreasing Appetite:

Almost all of them lose their appetite, decreased intake as death approaches
The causes are irreversible
Wrong: “starve to death” stop feeding is seen as “giving in” “loosing hope”
Not being hungry is normal at this stage.
Food: not appealing or may be nauseating
The patient would likely eat if he or she could
Clenching of teeth may be the only way for the patient to express desires
Parenteral or enteral feeding : no help: Multiple studies demonstrate that they do not help. (neither improves symptom control nor lengthens life nor are they beneficial)
Anorexia may be protective, as the resulting

can lead to a greater sense of well being & diminish pain

Food pushed upon the unwilling patients may be problematic (e.g., aspiration)
Help care givers to find alternate ways to provide appropriate physical care & emotional support to the patient so that they can continue to participate & feel valued during the dying process

Dehydration :

Most patients also reduce their fluid intake, or stop drinking entirely, long before death
If they are still able to drink but are not eating, salty fluids such as soups, soda water, sport drinks may maintain electrolytes, decrease nausea,
Whereas onlookers’ distress but patients are euphoric (endorphins)
This is an expected event.
Most experts feel that dehydration at this stage “does not cause distress”
Dehydration may stimulate endorphin release

that adds to the patient’s sense of well being

Hypotension / feeble pulse is part of the dying process, not an indication of dehydration
Patients who are not able to move in the bed do not get light-headed or dizzy, no orthostasis
Patients with peripheral edema or ascites have excess body water & salt and are not dehydrated
Consider sub Q or hypodermoclysis : if the goal is to reverse delirium
IV fluids : cumbersome, painful, uncomfortable, maintenance issues, changing, poor veins
Fluid overload results in peripheral or pulmonary edema, with significant hypoalbuminemia
Worsened breathlessness, cough, orotracheobronchial secretions, potential to prolong the dying process an undesirable side effect
Dehydration: Mucosal/Conjunctival Care
Even in the face of dehydration, maintain moisture in mucosal membranes with meticulous oral, nasal & conjunctival hygiene to comfort and minimize the sense of thirst
Moisten & clean oral mucosa Q 15 to 30 minutes with either baking soda mouthwash (1 teaspoon salt, 1 teaspoon baking soda, 1 quart tepid water) or an artificial saliva preparation to minimize the sense of thirst and avoid bad odors or tastes & painful cracking
Treat oral candidiasis with topical Nystatin or oral Fluconazole 200 mg then 100 mg /d for a week (if able to swallow)
Coat lips & anterior nasal mucosa hourly with a thin layer of petroleum jelly to reduce evaporation & dryness
Avoid perfumed lip balms and swabs containing lemon and glycerin, as these can be both desiccating & irritating, particularly on open sores
Eyelids open: use ophthalmic lubricating gel Q 3 to 4 hours, or artificial tears or physiological saline Q 15 to 30 minutes to avoid painful dry eyes
Decreasing Blood Perfusion, Renal Failure :

Diminished peripheral blood perfusion due to lack of intake
S/S : Tachycardia, Hypotension, Peripheral cooling, skin Mottling (livedoreticularis), Venous blood may pool along dependent skin surfaces, oliguria or Anuria
Parenteral fluids are useless: causes fluid retention, overload, congestion, increase urination

Neurological Issues surrounding terminal phase:

Nonreversible factors: Hypoxemia, Metabolic imbalance, Acidosis, accumulation of toxins due to liver and renal failure, Adverse effects of medication, Sepsis, Disease-related factors, Reduced cerebral perfusion, coma
Assume that all unconscious patient can hear everything. While we do not know what unconscious patients can actually hear, experience suggests that at times their awareness may be greater than their ability to respond
Advise caregivers to talk to the patient as if he is conscious & can understand
Include the patient in the conversations
Create an environment that is familiar & pleasant
Surround the patient with loved ones : the people, children, pets, things, music, that he would like
Encourage family to say the things they need to say
Occasionally it may seem that he may be waiting for permission to die
Ecourage caregivers to give the patient permission to “let go” & die in a manner that feels most comfortable to them
Caregivers / families verbalize “I know that you are dying, please do so when you are ready”
Do not assume patients knows the person, they need to verbalize loud enough : “I love you. I will miss you. I will never forget you. Please do what you need to do when you are ready”
If child: “Mommy and Daddy love you. We will miss you, but we will be OK”
It is ok to touch, massage & lie next to patients,

