Short notes on hospice.

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Hospice Admission Guidelines

Hospice Admission Guidelines

Hospice Admission Guidelines

Hospice care: 

 Terminal + Holistic patient centered care


💧Terminal diagnosis : primary / Hospice Dx

💧Life expectancy of six months or less;

💧Certified by 2 physicians

💧Patient must give consent (DPOA or family if patient is unable)

💧To bill for continuous care provide 8 hours a day care starting at 12 am

💧Patient can choose any physician to be his attending

💧Patient: consult another doc for secondary diagnosis (not for primary Dx : admitted with)

💧Respite care is for 5 days : should be use infrequently; Psychosocial crisis of the caregiver 

💧Worsening s/s despite the treatment💧Recurrent infections

💧Weight loss: > 10% in 6 months; 5% in 3 months ; despite food/fluid intake. Measuring weight or mid-arm circumference or abdominal girth or skin turgor or visualized, ill-fitting clothes or loose dentures or visual description of family members; decrease muscle mass.💧Ascites : weigh the patient & abdominal girth. 💧Severe edema 

💧Pain : not controlled or poorly controlled.

💧Patient / family / friends/ DPOA : all wants patient to be on hospice or comfort care.

💧Comfort care : last few days of life / towards the end of hospice. 



Core measures: 

💧General physical decline

💧PPS palliative performance scale = Karnofsky Scale < 50-60% (lower for HIV, stroke & coma)

💧FAST score for dementia worse than 7a or c & beyond

💧Decline in functional status of 3 of the 6 ADL’s: (ABCDEF) Ambulation, Bathing, Continence, Dressing, Elevate (transfer), Feeding,

💧Decline in Descriptive scale : (MMNPE) Mental status; Mobility; Nutritional; Pain; Endurance.

💧Stage 3 or 4 pressure ulcers

💧Increase ER visits / multiple hospitalizations /physician office visits

💧 Declining enteral / parenteral support

💧 Multiple co-morbities: other diseases or s/s afflicting the patient

💧 Rapid disease progression

💧 Documenting life threatening complications / emphasizing positive & negative clinical findings

💧 Worsening clinical status

💧Dyspnea at rest, increased respiratory rate, using abdominal or accessory muscles, forced vital capacity <30%, needs O2 at rest, declining artificial ventilation.

💧Intractable : cough, nausea, vomiting, diarrhea poorly responsive to treatment

💧Fluid retention: peripheral, pleural, pericardial & lymphatic spaces

💧Increased weakness

💧Systolic blood pressure < 90, or severe postural hypotension

💧Document all co-morbidities

💧Document clinical regression

💧Document declining in functional, emotional, social & ADLs

💧Changes in the level of consciousness8

💧Worsening of other symptoms : document all

💧Dysphagia: leading to recurrent aspiration &/or inadequate oral intake shown as decrease food / fluid intake 

💧Patient desire / will to die

💧Serum albumin < 2.5 gm/dl. 

💧> 3 ER / hospitalizations in the last 4-6 months

💧Labs (not essential) pCO2 or p02 or Sa02 ; high Calcium / creatinine / LFT (liver function tests); tumor markers (CEA or PSA) ; abnormal serum sodium or potassium (low or very high), Leukocytosis, Lymphocytopenia, high CRP, high LDH, low albumin, high calcium (Take an action on any tests being done).

💧Discharge or keep the patient on service:

☀️Safe discharge : should be discharged as soon as the team determines that they are not eligible & improved & stabilized then give 2 days of advance notice provided they are safe 

💥Keep: Patients originally qualify for hospice but stabilize & improve while under hospice care, yet have a reasonable expectation of continue decline with life expectancy of < 6 months remain eligible for hospice





💧FAST SCORE 🔺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) B. single word C. unable to ambulate D. unable to sit E. unable to smile F. 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: limitated activities, less than ordinary activities causes: fatigue, palpitation, dyspnea. 

❤️❤️❤️❤️4. Class IV : Severe: unable to carry out any physical activities without discomfort, symptomatic cardiac insufficiency at rest,







PPS

Palliative performance scale (PPS)

Karnofsky scale

50% =50% sit & 50% lie

40%=forty is flat; but able to feed

30% = unable to feed

100=normal;

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 : 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;

0=dead





ADL ( Activities of daily living)

Activities of daily living decline in 2 or more ADL’s

My mnemonic for (ABCDEF) Ambulation, Bathing, Continence, Dressing, Elevate (transfer),Feeding.

Scale is 1 to 4.

1 being completely dependent; 4 being independent.





DESCRIPTIVE SCALED 

My nemonic is : MMNPE :

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





Malignancy (cancer)

💧Diagnosis confirmed with pathology / radiology 

💧Pancreatic cancer, diffuse small cell cancer of lung, some CNS Tumors have poor prognosis 

💧Patient no longer receiving &/or declining curative or life prolonging therapies; 

💧Continued decline in spite of therapy progression of the disease with metastasis, 

💧Palliative performance scale < 70%

💧ADL 18 or less, dependent on 3 out of 6 ADL’s

💧Descriptive 25 or less 

💧Hypercalcemia > 12 

💧Weight loss10% in 6 months; 5% in 3 months; 

💧S/S of advanced disease: intractable nausea / vomiting, ascites, effusion, multiple transfusion, malignant ascites individually evaluate the patients for palliative chemo / radiation therapies, if team agrees, go for it. 

