Bukan sekadar nambah harinya.
"Ya Allah, hidupkanlah aku selama kehidupan lebih baik bagiku dan matikanlah aku jika kematian lebih baik bagiku"
(HR. Al-Bukhari : 567 dan HR. Muslim : 2680)
Palliative care is about people;
it is concerned with ordinary people
who find themselves facing
extraordinarily difficult situations:
- the loss of independence,
-
- the loss of financial security,
-
- the loss of all that is safe and familiar,
-
- the loss of friends and family,
-
- the loss of future and ultimately,
-
- the loss of life.
Key fact:
It is important to know
that there is no one definition of hospice care
in Australia or internationally.
In the USA hospice is defined
as care provided to those with
a prognosis of less than six months,
while in the UK, Canada, New Zealand and Australia
it does not apply.
When reviewing hospice models
and systems internationally,
ensure you understand their definitions
and care models.
SEDATION AT THE END OF LIFE
Sedation at the end of life
has been indicated for patients
with advanced or incurable
severe diseases,
intended to relieve symptoms refractory
to other ways of treatment
A symptom is deemed as “refractory”
when it cannot be relieved
and the option is to reduce consciousness
to avoid the patient’s perception of the symptom.
The symptoms that more frequently
become refractory are:
delirium,
dyspnea,
psychological stress,
and existential suffering;
this latter symptom requires
an exhaustive evaluation of the patient
before any pharmacological management attempt,
not only at a physical level
but also at an emotional level
so that the patient
can be given some other choices
such as spiritual accompaniment
and psychological support.
It is very important
to note that this treatment is
not intended to reduce
the patient’s life expectancy
and that onset of treatment
does not change the time the person
would stay alive,
since the treatment is
only intended to relieve symptoms.
Before starting the sedation process,
the informed consent process
should be completed
with both patient and family;
they should be explained
risks and benefits
and the patient’s diagnosis
should be evaluated.
The most frequently
used drug is Midazolam,
with a dosage
ranging from 30 to 120 mg/day.
This is the drug of choice
among benzodiazepines
since it exhibits a short half-life
and a rapid onset of action.
https://web.archive.org/web/20200920103648/http://www.scielo.org.co/pdf/cesm/v30n1/v30n1a05.pdf
PRINCIPLE OF DOUBLE EFFECT IN PALLIATIVE CARE
https://pharmacopallcare.blogspot.com/2020/09/principle-of-double-effect-in.html
THE SURPRISE QUESTION
The Surprise Question can help
in creating awareness among clinicians
about the possible presence
of a limited prognosis
and therefore may act
as a first screening tool
for patients who might benefit
from palliative care.
However,
the Surprise Question can probably
only moderately predict death
and the relationship
with palliative care needs
is currently unknown.
After a negative answer
to the Surprise Question,
further identification and assessment
of palliative care needs is needed.
https://journals.lww.com/co-supportiveandpalliativecare/Abstract/2018/03000/Palliative_care_needs_assessment_in_chronic_heart.6.aspx
INDICATIONS FOR A PALLIATIVE CARE CONSULT
- Goals of care
- Symptom control/unrelieved suffering
- Developing a treatment plan
- Advance care planning
- Terminal extubation help
- Evaluation/appropriateness for hospice
- Melding symptom management and disease modifying treatment
- Spiritual support
- High complexity social support needs
PALLIATIVE CARE PHYSICIAN CONSULTATION
A palliative care physician consultation
is an assessment resulting from a request
from a referring physician or nurse practitioner who,
in light of his/her knowledge of the patient,
requests the opinion of another physician
(the “Palliative Care Specialist Physician”)
competent to give advice in this field
because of the complexity,
seriousness,
or obscurity of the case,
or because another opinion
is requested
by the patient
or patient’s representative.
The palliative care consultant
will usually assess
physical,
social,
psychological
and spiritual concerns,
and recommend strategies
for their management.
It includes a comprehensive review
of pharmacotherapy,
appropriate counselling
and consideration of appropriate community services.
The Palliative Care Specialist Physician
is a member of an interdisciplinary team,
which will also be involved
in the consultation
and the resultant recommended plan.
A palliative care consultation
does not include assessment of eligibility for MAiD.
https://web.archive.org/web/20200920121831/https://library.nshealth.ca/ld.php?content_id=34202519
Fentanyl
Transdermal
Fentanyl patches (each patch over 72 hrs)
- Fentanyl is a potent opioid - a 25microgram/hr patch is equivalent to up to 90mg/day Oral Morphine
- Fentanyl is not suitable for unstable pain and should NOT be used as a 1st line strong opioid. It is more likely to cause respiratory depression than oral opioids. Rapid titration of fentanyl increases the risk of opioid induced hyperalgesia (OIH).
- Seek specialist advice if the Fentanyl dose exceeds 75microgram/hr
- When converting to Fentanyl from Modified Release Morphine 12 hourly:
- Apply the first patch at the same time as taking the final dose of Modified Release Morphine
- At end of life CONTINUE TO APPLY FENTANYL PATCH. Patients may require additional SC opioid via syringe driver: seek specialist advice.
- Dose Conversion for Fentanyl:
PAIN ASSOCIATED WITH LIVER DISEASE
Pain in end-stage liver disease may result from:
• Pressure sores/general discomfort secondary to weight loss/cachexia
• Abdominal distension secondary to ascites
• Subcostal discomfort if liver enlargement or scarring
Be aware that cognitive impairment secondary to encephalopathy may result in difficulties reporting pain.