“two roads to death”

The “usual road” most common, presents with decreasing level of consciousness leading to coma and peaceful death
The “difficult road” Terminal Delirium: a few present with agitated delirium secondary to CNS excitation, irritability, agitation, delirious, with or without myoclonic jerks that leads to coma, and death. Partial or Grand Mal seizures could occur (particularly with cerebral metastases)
“usual road to death” S/S : Decreasing Level of Consciousness in majority of patients, increasing drowsiness, sleep most if not all of the time, and eventually become unarousable, Absence of eyelash reflexes on physical examination indicates a profound level of coma equivalent to full anesthesia. Finally dies peacefully.
Rx : Plan ahead to reduce family distress due to their decreasing ability to communicate, feed, feelings loosing hope, losing a loved one, most of us wants to communicate with their loved one.

Terminal Delirium:

Restlessness & delirium may be the first sign to herald the “difficult road to death“
Impaired level of consciousness, confusion, restlessness, and/or agitation, moaning, groaning, irritation, restless, appears to be suffering, with or without day-night reversal,
this can accompany the dying process
Agitated terminal delirium can be very distressing to all involved in the care
Never let terminal delirium goes misdiagnosed or improperly managed (horrible death with terrible pain & suffering)
Everybody involved worry that their own death will be the same
Rx : educate and support everybody around the patient to understand dying process
That what the patient experiences may be very different from what onlookers see
Treat underlying causes only if death is not imminent
If delirium presents and the patient is not perceived to be actively dying, it may be appropriate to evaluate and try to reverse treatable conditions
However, if the patient is close to the last hours of his life, then do comfort care only
If death is imminent, it will not be possible to reverse the underlying causes.
Focus on the management of the symptoms associated with the terminal delirium
Help the patient & family so they settle down
Check for pain, fecal impaction & urinary retention, uncomfortable position,
Medicating for Delirium

Haloperidol (0.5–2.0 mg q 1 hr prn once settled q6 hrs ) given PO, bucal, skin, rectal subcutaneously (max 30 mg/d but up to 100 mg/d have been used)
Chlorpromazine (Thorazine) (10–25 mg PO q hs to q 4-6 hrs to start and titrate), po or rectally, it is a more sedating (up to 800 mg/d)
2. Benzodiazepines are used widely as they are anxiolytics, amnestic, skeletal muscle relaxants, & antiepileptic. use in alcohol or drug withdrawal, drug induced, seizures. use cautiously

Lorazepam (Ativan) 1–2 mg as an elixir or the tablet pre dissolved in 0.5–1.0 ml of water and administered, against the buccal mucosa q 1 h prn will settle most patients with 2–10 mg/24 hours. Once settled then give q 3–4h to keep the patient settled
For a few extremely agitated patients, high doses of Lorazepam 20–50+ mg/24 hours, may be required

A Midazolam (Versed) infusion of 1–5 mg SC or IV q 1h, preceded by repeated loading boluses of 0.5 mg q 15min titerate to effect, may be a rapidly effective alternative
Neuroleptic medications may be required to control delirium for patients for whom benzodiazepines prove excitatory and not have the desired settling effect

Antiepileptics : Seizures may be managed with high doses of benzodiazepines, Diazepam 10 mg suppository prn q 4-12 hrs. Other antiepileptics such as phenytoin PR or IV, Fosphenytoin SC, or phenobarbital 60–120 mg PR, IV, or IM q 10–20min prn may become necessary until control is established