ECOG

ECOG scale: Eastern Cooperative Oncology Group

0 = normal; 5 = dead.

0 = Normal

1 = Able to do light work

2. Ambulatory, self care, up > 50% of time

3. Limited self care, 50% confined to bed /chair

4. Totally confined to bed /chair

5.  Dead

Renal  diseases

💧Discontinuing or refusing dialysis & / or transplant. 

💧Signs of uremia (confusion, nausea, pruritus, and restlessness) 

💧Chronic or acute illness that precipitated renal failure 

💧Creatinine > 8 mg/dl (> 6 mg/dl in diabetes) 

💧Creatinine clearance < 10 cc / min (< 15 cc/ min in diabetes) 

💧Oliguria < 400 cc/ 24 hrs 

💧Hyperkalemia > 7.0

💧Others: Uremia; Uremic pericarditis; 

💧Fluid overload 

💧Karnofsky < 60%; 

💧ADL < 18. 

💧Descriptive < 20, 

💧Other co-morbidies

Cardiac  disorder

💧CHF with NYHA IV. 

💧Significant S/S at rest 

💧Dyspnea & angina with minimal physical activity, or at rest. 

💧Optimally treated with the Diuretics, ACEI, Vasodilators, Hydralazine, Nitrates. 

💧Not a candidate or declined curative / invasive /surgical therapies.

💧Declining despite maximal medical management. 

💧Arrhythmia's resistant to treatment. 

💧Ejection fractions EF < 20%. 

💧H/o cardiac related / unexplained syncope, cerebrovascular accident due to cardiac embolism. 

💧S/P cardiac resuscitation. 

💧PPS < 60%; 

💧ADL < 18 ; 

💧Descriptive < 20

Respiratory / Pulmonary 

COPD

💧Disabling dyspnea at rest or with minimal activities, 

💧little or no response to bronchodilators, 

💧Decrease functional capacity. 

💧O2 dependent; 

💧Hypoxemia at rest on room air, 

💧O-2 sat < 88% ,

💧pO-2 < 55 mm, 

💧FEV1 < 30% with bronchodilators; 

💧Multiple pulmonary medications; 

💧Recurrent pulmonary infections;

💧unintentional progressive Weight loss >10% in the last 6 month;

💧Resting tachycardia >100/min; 

💧Bed or chair bound, 

💧Fatigue, cough, 

💧Increasing ER, Office, hospital visits 

💧Pulmonary infections or respiratory failure 

💧Karnofsky < 60%; ADL <18; Descriptive <20. 

💧Cor pulmonale, right heart failure

Neurological disorders

💧Unable to walk, talk & eat.

💧Unable to walk without assistance; Needs assistance with ADLs,

💧Barely intelligible speech

💧Dysphagia nutritional status down General decline *Disease progression

💧Emphasis on core indicators

💧declines assisted ventilation complications: pneumonia, UTI, sepsis, and decubiti

Alzheimer’s disease (Dementia)

💧Alzheimer’s or related

💧Fast scale 7a 7c or beyond

💧Unable to walk without assistance

💧Urinary and bowel incontinent

💧Insufficient fluid/food intake with weight loss,

💧Albumin < 2.5 gm/dl

💧Speech less than 6 words

💧In the last 12 months aspiration; recurrent infections / fever; decubiti stage 3-4; sepsis; UTIs

CVA     (Crebrovascular  Examination)

💧Chair or bed-bound 

💧Large CVA: large anterior or bihemispheric infarct.

💧Basilar artery or bilateral vertebral arterial occlusion 

💧Dysphagia Decreased appetite,food/fluid intake, > 10% wt. loss in 6 months or > 5 % in 3 months,

💧Serum albumin < 2.5 gm./dl

💧Age >70. Aspiration: failed speech / other therapies 

💧Post-stroke dementia poor functional status; PPS < 40%, ADL 18 or less; Descriptive 20 or less

💧Complications: pneumonia, UTI, sepsis, and decubiti 

💧Non- traumatic hemorrhage > 20 ml infratentorial; > 50 ml suprtentorial; or intraventicular extension

💧Midline shift > 1.5 cm 

💧Stroke involving > 30% of cerebrum

💧Decline surgical intervention / curative therapies (or not a candidate)g

COMA

💧Comatose for > 3 days

💧Negative drugs screen, 

💧Abnormal brain stem response, 

💧Absent verbal response, 

💧Absent withdrawal response to pain, 

💧Serum creatinine > 1.5 gm. /dl progressively declined in the last year

💧PPS < 60%; ADL 18 or less; 

