Section 1: Management of Pain at the End of Life
Case 1 cont’d. Alan’s pancreatic cancer pain is 9/10 on a numeric pain scale. The pain is worse at night, better leaning forward, and only slightly improved with 10 mg of Oxycodone taken every 4 hours prescribed by the physician in the Emergency Room. Alan has no allergies or history of opioid use or misuse.
Family practitioners are well suited to provide end-of-life care because their training emphasizes treatment of the whole person, managing comorbidities, and coordination of care. Hospice care by definition is interdisciplinary and available around the clock, to allow even solo practitioners to manage terminal patients using a multidisciplinary team. Treatment focuses not only on medical
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Their availability as short and long acting medications, as well as various routes of administrations, makes them easy to use in most end-of-life circumstances. Most patients with end-of-life pain have already been treated using short acting opioids. Short acting opioids may be optimized by increasing dose and frequency. Though this approach has limitation and often the addition of a long acting opioid is necessary to control the pain.2 In patients with terminal pain, it is frequently necessary to use opioids in higher doses. Opioids act as pure agonist, and mixed agonist and antagonist. The latter in higher dosages can result in withdrawal. Therefore only pure opioid agonist should be used, to prevent un-necessary opioid withdrawal. Initial choices of opioids, may include short acting tramadol, hydrocodone, and oxycodone. However if they do not control end-of-life pain other opioids should be initiated. Morphine is typically the gold standard of initial terminal opioid prescribing, available in a long acting oral formulation, inexpensive, and on Hospice formulary.2 Other long acting opioids to consider are hydrocodone, hydromorphone, oxycodone, oxymorphone, and fentanyl.(Table 1) Though Methadone has been used as well, one must be familiar with its use and risks and prescribe with
The focus is on the needs of both the terminally ill person and the entire family. This care is provided by an interdisciplinary team which includes the physician, nurse, social worker, chaplain, certified nursing assistant, and hospice volunteers. A couple of examples are pain and symptom management, emotional, psychosocial and spiritual support, funeral planning and arrangement and most crucial are bereavement services for the family and caregivers after the patient’s death.
Caring Hospice will be made up of an inter-disciplinary team that collaborate together to provide holistic, competent, and compassionate care for terminally ill patients and their families. The team will consist of the Medical Director, Patient Care Coordinator, Registered Nurse, Bereavement Coordinator, Social Worker, Chaplain, Certified Nurse Assistant, and Office Manager. Each team member will play a vital role in creating an effective care giving system.
Hospice exists in the hope and belief that, through proper care and the encouragement of a caring and sensitive team, patients and their families may be free to achieve some level of mental and spiritual preparation for death that is comfortable to them. The goal is to help
Death is inevitable. It is one of the only certainties in life. Regardless, people are often uncomfortable discussing death. Nyatanga (2016) posits that the idea of no longer existing increases anxiety and emotional distress in relation to one’s mortality. Because of the difficulty in level of care for end-of-life patients, the patient and the family often need professional assistance for physical and emotional care. Many family caregivers are not professionally trained in medicine, and this is where hospice comes into play. Hospice aims to meet the holistic needs of both the patient and the patient’s family through treatment plans, education, and advocacy. There is a duality of care to the treatment provided by hospice staff in that they do not attempt to separate the patient’s care from the family’s care. Leming and Dickinson (2011) support that hospice, unlike other clinical fields, focuses on the patient and the family together instead of seeing the patient independent of the family. Many times in hospitals, the medical team focuses solely on the goal of returning the patient back to health in order for them to return to their normal lives. They do not take into account the psychological and spiritual components of the patient’s journey and the journey that the family must take as well. For treatment of the patient, Leming and Dickinson agree that hospice does not attempt to cure patients, and instead concentrates solely
Many terminally-ill patients give up hope when treatments are no longer available to help them and hospice care is given to them as an option. However, hospice care has proven itself to provide the best quality care for the last six months of the dying. The purpose of hospice is to provide the best care for terminally-ill patients at the end stage of their lives. Hospice offer services to support too many aspects a patient’s life such as medical, legal, spiritual care. Hospice includes art therapists, music therapists, and certified chaplains on the palliative team.