Use Opioids with Caution :

When moaning, groaning, and grimacing accompany agitation and restlessness, they are frequently misinterpreted as pain
Myth : that pain suddenly develops during the last hours of life when it has not previously been out of control
While a trial of opioids may be beneficial in the unconscious patient who is difficult to assess, physicians must remember that opioids may accumulate and add to delirium when renal clearance is poor
If the trial of increased opioids does not relieve the agitation or makes the delirium worse by increasing agitation or precipitating myoclonic jerks or seizures (rare), then pursue alternate therapies directed at suppressing the symptoms associated with the delirium

Changes in Respiration:

Changes in a dying patient’s breathing pattern may be indicative of significant neurological compromise
Breaths may become very shallow and frequent with a diminishing tidal volume
Periods of apnea and/or Cheyne-Stokes pattern respirations may develop
Accessory respiratory muscle use may become prominent
A last reflex breaths may signal death
Families and professional caregivers may frequently ask: will he be suffocated ?
The most distressing signs of impending death is that the comatose patient will experience a sense of suffocation
The unresponsive patient may not be experiencing breathlessness or “suffocating”
Oxygen may actually prolong the dying process
Rx: Low doses of opioids or benzodiazepines are appropriate to manage any perception of breathlessness

Loss of Ability to Swallow:

In the last hours of life, weakness & decreased neurological function frequently impair the patient’s ability to swallow
The reflexive clearing of the oropharynx decline & secretions from the tracheobronchial tree accumulate
These conditions may become more prominent as the patient loses consciousness
Buildup of saliva and oropharyngeal secretions may lead to gurgling, crackling or rattling sounds with each breath
Some have called this the “death rattle” (a term we want to avoid)
For unprepared families and professional caregivers, it may sound like the patient is choking
Rx: Once the patient is unable to swallow, stop all oral intake
Warn families and professional caregivers of the risk of aspiration
Reduce saliva and secretion production
Use of medications to reduce saliva: the earlier treatment is initiated, the better it works, as larger amounts of secretions in the upper aerodigestive tract are more difficult to eliminate
However, premature use in the patient who is still alert may lead to unacceptable drying of oral & pharyngeal mucosa
Recommended medications and dosages include:
Atropine: 4 drops in the beginning the 1-2 drops q1-4 hrs (cardiac / CNS excitation)
Scopolamine 0.2–0.4 mg SC q 4 h or 1–3 transdermal patches q 72h or 0.1–1.0 mg/h by continuous IV or SC infusion
Glycopyrrolate (Robinul) 0.2 mg SC q 4–6 h or 0.4–1.2 mg/day by continuous IV or SC. 1-2 mg tab q 8 hrs prn
Use repositioning to clear accumulated fluids
If excessive fluid accumulates in the back of the throat and upper airways, it may need to be cleared by repositioning the positioning or postural drainage
Turning the patient onto one side or a semiprone position may reduce gurgling
Lowering the head of the bed and raising the foot of the bed while the patient is in a semi-prone position may cause fluids to move in the oropharynx from which they can be easily removed, maintain only for few minutes at a time as stomach contents may also move unexpectedly in to oropharynx
Avoid suctioning, Oropharyngeal suctioning is not recommended
Fluids / food are ineffective, could be dangerous
Suctioning may have only undesirable effects, such as: stimulating a peaceful patient or distressing for family members who are watching

Loss of Sphincter Control:

Fatigue and loss of sphincter control in the last hours of life may lead to incontinence of urine and/or stool
Both can be very distressing to patients and family members, particularly if people are not warned in advance that
these problems may arise
Loss of Sphincter Control: Management
If incontinence occurs, attention needs to be paid to cleaning and skin care
A urinary catheter may minimize the need for frequent changing and cleaning to prevent skin breakdown
Reduce the demand on caregivers
However, catheterization is not always necessary if urine flow is minimal and can be managed with absorbent pads or surfaces
If diarrhea is considerable and relentless, a rectal tube may be similarly effective Pain: Signs and Symptoms
While many fear that pain will suddenly increase as the patient dies, there is no evidence to suggest this occurs
Though difficult to assess, continuous pain in the semiconscious or obtunded patient may be associated with:
Grimacing and continuous facial tension, particularly across the forehead and between the eyebrows
Physiologic signs, such as transitory tachycardia, that may signal distress
Do not over-diagnose pain when fleeting forehead tension comes and goes with movement or mental activity (e.g.,
dreams or hallucinations)
Do not confuse pain with the restlessness, agitation, moaning, and groaning that accompany terminal delirium
If the diagnosis is unclear, a trial of a higher dose of opioid may be necessary to judge whether pain is driving the observed behaviors


Knowledge of opioid pharmacology becomes critical during the last hours of life
The liver conjugates codeine, morphine, oxycodone, and hydromorphone into glucuronides
Some of their metabolites remain active as analgesics until they are renally cleared, particularly morphine
As dying patients experience diminished hepatic function and renal perfusion, and usually become oliguric, anuric, routine dosing or continuous infusions of morphine may lead to: Increased serum concentrations of active metabolites, Toxicity, Increased risk of terminal delirium
Discontinue routine dosing
Titrate morphine breakthrough (rescue) doses to manage expressions suggestive of continuous pain.
Consider the use of alternative opioids with inactive metabolites, Fentanyl, Hydromorphone
Morphine neurotoxicity :

Loss of Ability to Close Eyes:

Advanced wasting leads to loss of the retro-orbital fat pad, and the orbit falls posteriorly within the orbital socket
As eyelids are of insufficient length to both extend the additional distance backward and cover the conjunctiva, they may not be able to fully appose
This may leave some conjunctiva exposed even when the patient is sleeping
Eyes that remain open can be distressing to people unless the reason is understood
If conjunctiva remains exposed, maintain moisture by using ophthalmic lubricants, artificial tears, or physiological saline as previously discussed

Changes in Medication Needs :

This is it. This is terminal event. No point of return. Involve the whole team.

As patients approach the last hour of their lives, reassess the need for each medication and minimize the number of meds that the patient is taking
Use only those medications which are essential to manage symptoms such as pain, breathlessness, excess secretions, meds needed for terminal delirium & reduce the risk of seizures
Choose the least invasive route of administration: The buccal mucosa or oral routes first; then rectal ; then subcutaneous or intravenous routes only if necessary
Never use intramuscular injections



XV prognosis in End of life 

“How long, Doc?”

By Dr. Kazmi, Hospice of Havasu Medical Director



*We predict everything in life but life itself

*20 % accuracy for prognosis in terminal ill. Weather is 60%

*Foreseeing / Foretelling, eye baling, intuition, our gut feeling

* “Would you be surprised if this patient died in the next 6-12 months?”

*Terminal patients asks us “how long do I have doc or nurse?”

*Providing intensive therapies to who have poor prognosis is not beneficial to anyone

*Prognostic estimates are not guaranteed.

*Difficult to predict the future

*”how long have I got?”

  1. Clarify the question: discharge from hospital, death?
  2. Acknowledge uncertainty, patients feelings
  3. Give a general realistic time frame
  4. Recommend “doing the things that should be done.” Do not to promise that everything would be done
  5. Assure the patient that you will be there to help him go through the dying process
  6. Involve other team members “social and spiritual help”
  7. What would patient like to accomplish
  8. Encourage questions
  9. Follow-up appointment



*Poor prognosis: Pancreatic ca, biliary tract ca, untreated small cell ca, metastatic adenocarcinoma of unknown primary,

*Very poor prognosis:  cancer with multiple mets (brain, liver & lung), refractory Hypercalcemia, ongoing bleed from tumor, bone marrow failure without transfusion,

*Very poor prognosis: congestive heart failure with repeated hospital admission, progressive renal insufficiency, hemodynamic insufficiency with inotropic support

*Renal failure: discontinuation of dialysis, untreated severe hyperkalemia

*COPD: with respiratory failure

*Sepsis in frail bedridden patient

*Coma where no fluids were given: due to CVA or post-resuscitated hypoxic encephalopathy, etc.