💧Descriptive 20 or less

💧Plus other core measures



HIV

💧CD 4 < 25/ ml Viral load > 100,000 /ml 

💧Wasting syndrome ( loss of > 33% lean body mass or 10% weight loss 

💧Chronic persistence diarrhea for > 1 year 

💧Not receiving TPN 

💧Reccurent opportunistic infections 

💧Patient not receiving active treatment AIDS 

💧Age> 50 years 

💧Renal failure not on hemodialysis 

💧PPS of < 60%; 

💧ADL of 18 or less; 

💧Descriptive score of 20 or less 

Hospice Admission Guidelines

 

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Hospice Admission Guidelines

Hospice

Hospice care:  

Terminal + Holistic  

patient centered care

💧Terminal diagnosis : primary / Hospice Dx

💧Life expectancy of six months or less;

💧Certified by 2 physicians

💧Patient must give consent (DPOA or family if patient is unable)

💧To bill for continuous care provide 8 hours a day care starting at 12 am

💧Patient can choose any physician to be his attending

💧Patient: consult another doc for secondary diagnosis (not for primary Dx : admitted with)

💧Respite care is for 5 days : should be use infrequently; Psychosocial crisis of the caregiver 

💧Worsening s/s despite the treatment💧Recurrent infections

💧Weight loss: > 10% in 6 months; 5% in 3 months ; despite food/fluid intake. Measuring weight or mid-arm circumference or abdominal girth or skin turgor or visualized, ill-fitting clothes or loose dentures or visual description of family members; decrease muscle mass.💧Ascites : weigh the patient & abdominal girth. 💧Severe edema 

💧Pain : not controlled or poorly controlled.

💧Patient / family / friends/ DPOA : all wants patient to be on hospice or comfort care.

💧Comfort care : last few days of life / towards the end of hospice. 

Core measures: 

💧General physical decline

💧PPS palliative performance scale = Karnofsky Scale < 50-60% (lower for HIV, stroke & coma)

💧FAST score for dementia worse than 7a or c & beyond

💧Decline in functional status of 3 of the 6 ADL’s: (ABCDEF) Ambulation, Bathing, Continence, Dressing, Elevate (transfer), Feeding,

💧Decline in Descriptive scale : (MMNPE) Mental status; Mobility; Nutritional; Pain; Endurance.

💧Stage 3 or 4 pressure ulcers

💧Increase ER visits / multiple hospitalizations /physician office visits

💧 Declining enteral / parenteral support

💧 Multiple co-morbities: other diseases or s/s afflicting the patient

💧 Rapid disease progression

💧 Documenting life threatening complications / emphasizing positive & negative clinical findings

💧 Worsening clinical status

💧Dyspnea at rest, increased respiratory rate, using abdominal or accessory muscles, forced vital capacity <30%, needs O2 at rest, declining artificial ventilation.

💧Intractable : cough, nausea, vomiting, diarrhea poorly responsive to treatment

💧Fluid retention: peripheral, pleural, pericardial & lymphatic spaces

💧Increased weakness

💧Systolic blood pressure < 90, or severe postural hypotension

💧Document all co-morbidities

💧Document clinical regression

💧Document declining in functional, emotional, social & ADLs

💧Changes in the level of consciousness8

💧Worsening of other symptoms : document all

💧Dysphagia: leading to recurrent aspiration &/or inadequate oral intake shown as decrease food / fluid intake 

💧Patient desire / will to die

💧Serum albumin < 2.5 gm/dl. 

💧> 3 ER / hospitalizations in the last 4-6 months

💧Labs (not essential) pCO2 or p02 or Sa02 ; high Calcium / creatinine / LFT (liver function tests); tumor markers (CEA or PSA) ; abnormal serum sodium or potassium (low or very high), Leukocytosis, Lymphocytopenia, high CRP, high LDH, low albumin, high calcium (Take an action on any tests being done).

💧Discharge or keep the patient on service:

☀️Safe discharge : should be discharged as soon as the team determines that they are not eligible & improved & stabilized then give 2 days of advance notice provided they are safe 

💥Keep: Patients originally qualify for hospice but stabilize & improve while under hospice care, yet have a reasonable expectation of continue decline with life expectancy of < 6 months remain eligible for hospice




💧FAST SCORE 🔺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) B. single word C. unable to ambulate D. unable to sit E. unable to smile F. 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: limitated activities, less than ordinary activities causes: fatigue, palpitation, dyspnea. 

❤️❤️❤️❤️4. Class IV : Severe: unable to carry out any physical activities without discomfort, symptomatic cardiac insufficiency at rest,






PPS

Palliative performance scale (PPS)

Karnofsky scale

50% =50% sit & 50% lie

40%=forty is flat; but able to feed

30% = unable to feed

100=normal;

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 : 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;

0=dead

ADL ( Activities of daily living)

Activities of daily living decline in 2 or more ADL’s

My mnemonic for (ABCDEF) Ambulation, Bathing, Continence, Dressing, Elevate (transfer),Feeding.

Scale is 1 to 4.

1 being completely dependent; 4 being independent.

