para>Avoid morphine in patients with renal failure, can induce delirium, hyperalgesia, agitation, and seizures. é á
- Vomiting associated with a particular opioid may be relieved by substitution with an equianalgesic dose of another opioid or a sustained-release formulation (5).
- Dopamine receptor antagonists (metoclopramide, prochlorperazine, promethazine) are commonly used. Haloperidol may help with nausea.
- Droperidol: insufficient evidence to advise on the use for the management of nausea and vomiting
- Constipation: Consider prophylactic stool softeners (docusate) and stimulants (bisacodyl or senna) or osmotic laxatives (6)[A].
ALERT
Laxatives should be started when opioid treatment has begun to avoid constipation.
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- SC methylnaltrexone is effective in inducing bowel movements without inducing withdrawal with opioid-induced constipation (7)[A].
- Dyspnea: Consider oxygen, if congestive heart failure (CHF); diuretics and/or long-acting nitrates, benzodiazepines
- In addition to treating the underlying cause of breathlessness, as the disease advances, low-dose opioids may be beneficial to patients (4,8)[C]. Immediate-release opioids PO/IV treat dyspnea effectively and typically at doses lower than necessary for the relief of moderate pain.
- Delirium: lowest doses necessary of benzodiazepines or antipsychotics (haloperidol, etc.)
- Monitor patient safety and use nonpharmacologic strategies to assist orientation (clocks, calendars, environment, and redirection).
- Droperidol: When cause of delirium cannot be identified/corrected rapidly, consider neuroleptics (haloperidol or risperidone).
- Pruritus: no optimal therapy (9)[A]
- Anxiety: insufficient data for recommendations of specific medication, but anxiolytics and/or other agents may be tried (10)[A].
- Megestrol acetate improves appetite and slight weight gain in patients with anorexia-cachexia syndrome (11)[A].
ISSUES FOR REFERRAL
- Referral to palliative care
- Any patient with a serious, life-limiting illness who could benefit from help with burdensome symptoms or suffering and/or complex goals of care discussion (12)[A].
- Early referral to palliative care may improve quality of life and longevity for patients with advanced cancer (13)[A].
- Referral to hospice care
- Any patient with an average life expectancy of 6 months or less. Consider the question, "Would you be surprised if the patient died within the next 6 months? " Ł If the answer is no, they likely meet prognostic criteria for hospice.
- Consider patients who have multiple hospitalizations and/or emergency department visits in the prior 6 months.
- Refer to local hospice guidelines for additional disease-specific criteria.
REFERENCES
11 Okon é áTR, Evans é áJM, Gomez é áCF, et al. Palliative educational outcome with implementation of PEACE tool integrated clinical pathway. J Palliat Med. 2004;7(2):279 " ô295.22 Puchalski é áC, Romber é áAL. Taking a spiritual history allows clinicians to understand patients more fully. J Palliat Med. 2000;3(1):129 " ô137.33 Anandarajah é áG, Hight é áE. Spirituality and medical practice: using the HOPE questions as a practical tool for spiritual assessment. Am Fam Physician. 2001;63(1):81 " ô89.44 Lorenz é áKA, Lynn é áJ, Dy é áSM, et al. Evidence for improving palliative care at the end of life: a systematic review. Ann Intern Med. 2008;148(2):147 " ô159.55 Smith é áHS, Smith é áJM, Smith é áAR. An overview of nausea/vomiting in palliative medicine. Ann Palliat Med. 2012;1(2):103 " ô114.66 Candy é áB, Jones é áL, Larkin é áPJ, et al. Laxative for the management of constipation in people receiving palliative care. Cochrane Database Syst Rev. 2015;(5):CD003448.77 Candy é áB, Jones é áL, Goodman é áML, et al. Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011;(1):CD003448.88 Ben-Aharon é áI, Gafter-Gvili é áA, Paul é áM, et al. Interventions for alleviating cancer-related dyspnea: a systematic review. J Clin Oncol. 2008;26(14):2396 " ô2404.99 Xander é áC, Meerpohl é áJJ, Galandi é áD, et al. Pharmacological intervention for pruritus in adult palliative care patients. Cochrane Database Syst Rev. 2013;(6):CD008320.1010 Candy é áB, Jackson é áKC, Jones é áL, et al. Drug therapy for symptoms associated with anxiety in adult palliative care patients. Cochrane Database Syst Rev. 2012;(10):CD004596.1111 Ruiz Garcia é áV, L â │pez-Briz é áE, Carbonell Sanchis é áR, et al. Megestrol acetate for treatment of anorexia-cachexia syndrome. Cochrane Database Syst Rev. 2013;(3):CD004310.1212 Weissman é áDE, Meier é áDE. Identifying patients in need of a palliative care assessment in the hospital setting: a consensus report from the Center to Advance Palliative Care. J Palliat Med. 2011;14(1):17 " ô23.1313 Temel é áJS, Greer é áJA, Muzikansky é áA, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733 " ô742.
CODES
ICD10
Z51.5 Encounter for palliative care é á
ICD9
V66.7 Encounter for palliative care é á
SNOMED
- 103735009 palliative care (regime/therapy)
- 441874000 Seen by palliative care service
- 305496007 Under care of palliative care physician
CLINICAL PEARLS
- Early referral to palliative care may help enhance the quality of life and potential longevity of patients living with serious illness.
- Bone pain: NSAIDs added to narcotics are more effective than narcotics alone.
- Laxatives should be started when opioid treatment has begun to avoid constipation.