*The single most important predictor for cancer survival is Performance Status, their activity level, energy, functional status, functional abilities,

*Ask how do you spend time? If > 50% in chair or lying down & declining: prognosis < 3 months or less

*Decrease survival is directly proportional to increasing number of symptoms, especially dyspnea in cancer patients plus 6 Ds

*Solid tumors:  loose about 70% of their functional ability in the last 3 months.

*Sudden death: final exit could happen quickly, apparently patient was doing ok

*Functional decline:

SLOW: month to month decline;

LITTLE FASTER: weekly decline;

FASTER: daily decline? Life expectancy will be in Days (depends on reversible or irreversible S/S)

*Reversible / irreversible functional decline such as minor reversible trauma

*Pain& Opioids have not be related to Length of survival

*The loss of > 20 pounds; MMSE < 24; dysphagia to solids or liquids the survival is < 4 weeks; accuracy of 74% in one small study.

*Prospective study BMJ 2011:On multivariate analysis, 11 core variables (pulse rate, general health status, mental test score, performance status, presence of anorexia, presence of any site of metastatic disease, presence of liver metastases, C reactive protein, white blood count, platelet count, and urea) independently predicted both two week and two month survival. Four variables had prognostic significance only for two week survival (dyspnea, dysphagia, bone metastases, and alanine transaminase), and eight variables had prognostic significance only for two month survival (primary breast cancer, male genital cancer, tiredness, loss of weight, low lymphocyte count, neutrophil count, alkaline phosphatase, and albumin).


*Most patients who have in hospital cardiac arrest will not survive to be discharged, but who do will have very poor over all functional status.


*Poor prognosis: irreversible diseases, malignant ascites,

*Poor prognosis in pericardial effusion with Lung cancer (20%), Lymphoma, Leukemia, Breast cancer,

*Support study: 1995 journal of AMA: many of our patients are dying with prolong inevitable dying process, alone in hospitals, with pain & suffering & unnecessary treatments.


*Actuary: using the knowledge available

*20% accuracy, 63% optimistic, 17% pessimistic; other studies suggested only 1/3 were correct in predicting, errors divided equally on either side optimistic & pessimistic

*Advance cancer: harm vs benefit

*Prognosis is a dynamic: cancer type, genetic, individual (co-morbidities, symptom, and progression, psychological)

*Communicated prognosis is more optimistic than formulated than actual

*6 +1 D for prognosis: Debility, Dyspnea, Dysphagia (anorexia / Cachexia), Delirium, Decrease weight, Dry mouth + dying

*Most important predictors are: ECOG SCORE, PPS plus clinical S/S

*OTHERS: PaP Palliative prognostic score, palliative prognostic index,


*LABS: Leukocytosis, Lympocytopenia, high CRP, high Cacium, high LDH, decrease Albumin

*Doubtful: second opinion, utilize the scales, for cancer visit university of Victoria Health Terminology Group prognostic tools,

*Communication should be tailored to the comprehension level.

*Oncologist are highly accurate in predicting cure but not the prognosis

*Prognostic errors are 60 to 70%
*Congestive heart failure visit Seattle Heart Failure Model site.
*In AIDS lower CD4 count < 200 and higher the Viral load > 100,000 have poor prognosis

*The trajectory of chronic diseases is different it fluctuates compare to cancer. And one of these exacerbations could be terminal.
*Clinical prediction for diseases other than cancer is even more difficult and less accurate.