DESCRIPTIVE SCALED 

My nemonic is : MMNPE :

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






Malignancy (cancer)

💧Diagnosis confirmed with pathology / radiology 

💧Pancreatic cancer, diffuse small cell cancer of lung, some CNS Tumors have poor prognosis 

💧Patient no longer receiving &/or declining curative or life prolonging therapies; 

💧Continued decline in spite of therapy progression of the disease with metastasis, 

💧Palliative performance scale < 70%

💧ADL 18 or less, dependent on 3 out of 6 ADL’s

💧Descriptive 25 or less 

💧Hypercalcemia > 12 

💧Weight loss10% in 6 months; 5% in 3 months; 

💧S/S of advanced disease: intractable nausea / vomiting, ascites, effusion, multiple transfusion, malignant ascites individually evaluate the patients for palliative chemo / radiation therapies, if team agrees, go for it. 




ECOG

ECOG scale: Eastern Cooperative Oncology Group

0 = normal; 5 = dead.

0 = Normal

1 = Able to do light work

2. Ambulatory, self care, up > 50% of time

3. Limited self care, 50% confined to bed /chair

4. Totally confined to bed /chair

5.  Dead



Renal  diseases

💧Discontinuing or refusing dialysis & / or transplant. 

💧Signs of uremia (confusion, nausea, pruritus, and restlessness) 

💧Chronic or acute illness that precipitated renal failure 

💧Creatinine > 8 mg/dl (> 6 mg/dl in diabetes) 

💧Creatinine clearance < 10 cc / min (< 15 cc/ min in diabetes) 

💧Oliguria < 400 cc/ 24 hrs 

💧Hyperkalemia > 7.0

💧Others: Uremia; Uremic pericarditis; 

💧Fluid overload 

💧Karnofsky < 60%; 

💧ADL < 18. 

💧Descriptive < 20, 

💧Other co-morbidies




Cardiac  disorder

💧CHF with NYHA IV. 

💧Significant S/S at rest 

💧Dyspnea & angina with minimal physical activity, or at rest. 

💧Optimally treated with the Diuretics, ACEI, Vasodilators, Hydralazine, Nitrates. 

💧Not a candidate or declined curative / invasive /surgical therapies.

💧Declining despite maximal medical management. 

💧Arrhythmia's resistant to treatment. 

💧Ejection fractions EF < 20%. 

💧H/o cardiac related / unexplained syncope, cerebrovascular accident due to cardiac embolism. 

💧S/P cardiac resuscitation. 

💧PPS < 60%; 

💧ADL < 18 ; 

💧Descriptive < 20




Respiratory / Pulmonary 

COPD

💧Disabling dyspnea at rest or with minimal activities, 

💧little or no response to bronchodilators, 

💧Decrease functional capacity. 

💧O2 dependent; 

💧Hypoxemia at rest on room air, 

💧O-2 sat < 88% ,

💧pO-2 < 55 mm, 

💧FEV1 < 30% with bronchodilators; 

💧Multiple pulmonary medications; 

💧Recurrent pulmonary infections;

💧unintentional progressive Weight loss >10% in the last 6 month;

💧Resting tachycardia >100/min; 

💧Bed or chair bound, 

💧Fatigue, cough, 

💧Increasing ER, Office, hospital visits 

💧Pulmonary infections or respiratory failure 

💧Karnofsky < 60%; ADL <18; Descriptive <20. 

💧Cor pulmonale, right heart failure






Neurological disorders

💧Unable to walk, talk & eat.

💧Unable to walk without assistance; Needs assistance with ADLs,

💧Barely intelligible speech

💧Dysphagia nutritional status down General decline *Disease progression

💧Emphasis on core indicators

💧declines assisted ventilation complications: pneumonia, UTI, sepsis, and decubiti




Alzheimer’s disease (Dementia)

💧Alzheimer’s or related

💧Fast scale 7a 7c or beyond

💧Unable to walk without assistance

💧Urinary and bowel incontinent

💧Insufficient fluid/food intake with weight loss,

💧Albumin < 2.5 gm/dl

💧Speech less than 6 words

💧In the last 12 months aspiration; recurrent infections / fever; decubiti stage 3-4; sepsis; UTIs





CVA     (Crebrovascular  Examination)

💧Chair or bed-bound 

💧Large CVA: large anterior or bihemispheric infarct.

💧Basilar artery or bilateral vertebral arterial occlusion 

💧Dysphagia Decreased appetite,food/fluid intake, > 10% wt. loss in 6 months or > 5 % in 3 months,

💧Serum albumin < 2.5 gm./dl

💧Age >70. Aspiration: failed speech / other therapies 

💧Post-stroke dementia poor functional status; PPS < 40%, ADL 18 or less; Descriptive 20 or less

💧Complications: pneumonia, UTI, sepsis, and decubiti 

💧Non- traumatic hemorrhage > 20 ml infratentorial; > 50 ml suprtentorial; or intraventicular extension

