PALLIATIVE CARE 101 DO’S, DON’TS AND CONSULTS James Hallenbeck, MD Director, Palliative Care Services VA Palo Alto

Agenda Palliative and Hospice Care –definitions Palliative Care in the VA Do’s and Don’ts of Palliative Care Palliative Care Consults

Hospice and Palliative Care – not the same thing… Hospice –overtly focused on care for the dying A place, an organization, a philosophy Palliative Care – Definition: “Care focused on the misery of illness”

A small percentage of veterans die as inpatients in VA facilities Annual Veteran Deaths A small percentage of veterans die as inpatients in VA facilities

Palliative Care at VA Palo Alto HCS 1979 – Menlo Park Hospice opens (one of the first publicly funded hospice in the country) 1994 –1999 Expansion from 7 to 25 beds 1999 Moved to 2C, began non-vet admits 2000 Palliative Care fellowship and consult service started 2002 Palliative Medicine Clinic started

10 DON’T forget the bowels, when prescribing opioids DO use promotility agents such as senna proactively DSS, stool softeners usually inadequate

9 DON’T use the O2 sat meter to evaluate dyspnea DO ask if patients are short of breath and treat accordingly

8 DON’T use Phenergan and Compazine interchangeably These agents opposites in action: Phenergan antihistimine/anticholinergic, Compazine antidopaminergic DO use Compazine as suppository of choice in opioid related nausea

7 DON’T prescribe opioids (or any drug with potentially serious side-effects) with wide dose ranges such as 2-10 mg morphine q 20 minutes DO check to see that any drug is safe across the dose range you prescribe

6 DON’T prescribe Ativan (lorazepam) as a sole agent for nausea Ativan only helpful if anticipatory nausea or anxiety associated with nausea DO try to figure out why the patient is nauseated, what receptors are involved and treat accordingly

5 DON’T just think about differential diagnosis relative to disease DO consider that differential diagnosis can apply to symptoms. Why is a particular disease causing this symptom? What is the physiology of the symptom?

4 DON’T use only short-acting agents (opioids) for chronic pain Special concern re combo drugs – Vicodin, T&C #3 and Percocet DO use sustained-release or long acting opioids, if indicated, for chronic pain

3 DON’T just tell patients what is wrong with them DO elicit patients’ understandings of their illness by asking questions like, “What is your understanding of why you are sick?’

2 DON’T just tell people what you are not going to do. Nobody loves you for what you don’t do DO tell them what you are going to do (or how you will help them) Especially important when discussing “treatment withdrawal”

1 DON’T set out to “get the DNR” Resuscitation status is only one of many “difficult decisions” that should incorporate patient and family goals DO assess and document patients’ goals of care

Palliative Care Consults Help with: Difficult decisions Communication Symptom management Identifying appropriate venues of care for patients with serious, life-limiting illnesses

Palliative Care Consults What they are not A excuse for ward teams not to talk with patients about difficult subjects Shock troops to break through patient/family denial, thereby “getting” the DNR Solely about hospice referral as a “placement” issue

How you can help with Palliative Care Consults Be as clear as you can as to what help you would like At least try to address patient/family goals of care and document prior to consult If you have special concerns you would rather not put in the consult request in GUI, call the consult fellow, beeper: 21656