Predictors in advance cancer (palliative care) or in irreversible disease process



Presentation scale Median survival (days)
Palliative Performance scale 10-20 7-16
30-40 8-50
50 50-90
Anorexia (Dysphagia) present < 58
Confusion (Delirium) present < 38
Dysphagia (Delirium) present < 30
Dyspnea present < 30
Dry mouth (Xerostomia) present < 50





Palliative performance scale (PPS)




Palliative performance scale (PPS) or Karnofsky scale: (memorize this: fifty sit & lie; forty is flat; thirty is unable to feed). Uses 5 domains: ambulation, activity level, self-care, intake, level of consciousness




80= normal with some disease, reduced or normal intake;


70= reduced ambulation, full self-care, unable to work; some disease;


60=reduced ambulation, able to care for most needs but occasionally require assistance;


50= sit/lie remember 50/50, needs considerable assistance, extensive disease;


40= mainly in bed but able to feed self, disable, require assistance; reduced intake;


30= unable to feed himself, totally bed bound, severely disable, extensive disease;


20=totally bed bound, very sick, extensive disease;


10=totally bed bound, total care;







FAST SCORE: functional assessment scale



  1. No difficulties.
  2. Subjective forgetfulness
  3. Difficulties at work / organizational activities
  4. Difficulties with complex tasks, instrumental ADL’s
  5. Require help with ADL’s
  6. Impaired ADL’s with incontinent.
  7. A. speech limited to 6 words (qualifies for hospice)
  8. single word
  9. unable to ambulate
  10. unable to sit
  11. unable to smile
  12. unable to hold head up.



NYHA CRITERIA (New York Heart association criteria)


  1. No limitation.
  2. Mild: Ok at rest, fatigue, palpitation, dyspnea with ordinary activity.
  3. Moderate: limited or less than ordinary activities causes: fatigue, palpitation and dyspnea.
  4. Class IV: Severe: unable to carry out any physical activities without discomfort, symptomatic cardiac insufficiency at rest,



ADL (Activities of daily living)



Decline in 2 or more ADL’s


(ABCDEF) I mnemonic for

Ambulation, Bathing, Continence, Dressing, Elevate (transfer), Feeding.


Scale is 1-4.


1 being completely dependent;


4 being independent.



MMNPE:  I made mnemonic for

Mental status; Mobility; Nutritional; Pain; Endurance.


Scale 1 to 5

5 being normal


Mental status: 1 comatose, 5 normal;

Mobility: 1 unable to turn in bed, 5 up ad lib Nutritional: 1 no fluids, 5 eats/drink normally; Pain: 1 pain 9-10, 5 pain is 0-2

Endurance: 1 needs maximum assist; 5 no assistance


ÂECOG scale: Eastern Cooperative Oncology Group 0 = normal; 5 = dead.

ÂKarnofsky score <40 or ECOG > 3: median survival is < 3 months







***The “SPIKES” for sharing prognosis with patients:

S : Setting Up: privacy, place, turn phones off, invite people whoever patient wants, sitting down with good eye contact.

P: Perception: how patient perceive what was told, past & future status.

I : Invitation / Information: How much they want to know ?, prior experiences ?. is this worse than being dead?. They do not want anybody to change their decisions.

K : Knowledge: small bits of inpatients formation, simple language, are they understanding.

E : Emotions : empathic response, acknowledge, listen, ask.

S: Strategy / Summary: summarize, plan for future visits.