💧Midline shift > 1.5 cm 

💧Stroke involving > 30% of cerebrum

💧Decline surgical intervention / curative therapies (or not a candidate)g






COMA


💧Comatose for > 3 days

💧Negative drugs screen, 

💧Abnormal brain stem response, 

💧Absent verbal response, 

💧Absent withdrawal response to pain, 

💧Serum creatinine > 1.5 gm. /dl progressively declined in the last year

💧PPS < 60%; ADL 18 or less; 

💧Descriptive 20 or less

💧Plus other core measures




HIV

💧CD 4 < 25/ ml Viral load > 100,000 /ml 

💧Wasting syndrome ( loss of > 33% lean body mass or 10% weight loss 

💧Chronic persistence diarrhea for > 1 year 

💧Not receiving TPN 

💧Reccurent opportunistic infections 

💧Patient not receiving active treatment AIDS 

💧Age> 50 years 

💧Renal failure not on hemodialysis 

💧PPS of < 60%; 

💧ADL of 18 or less; 

💧Descriptive score of 20 or less





Files coming soon.

Hospice Admission Guidelines

Hospice


Hospice care:  

Terminal + Holistic  

patient centered care

💧Terminal diagnosis : primary / Hospice Dx

💧Life expectancy of six months or less;

💧Certified by 2 physicians

💧Patient must give consent (DPOA or family if patient is unable)

💧To bill for continuous care provide 8 hours a day care starting at 12 am

💧Patient can choose any physician to be his attending

💧Patient: consult another doc for secondary diagnosis (not for primary Dx : admitted with)

💧Respite care is for 5 days : should be use infrequently; Psychosocial crisis of the caregiver 

💧Worsening s/s despite the treatment💧Recurrent infections

💧Weight loss: > 10% in 6 months; 5% in 3 months ; despite food/fluid intake. Measuring weight or mid-arm circumference or abdominal girth or skin turgor or visualized, ill-fitting clothes or loose dentures or visual description of family members; decrease muscle mass.💧Ascites : weigh the patient & abdominal girth. 💧Severe edema 

💧Pain : not controlled or poorly controlled.

💧Patient / family / friends/ DPOA : all wants patient to be on hospice or comfort care.

💧Comfort care : last few days of life / towards the end of hospice. 




Core measures: 


💧General physical decline

💧PPS palliative performance scale = Karnofsky Scale < 50-60% (lower for HIV, stroke & coma)

💧FAST score for dementia worse than 7a or c & beyond

💧Decline in functional status of 3 of the 6 ADL’s: (ABCDEF) Ambulation, Bathing, Continence, Dressing, Elevate (transfer), Feeding,

💧Decline in Descriptive scale : (MMNPE) Mental status; Mobility; Nutritional; Pain; Endurance.

💧Stage 3 or 4 pressure ulcers

💧Increase ER visits / multiple hospitalizations /physician office visits

💧 Declining enteral / parenteral support

💧 Multiple co-morbities: other diseases or s/s afflicting the patient

💧 Rapid disease progression

💧 Documenting life threatening complications / emphasizing positive & negative clinical findings

💧 Worsening clinical status

💧Dyspnea at rest, increased respiratory rate, using abdominal or accessory muscles, forced vital capacity <30%, needs O2 at rest, declining artificial ventilation.

💧Intractable : cough, nausea, vomiting, diarrhea poorly responsive to treatment

💧Fluid retention: peripheral, pleural, pericardial & lymphatic spaces

💧Increased weakness

💧Systolic blood pressure < 90, or severe postural hypotension

💧Document all co-morbidities

💧Document clinical regression

💧Document declining in functional, emotional, social & ADLs

💧Changes in the level of consciousness8

💧Worsening of other symptoms : document all

💧Dysphagia: leading to recurrent aspiration &/or inadequate oral intake shown as decrease food / fluid intake 

💧Patient desire / will to die

💧Serum albumin < 2.5 gm/dl. 

💧> 3 ER / hospitalizations in the last 4-6 months

💧Labs (not essential) pCO2 or p02 or Sa02 ; high Calcium / creatinine / LFT (liver function tests); tumor markers (CEA or PSA) ; abnormal serum sodium or potassium (low or very high), Leukocytosis, Lymphocytopenia, high CRP, high LDH, low albumin, high calcium (Take an action on any tests being done).

💧Discharge or keep the patient on service:

☀️Safe discharge : should be discharged as soon as the team determines that they are not eligible & improved & stabilized then give 2 days of advance notice provided they are safe 

💥Keep: Patients originally qualify for hospice but stabilize & improve while under hospice care, yet have a reasonable expectation of continue decline with life expectancy of < 6 months remain eligible for hospice

💧FAST SCORE 🔺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) B. single word C. unable to ambulate D. unable to sit E. unable to smile F. 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: limitated activities, less than ordinary activities causes: fatigue, palpitation, dyspnea. 

❤️❤️❤️❤️4. Class IV : Severe: unable to carry out any physical activities without discomfort, symptomatic cardiac insufficiency at rest,




PPS

Palliative performance scale (PPS)

Karnofsky scale

50% =50% sit & 50% lie

40%=forty is flat; but able to feed

30% = unable to feed

100=normal;

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 : 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;

0=dead




ADL ( Activities of daily living)


Activities of daily living decline in 2 or more ADL’s

My mnemonic for (ABCDEF) Ambulation, Bathing, Continence, Dressing, Elevate (transfer),Feeding.