Prescribing in hepatic impairment
Drug metabolism is usually only affected when hepatic impairment is severe, as evidenced by encephalopathy, varices, ascites or evidence of impaired synthetic function (raised prothrombin time/INR, hypoalbuminaemia) and deranged liver function tests (particularly bilirubin >100mcg/l).
Drugs tend to have an increased half-life and be more sedating in hepatic impairment.
OPIOIDS IN HEPATIC IMPAIRMENT
- ☛ Morphine can be used safely in liver failure. However, the plasma clearance is decreased, and elimination half-life prolonged. Therefore, use reduced doses and increased p.r.n. dosing intervals.
- ☛ During the titration phase, consider using short acting preparations as required, rather than modified release tablets or continuous subcutaneous infusions, and seek specialist advice.
- ☛ Alfentanil can be used for patients with severe renal impairment and liver impairment, however the plasma clearance is decreased and elimination half-life prolonged, therefore reduced doses should be used – seek specialist advice.
- ☛ Fentanyl is safe even in severe liver failure, therefore if a fentanyl patch is prescribed, this can be left in situ. Morphine should be used for breakthrough pain – seek specialist advice regarding appropriate breakthrough dose.
- ☛ Oxycodone should be avoided in severe liver impairment, due to severely impaired elimination. Patient already established on oxycodone who develop severe liver impairment should be switched to an alternative strong opioid – seek specialist advice.
- ☛ Care should be taken to avoid opioid-induced constipation, as this may precipitate or worsen encephalopathy. When prescribing strong opioids for patients with liver impairment, it is therefore especially important to ensure co-prescription of regular laxatives.
PRESCRIBING IN LIVER DISEASE
Practice points
• Use hepatotoxic drugs with caution.
• Aim to use short acting drugs.
• Start with a small dose and increase slowly or as required.
• Monitor response to titrations closely (for example analgesic control).
• Consider overall goals of care, mindful of prognosis.
Specific considerations
• Hepatic encephalopathy: be aware of increased sensitivity to sedatives, hypnotics andcentral nervous system depressants; use caution when prescribing constipating agents.
• Be vigilant for concurrent renal impairment and prescribe accordingly.
• In patients with a low albumin: be mindful of prescribing drugs that are highly proteinbound (such as warfarin, anticoagulants, oral antidiabetics).
PALLIATIVE CARE IN LIVER DISEASE
https://pharmacopallcare.blogspot.com/2020/09/palliative-care-in-liver-disease-ika.html
CONGESTIVE HEART FAILURE
General predictors of shorter prognosis:
• Cardiac hospitalization (triples 1-year mortality; nearly 1 in 10 die within 30 days of admission)
• Intolerance to neurohormonal therapy (i.e. beta-blockers or ACE-inhibitors) is associated with high 4-month 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)
• Cachexia or reduced functional capacity
• Orthopnea
• PAD in the geriatric population
• Co-morbidities: diabetes, depression, COPD, cirrhosis, cerebrovascular disease, and cancer
• Patients who are hospitalized for advanced HF/decompensated HF have a high mortality rate:
☛ 2-22% die in the hospital
☛ 11% die within 30 days
☛ 33% die within one year
Antidepressants, psychotherapy
can improve dying patients’
quality of life.
Don’t underestimate the impact
of depression in this setting.
Left untreated, depression
in seriously ill patients
can be associated with
increased physical symptoms,
suicidal thoughts,
worsened quality of life,
and emotional distress.
Moreover, depression can impair
the patient’s interaction with family during
a pivotal time in which patients may be
saying goodbye,
thank you,
or planning
for their death.
Depressive symptoms even can
erode the construct of patient autonomy
by interfering with one’s ability
to engage in medical decisions
and attain a sense
of meaning from their illness.
Side effects from
commonly used
therapeutics for
cancer patients can
mimic depressive
symptoms.
Placebo-controlled
trials of SSRIs and
SNRIs have yielded
mixed results in
cancer patients;
differences in efficacy
may not be significant.
Psychostimulants
can improve cancerrelated
fatigue
and quality of life
while augmenting
the action of
antidepressants.
When a patient
requests a hastened
death, a clinician’s
role is to identify
suicidality and
perform a suicide
risk assessment.
Clinicians can
assist patients with
advance planning by
helping them fill out
advance directives,
such as a living will.
In the care of patients with HF,
the unpredictable trajectories
and the lack
of obvious transition points
in disease progression
can make conversations
about goals of care,
values,
and advance care planning
with these patients
quite challenging.
It is useful
to begin by educating
patients and caregivers
about the natural history of HF.
By drawing the trajectory of HF
for patients
and caregivers,
you can explain
the variable nature of the illness
and explain that each decompensation
is a time when death
is possible.
You can explain
that the diuresis and
other management
during a decompensation
is an attempt
to regain previous function;
However,
at some point that
will not be possible.
This can help patients and families
better understand
the variable trajectory
and the uncertainty
associated with HF.
https://web.archive.org/web/20200908152519/https://www.cfp.ca/content/cfp/63/9/674.full.pdf
End-of-life discussions and early palliative care referral are
both associated with improved quality of end-of-life care.
Outpatient palliative care clinics can play a particularly important role
in facilitating these important discussions over time and helping patients refine their goals of care.
https://pubmed.ncbi.nlm.nih.gov/27185614/
Okay kan, Bro!