My Rx


*Quality of life and prognosis should be consider in future decision making        process

*Use clinical judgment plus all the scales, the knowledge, investigations & labs we discussed (these scales are validated)

*Consider 6+1 Ds are very bad in hospice patients: Debility, Dyspnea, Dysphagia, Delirium, Dry mouth, decrease weight plus dying

*SPIKES with empathy, avoiding medical jargons

*Formulate a prognosis, then communicate softly, empathetically







  • PROGNOSIS IN COPD (summary)

FEV1 < 35% of the predicted value represents severe disease; 25% of these patients will die within two years and 55% by four years. A number of other studies have shown that age, low body mass index (BMI), and low PaO2 were independent predictors that correlated to reduced survival time. The BODE scale, consisting of BMI, exercise capacity, and subjective estimates of dyspnea, has been shown to help predict survival over 1-3 years (Celli 2004):


Variable Points on BODE Index
0 1 2 3
FEV1 (% predicted) ≥65 50-64 36-49 ≤35
Distance walked in 6 min (meters) >350 250-349 150-249 ≤149
MMRC dyspnea scale* modified medical research council dyspnea scale 0-1 = strenuous exercise 2 = walk slower due to dyspnea 3 = stop 100 yards 4 = breathless on dressing
Body-mass index (BMI) >21 ≤21


BODE Index Score One year mortality Two year mortality 52 month mortality,

4.33 YRS

           0-2 2% 6% 19%
           3-4 2% 8% 32%
           4-6 2% 14% 40%
          7-10 5% 31% 80%

*These may not predict 6 month survival

*Cor pulmonale, pO2 <55 mmHg while on oxygen, albumin < 2.5 gm/dl, weight loss of > 10%, progression of disease, and poor functional status. 50% of the patients were still alive at six months,

*Prolonged or recurrent mechanical ventilation is predictive of shorter prognosis plus BODE INDEX predict hospitalized patient’s prognosis

*COPD exacerbations depending on age, functional status, co-morbidities, and physiological variables such as hypoxia and hypercarbia. co-morbid illnesses, severity of illness (APACHE II score), low serum albumin, and/or low hemoglobin. Previous mechanical ventilation, failed extubation, or intubation for greater than 72 hours all increase mortality (Nevins 2001). Patients ventilated more than 48 hours had a 50% one year survival; functional status and severity of illness were associated with short term mortality while age and co-morbidities were associated with one year mortality (Celli 2004).


***Ref: Fast facts #141;




CHF prognosis


  • CONGESTIVE HEART FAILURE PROGNOSIS: CHF follows an unpredictable disease trajectory. The Framingham Heart Study (1990-1999) showed a 5-year mortality rate of 50% for newly identified cases, providing accurate prognostic data for 6-12 month mortality in HF has been nearly impossible due to multiple variability & reasons.
  • NYHA Classification The major gauge of disease severity. Based on data from SUPPORT, Framingham, IMPROVEMENT, and other studies, 1-year mortality estimates are as follows:
    • Class II (mild symptoms): 5-10%.
    • Class III (moderate symptoms): 10-15%.
    • Class IV (severe symptoms): 30-40%.
  • The following are independent general predictors of poor prognosis:
    • Recent cardiac hospitalization (triples 1-year mortality).
    • Elevated BUN (defined by upper limit of normal) and/or creatinine ≥1.4 mg/dl (120 μmol/l).
    • Systolic blood pressure <100 mm Hg and/or pulse >100 bpm (each doubles 1-year mortality
    • Decreased left ventricular ejection fraction (linearly correlated with survival at LVEF ≤ 45%).
    • Ventricular dysrhythmias, treatment resistant.
    • Anemia (each 1 g/dl reduction in hemoglobin is associated with a 16% increase in mortality).
    • Hyponatremia (serum sodium ≤135-137 mEq/l).
    • Reduced functional capacity.

Co-morbidities: diabetes, depression, COPD, cirrhosis, cerebrovascular disease, cancer, and HIV-associated cardiomyopathy.

  • symptoms of recurrent HF at rest (NYHA class IV)
  • optimally treated with ACE inhibitors, diuretics, and vasodilator, β-blockers, aldosterone antagonists, and device therapies.
  • ejection fraction < 20% is “helpful supplemental objective evidence,” but not required.
  • The treatment resistant ventricular or supraventricular arrhythmias, history of cardiac arrest in any setting, history of unexplained syncope, cardiogenic brain embolism, and concomitant HIV disease.
  • The web-based interactive calculator can be accessed at



Dementia prognosis

·       When caused by certain diseases or injury, dementia is irreversible, leading to progressive brain failure and death.