Scale is 1 to 4.

1 being completely dependent; 4 being independent.




DESCRIPTIVE SCALED 


My nemonic is : MMNPE :

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






Malignancy (cancer)


💧Diagnosis confirmed with pathology / radiology 

💧Pancreatic cancer, diffuse small cell cancer of lung, some CNS Tumors have poor prognosis 

💧Patient no longer receiving &/or declining curative or life prolonging therapies; 

💧Continued decline in spite of therapy progression of the disease with metastasis, 

💧Palliative performance scale < 70%

💧ADL 18 or less, dependent on 3 out of 6 ADL’s

💧Descriptive 25 or less 

💧Hypercalcemia > 12 

💧Weight loss10% in 6 months; 5% in 3 months; 

💧S/S of advanced disease: intractable nausea / vomiting, ascites, effusion, multiple transfusion, malignant ascites individually evaluate the patients for palliative chemo / radiation therapies, if team agrees, go for it. 





ECOG

ECOG scale: Eastern Cooperative Oncology Group


0 = normal; 5 = dead.


0 = Normal

1 = Able to do light work

2. Ambulatory, self care, up > 50% of time

3. Limited self care, 50% confined to bed /chair

4. Totally confined to bed /chair

5.  Dead





Renal  diseases

💧Discontinuing or refusing dialysis & / or transplant. 

💧Signs of uremia (confusion, nausea, pruritus, and restlessness) 

💧Chronic or acute illness that precipitated renal failure 

💧Creatinine > 8 mg/dl (> 6 mg/dl in diabetes) 

💧Creatinine clearance < 10 cc / min (< 15 cc/ min in diabetes) 

💧Oliguria < 400 cc/ 24 hrs 

💧Hyperkalemia > 7.0

💧Others: Uremia; Uremic pericarditis; 

💧Fluid overload 

💧Karnofsky < 60%; 

💧ADL < 18. 

💧Descriptive < 20, 

💧Other co-morbidies





Cardiac  disorder

💧CHF with NYHA IV. 

💧Significant S/S at rest 

💧Dyspnea & angina with minimal physical activity, or at rest. 

💧Optimally treated with the Diuretics, ACEI, Vasodilators, Hydralazine, Nitrates. 

💧Not a candidate or declined curative / invasive /surgical therapies.

💧Declining despite maximal medical management. 

💧Arrhythmia's resistant to treatment. 

💧Ejection fractions EF < 20%. 

💧H/o cardiac related / unexplained syncope, cerebrovascular accident due to cardiac embolism. 

💧S/P cardiac resuscitation. 

💧PPS < 60%; 

💧ADL < 18 ; 

💧Descriptive < 20











What is Hospice

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. For the best 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 with other colleague as needed, plan in advance. Deliver the best treatment plan for terminal patients. Palliative rather than curative treatment. Quality rather than quantity of life. Dying are comforted here. Symptoms relief is provided. Discuss prognosis/ issues surrounding death & dying. Give anticipatory guidance.

Offer realistic goals. Give honest assessments. Discuss choices of care early on. Family to take part in the care of the person.

Affirm life & regard dying as a normal life process with respect and dignity. Personalized services. All need compassionate, respectful Rx even if their life style was not conventional.

Hospice 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." In hospice we use team work 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. They asses the pain / other S/S & provide prompt treatment. Respect the dying.

Prepare patient & family / friends for the terminal event. Speak to the patient directly. Be courteous. Good symptom management. Routine vital signs not required. Brief history & physical examination are required. Get records from all the sources and treating facilities which include pathology, labs, procedures & biopsy results, consultation, prior history & physical, medication list etc. 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. The 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. The provide Inpatient and Outpatient care. Provide prescription drugs related to admitting diagnosis.

They provide Medical equipment & supplies. Ambulance services, Physician services , Chaplaincy services , Volunteer support , Bereavement counseling & group therapy. Respite care is provided on as needed basis. Closure letter are sent after the patient passed on. Counseling services for all involve. Nurses and all of the staff can visit the patient at home. The patient is independent & able to go out of the house, not when they are with home health. Nurses provide in home care around the clock for a medical crisis instead of going to hospital. Family bereavement care is available. The patient will be 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 for other issues not related to primary diagnosis. The primary diagnosis is the one they are admitted with.

ELIGIBILITY: Needs a Terminal diagnosis. Diagnosis by 2 physician that the patient has a limited life expectancy (<6 months; testified by 2 physicians ). Patient, family, attending physician, and Hospice team consent to the service. The patients requires terminal care. They decided against any curative therapies.

DYING: Dying is a unique experience which needs respect, comfort, caring and easy transition. It is not a disease. The patient should be the center of attention and concern. Please follow patients' preferences. Do not impose your values. The realistic treatment is the best symptom control. health and medical hospice admission guidelines

Files coming soon.