Hospice is compassionate care provided to patients facing terminal illness or illness for which there is no cure. These patients are diagnosed with an illness from which they will never recover and usually have a life prognosis of six months or less (Hospice Foundation of America, 2014). The goal of hospice care is improving quality of life and managing the symptoms of disease and the dying process. The care hospice offers is focused on pain management and emotional and spiritual support for both the patient and family (National Hospice and Palliative Care Organization, 2012). Hospice care can be provided in many different settings, often the patient’s own home. Hospice care can also be provided in hospitals, nursing homes, long-term care facilities and free-standing hospice centers and is available to patients of all ages (NHPCO, 2012). A patient receiving care in a hospice program has a team of healthcare individuals that can consist of the patients own physician, nurses, home health aides, clergy, social workers, and speech and physical therapists (NHPCO, 2012). Usually, a care plan is developed by the hospice team and care of the patient is provided by family members with the support of the hospice staff (NHPCO, 2012). Nurses make regular visits to the patient and family and are on call 24/7. Once enrolled in a hospice program hospice covers everything that will be needed to care for you, from medications to manage pain to
Hospice crusade in the United States has advanced over the past 25 years. The focus of hospice is comprehensive physical, psychosocial, emotional and spiritual therapy in people, who are terminally ill and their families. Hospice providers are helping the quality of life by whenever they can, instead of hospitals, protecting patients treated at home from the burden and provide intervention. Hospice nurses are mainly in accordance with the 1983 Medicare Benefits Act, guidelines of the federal program that allows the patient to die in their own home with family and friends at their next offer treatment (Nurses for a Healthier Tomorrow, n.d).
In nursing, the goal of care is usually to restore the patient back to the highest level of health possible. In some cases, however, the goals of care change when a curative approach is no longer appropriate. The new goals of care could simply be palliation and pain control rather than a restoration back to full health. This type of care is called palliative care. Palliative care is not the same as end-of-life care, but the two go hand-in-hand at times. The goal of end-of-life care is a “good” death, good being defined by the patient. Palliation is part of that “good” death. Both palliative care and end-of-life
At some point in a terminally ill person 's life, there comes a time when all treatment options have been exhausted, and patient comfort is the number one priority. During this process, hospice care comes into play to ensure quality of life of a patient. Pain management and supportive services are provided to anyone who is willing by Medicare, and other government assistance programs, for individuals and families that cannot afford private home care. These services are provided by a trained group of professionals, including; Doctors, Nurses, Counselors, Social workers, Physical therapists, Volunteers and Chaplains. There are different types of hospice
Hospice is a special healthcare option for patients and families faced with a terminal illness. At Hospice there’s a multidisciplinary team of physicians, nurses social workers, bereavement counselors and volunteers that work together to address the physical, social, emotional and spiritual needs of each patient and
Opioids are effective for the treatment of acute pain, such as pain following surgery. They have also been found to be important in palliative care (hospice) to help with the severe, chronic, disabling pain that may occur in some terminal conditions such as cancer. In many cases opioids are successful long-term care strategies for those with chronic cancer pain (CCP). There are not many alternatives for those with CCP like there are for those suffering acute or chronic non cancer pain (CNCP). In one study, conducted by Furlan et al. (2006), opioids were effective in the treatment of CNCP overall; they reduced pain and improved functional outcomes better than placebo. Strong opioids (oxycodone and morphine) were significantly superior, to naproxen and nortriptyline (respectively) for pain relief but not for functional outcomes. Unfortunately, Weak opioids (propoxyphene, tramadol and codeine) did not significantly outperform NSAIDs or TCAs for either pain relief or functional outcomes. Overall, if opioids are
Hospice and palliative care are still new concepts to many that come into the facility. While the process and the goals of palliative and hospice care can be described to the patients and family members, the terminology and interpretation may be challenged by their previous beliefs and ideologies. However, after careful counseling and education, many family members agree to undergo hospice or palliative care at the appropriate time. Considering that five years ago, hospice utilization in the workplace was scarce in comparison to today where there is an entire unit devoted to promoting palliative and hospice care, it can be said that these new forms of care are becoming accepted practices with favorable
In the alleviation of pain in chronic conditions such as cancer and rheumatoid arthritis, opioids are used. The codeine that falls under opioids is ten times less efficient compared to morphine. Some opioid analgesics such as hydromorphone are more potent compared to morphine, reports Rxlist. The opioid drugs act by binding to opioid receptors in the central nervous system. Unlike other analgesics that inhibits cyclooxygenase enzymes involved in mediating the
Hospice care is for people who are nearing the end of life. Hospice care services are provided by a team of health care professionals who maximize comfort for a terminally ill person by reducing pain and addressing physical, psychological, social and spiritual needs. To help families, hospice care also provides counseling, respite care and practical support. Hospice staff is on-call 24 hours a day, seven days a week.
There is technology and medicine that exists today that can control pain effectively. While there are still some obstacles, some major efforts have been made to overcome them. Many medical personnel are uninformed and may use outdated or unsatisfactory methods and often do not properly relieve their patient's pain. As a result, many patients see Physician Assisted Suicide as the only way out. For patients in severe pain, administration of an opioid, in particular morphine, has been proven to provide effective pain management for the majority of patients.