·       Olson (2003) classifies dementia into four functionally defined categories: mild, moderate, severe, and terminal.

·       ‘Terminal dementia’ is defined as loss of communication, ambulation, swallowing, and continence.

·       Shortened survival: male gender, older age, diabetes mellitus, CHF, COPD, cancer, cardiac dysrhythmias, peripheral edema, aspiration, bowel incontinence, recent weight loss, dehydration, fever, pressure ulcers, seizures, shortness of breath, dysphagia, low oral intake, not being awake for most of the day, low Body Mass Index, and recent need for continuous oxygen requirement.

·       Hospitalized  with acute illness and end-stage or terminal dementia have a particularly poor prognosis.

·       A study of hospitalized patients with end-stage dementia demonstrated that the six month mortality after hospitalization for pneumonia was 53% compared with 13% for cognitively intact patients. For patients with a new hip fracture, 55% of end-stage dementia patients died within 6 months compared with 12% for cognitively intact patients (Morrison 2000).

·       NHPCO guidelines state that a FAST stage 7A is appropriate for hospice enrollment, based on an expected six month or less prognosis,

·       Dementia-related co-morbidities (aspiration, upper urinary tract infection, sepsis, multiple stage 3-4 ulcers, persistent fever, weight loss >10% within six months).

o    The Mortality Risk Index (MRI), a composite score based on 12 risk factor criteria obtained from using the MDS (Minimum Data Set), has been suggested as an alternative to FAST. Mitchell (2004) developed and then validated the MRI by examining data from over 11,000 newly admitted nursing home patients. Among patients with a MRI score of ≥ 12, 70% died within 6 months (mean survival time not reported). Compared to FAST Stage 7C, the MRI had greater predictive value of six month prognosis. The MRI as only been evaluated in newly admitted nursing home residents; it has yet to be validated in the community setting or for previously established long-term nursing home residents.

o    no gold standard to help clinicians determine a less than six months prognosis with any degree of certainty. The criteria adopted by NHPCO for hospice eligibility is based on very limited research and lacks important studies to determine FAST scale reliability and validity among referring physicians and hospice staff. The MRI is a promising new scale but more research is needed. Physicians can best help their patients by working with families to help them establish goals of care and levels of medical intervention that are most consistent with current medical research and family/patient preferences.


***Functional Assessment Staging (FAST)


1.  No difficulties
2.  Subjective forgetfulness
3.  Decreased job functioning and organizational capacity
4.   Difficulty with complex tasks, instrumental ADLs
5.   Requires supervision with ADLs
6.   Impaired ADLs, with incontinence
7.  A. Ability to speak limited to six words
B. Ability to speak limited to single word
C. Loss of ambulation
D. Inability to sit
E. Inability to smile
F. Inability to hold head up


***Mortality Risk Index Score (Mitchell)

Points   Risk factor

1.9      Complete dependence with ADLs
1.9      Male gender
1.7      Cancer
1.6      Congestive heart failure
1.6       O2  therapy needed w/in 14 day
1.5      Shortness of breath
1.5      <25% of food eaten at most meals
1.5      Unstable medical condition
1.5      Bowel incontinence
1.5      Bedfast
1.4      Age > 83 y
1.4      Not awake most of the day

Risk estimate of death within 6 months

Score                               Risk %
0                                       8.9
1-2                                   10.8
3-5                                   23.2
6-8                                   40.4
9-11                                 57.0
= 12                                 70.0




Seattle Heart Failure Model :

Palliative Prognostic Index:



Fast Facts #013; #030; #124; #125; #141; #143; #150; #179; #188; #189;                    #191; #214; #234