Pain Management

PAIN: It is a subjective unpleasant physical & emotional experience. “Pain” what patient says "hurts" in hospice. Believe the patient. Pain is not: due to old age, a last ditch, wrath of God. The 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! The pain is often under treated, > 90% of pain in hospice can be controlled. There is 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. The 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 in the past. Frequently evaluate & re-evaluate the pain.

Treatment: start low, go slow but keep going up till you achieve patient’s goals. Please do not wait for testing, investigations and records to be collected, start the treatment asap. 50 million people in US have chronic pain. Pain: 70-78% in cancer and MS; 30-79% in AIDS. It cost 100 billion / year. The pain is fifth vital sign. The 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: The nociceptive pain: can be somatic / visceral, can be controlled by NSAID's; steroids. The visceral pain: involves the viscera, cramp, pressure, due to lung cancer, gallbladder, bowel obstruction. The somatic pain: due to soma, localized, trauma, tissue damage, burn, metastasis. It is throbbing, aching, gnawing. The Neuropathic pain: due to nerve involvement and it is sharp, shooting, lancinating, burning. It requires TCA’s; anticonvulsants.

Pain increased by: Pain is caused by disease process but increases due to fear, fatigue, frustration, untreated depression; unresolved spiritual, mental, physical and social issues or may be due to disease progression.

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 meds, Adjuvant medications, etc.

Pain can / should be controlled. The escalating / acutely increasing pain is an emergency. The 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.

The pain could be due to: disease +/- physical, mental, emotional & spiritual problems. Believe pain reported by patient or care givers.

The pain scale: 0-10; 0= no pain; 10 is maximum; target to bring pain down to < 4. Please review the medications with each visit. Asses the total patient. Total Pain : physical, emotional, spiritual, mental, social etc etc. Always 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 (nursing) 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 them as needed,

  1. % of total dose; to start oral q 1-2 hrs then change to q 4 hrs; never longer than q 4 hrs.

SQ / IV PRN is q 30-60 minutes, later on change to q 4 hrs as needed.

Adjust the baseline meds daily up in the amount equivalent to daily PRN, except Methadone. The oral route better than SQ better than IV. Renal failure, liver problems, elderly and start low and go slow. Opioids are renally excreted except Methadone. The treatment: start low, go slow, and keep going up till goals are met and pain is under control. We prefer PO,

For constant pain give meds routinely and cover with prn for breakthrough 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.

Severe pain: Oxycodone, Morphine, Methadone, Dilaudid, 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, Lyrica, Calcitonin, Capsaicin, Baclofen, Clonidine, Dextro-methorphan, Neuroleptics, Bisphosphonates (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. 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 or diminish potency.

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 / liver 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.

OPIOID ANALGESICS:

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. The good dose is the one which keeps patient alert but pain free. Opioids have no ceiling dose of effectiveness. Anticipate constipation & treat effectively. Treat nausea: Reglan, Haldol, Scopolamine. The tolerance & addiction is rare. Morphine does not shorten life.

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

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

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

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

Duragesic (fentanyl) are available in patch or lollipop, nasal spray plus injectable.

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. The most commonly used in hospice. Poor pain control: increased MS by 50% & add TCA or adjuvant meds (may enhance MS effect). If the patient is still in pain: Re-evaluate, consider: Neuropathic pain, neuralgia, infection, muscle spasm, bony pain, vascular disorders, Stress, depression. Still no help: consider 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. For nausea: Antiemetic: Compazine, Haldol.

For Constipation: Docusate; Senakot; Pericolace, Enema. Narcotic excess: miosis, sedation, hypo-ventilation severe respiratory depression if < 8 / minute. For prolong confusion: lower the dose by 50% or more.

Morphine-intolerance change to Dilaudid.

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

If opioids are used in appropriate patients, Morphine/ opioids does not cause addiction, or tolerance.

When patient is on higher dosage the increments should be larger for prn dose.

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.

About > 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, you do not have much time and addiction is not a problem but start low and go slow till you achieve the desired effects.

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

Methadone:

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

Mechanism of action: 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 by doctors.

QT interval prolongation A potent opioid agonist is useful when continuous opioid analgesia is needed.

Special license is required to prescribe methadone for the treatment of addiction.

Methadone is 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. The half-life is about 190 hrs. The pain relief lasts for 6-12 hrs, once steady state is reached. The rapid dose adjustment could be dangerous

Morphine to Methadone conversion:

< 90 mg/ d morphine = 4:1 90-300 mg / d morphine= 8:1

> 300 mg/ d morphine to 800 = 12 :1

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 - 7 days.

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

Education is important because patients and the family may think that the physician is considering the Methadone because the patient had addiction problem. As you know Methadone is  used in addiction

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

Visceral pain: pain in the viscera. Cramping.

Somatic pain: due to soma, body part injury. Gnawing, aching type.

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. Bisphosphonates. 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. 


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. It is 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: In cord compression,pathological fracture, WBC < 3, platelets < 60-100 K.

