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

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

3. 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”

4. 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

5. 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

6. 10 DON’T forget the bowels, when prescribing opioids
DO use promotility agents such as senna proactively
DSS, stool softeners usually inadequate

7. 9 DON’T use the O2 sat meter to evaluate dyspnea
DO ask if patients are short of breath and treat accordingly

8. 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

9. 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

10. 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

11. 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?

12. 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

13. 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?’

14. 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”

15. 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

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

17. 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

18. 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