Pointers:

Naloxone: only to be used in dire emergency in hospice: dilute

  1. mg with 9 ml NS, give -2 ml q 15 minutes until effective; repeat 30-60 min

Morphine gel & Morphine mouthwash are both in effective.

Pseudo addiction: 1989, due to poorly treated pain. Improves with adequate adjustment of medications. aggressive dose escalation, establish trust & confidence.

Addiction: (psychological dependency) Patients lie 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 of your colleague 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. SQ / 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 so needs continuous treatment.

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 removing the patch may not stop the absorption of Fentanyl.

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

Anticipate, Prevent, & Manage effects & side effects of medications.

Constipation: Anticipate and manage constipation, as the patients never gets use to it. It will never reverse itself unless being treated. A physician who writes an opioid prescription must right medications for 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.

Common Opioids Used to Palliate Pain in Terminally Patients: Generic names Brand name

Hydrocodone Vicodin

Morphine MS contin,

Oxycodone Roxanol, Oxy-contin

Hydromorphone. Dilaudid

Fentanyl Duragesic

Methadone Dolophine

My formula to calculate the Opioid dose is:

N

X = ............................ multiply by OD 24 hrs dose of old med O

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 current drug po (old drug patient was using). Convert old meds to total oral dose.

  1. Calculate total daily dose of long + short acting  meds.
  2. Put the numbers in the formula.
  3. Convert where X = total daily dose of new medicine.

After conversion:

It's a starting point, from there a diligent titration is required. After the calculation: 25% to 50% reduction for incomplete tolerance.

More reduction up to 50-75% reduction in higher dose conversion with Methadone & Fentanyl.

FENTANYL conversion: be careful using Fentanyl, use lower round number. Pick lower dosage when converting from higher doses of morphine. Takes 13-24 hrs to achieve therapeutic level after the first dose. Apply the patch concurrently with last dose of morphine. Parenteral Fentanyl is about 100 times more potent than oral Morphine.


METHADONE dose calculation  &  conversion: The long half-life can lead to drug accumulation, sedation, confusion, and respiratory depression, especially in the elderly & terminal patients. It could happen with rapid dose escalation. Methadone in moderate to high dosages can prolong the QTc interval > 500 milliseconds = high risk, consideration should be given to lowering the methadone dosage or rotating to an alternate opioid. Meds decrease methadone levels: rifampin, phenytoin, corticosteroids, carbamazepine, Phenobarbital, St. John’s Wort, and a number of antiretroviral agents. Meds increases methadone level: tricyclic antidepressants, antifungals (conazoles), macrolides, fluoroquinolones, amiodarone, SSRIs, diazepam, & Grapefruit juice. Preferably give methadone in 3 equally divided dosage. Advised to hold if too sedated. Use Short acting opioids for prn dose which is about 10% of total opioid   dose.

After the calculation: 25% reduction for incomplete tolerance Steps to follow for pain Med conversion:

  1. Thorough evaluation, best medication for that particular reason.
  2. Opioid naïve: start low / go slow.
  3. Titrate to effective dose in increment.
  4. Individualize the dose.
  5. Conversion / dosing chart is just a guideline
  6. Monitor.
  7. Convert : calculate total dose of all opioids taken in 24 hrs, use above formula
  8. Reduce for cross tolerance by  25-50%
  9. Increase by 50-125% for un-control  pain
  10. Reassess q 2-3 days
  11. Fentanyl & Methadone : can be use in renal insufficiency
  12. Titrate Fentanyl patch q 3 days or 72 hrs.
  13. Titrate Methadone q 4-7 days. Never faster.

***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.

Mild pain : 1-3/10 (scale of 0-10). Rx Non-opioid + Adjuvants Moderate pain : 4-7/10. Opioids + Non-opioid + Adjuvants Severe pain: >8. Opioids + Non-opioid + Adjuvants


Further reading : http://endlink.lurie.northwestern.edu http:// endoflife.stanford.edu http://eperc.mcw.edu/EPERC/ FastFactsandConcepts www.globalrph.com

Send comments to harleykazmi@live.com

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METHADONE: The long half-life can lead to drug accumulation, sedation, confusion, and respiratory depression, especially in the elderly & terminal patients. It could happen with rapid dose escalation. Methadone in moderate to high dosages can prolong the QTc interval > 500 milliseconds = high risk, consideration should be given to lowering the methadone dosage or rotating to an alternate opioid. Meds decrease methadone levels: rifampin, phenytoin, corticosteroids, carbamazepine, Phenobarbital, St.

John’s Wort, and a number of antiretroviral agents. Meds increases methadone level: tricyclic antidepressants, antifungals (conazoles), macrolides, fluoroquinolones, amiodarone, SSRIs, diazepam, & Grapefruit juice. Preferably give methadone in 3 equally divided dosage. Advised to hold if too sedated. Use Short acting opioids for prn dose which is about 10% of total opioid dose

***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. Give  the lowest possible dose.



Further2 reading : http://endlink.lurie.northwestern.edu http:// endoflife.stanford.edu http://eperc.mcw.edu/EPERC/ FastFactsandConcepts www.globalrph.com



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